Kelsey Hinther completed her Bachelor of Science in 2013 from University of Saskatchewan. She is currently a third year medical student at the University of Saskatchewan. She has profound interest in research and would like to continue to be involved in research in her future career.
This retrospective pre-post study analyzed if dialysis patients with secondary hyperparathyroidism who receive a postoperative standardized order set of intravenous calcium following a subtotal parathyroidectomy (PTX) will have shorter hospital stays. The medical records of dialysis patients who underwent subtotal PTX for symptomatic secondary hyperparathyroidism were reviewed prior to and after the introduction of a standard postoperative order set. The gender, duration of hospital stay as well as readmission rates of all patients were analyzed. The study population included 50 patients, with a mean age of 49 years. 25 patients were administered the standardized order set of intravenous calcium treatment following a subtotal PTX. There was no statistical difference (p = 0.7063) between the length of hospital stay in the group of the patients that received the post-operative standardized order set of intravenous calcium and the group that did not. Only 1 patient was readmitted during the study period. There was no statistical difference in the length of hospital stay between the dialysis patients with secondary hyperparathyroidism who received the standardized order set of intravenous calcium and the patients who did not following a PTX. This could have been largely due to limitations of the study, including a small sample size and a non-randomized study design, and not examining other metrics, including the number of inpatient episodes of significant hypocalcaemia and nursing time. Further studies are warranted to assess postoperative hypocalcaemia in the setting of PTX, including studying a larger sample size, utilizing various order sets, and taking into account patient co-morbidities.
Dhaval Save has finished his medical school from Seth GS medical College, Mumbai, India and is currently PGY-2 of his residency in Internal Medicine at John H Stroger Jr Hospital of Cook County in Chicago, IL. This clinical vignette was written under supervision of Joy Bressler MD who is an Attending Physician at department of Medicine at John H Stroger Hospital.
Introduction: The synchronous occurrence of malignancy in the TGC and thyroid gland is extremely rare. We report a case of coexistence of papillary carcinomas in the TGC and Follicular carcinoma thyroid gland. Case: 48 year old African-American female with no significant medical history presented with a neck swelling present since birth, but growing rapidly for the past 6-7 months. Physical examination was pertinent for midline, cystic, tense, mobile, illuminant neck swelling of 6 x 5 centimeter (cm), moving with swallowing and protrusion of tongue. Laboratory findings were unremarkable including normal thyroid function tests. Chest radiograph revealed a rightward deviated trachea. Thyroid Ultrasound demonstrated a 6.0 x 4.4 x 5.4 cm complex cystic mass above isthmus with internal vascularity, micro-calcifications, and a 5.4 x 3.3 x 4.3 cm hyper-echoic nodule within the lower pole of the left lobe with internal vascularity but no calcification. A Computed tomographic (CT) scan of the neck revealed a large irregular enhancing solid cystic mass, likely TGC, and a large solid mass in the left lobe of thyroid gland. Fine Needle Aspiration cytology (FNAC) of the cystic neck mass was non diagnostic. Patient underwent Sistrunk Surgery for TGC removal and a biopsy of thyroid mass. Pathology was positive for papillary carcinoma arising in a TGC with no vascular invasion and margins free of carcinoma. Biopsy of the thyroid mass showed an atypia of undetermined significance. Patient underwent total thyroidectomy. Pathology showed a follicular thyroid carcinoma variant with focal Hurthle cell differentiation. Patient was referred for radioactive iodine therapy. Discussion: Malignant transformation is a very rare(less than 1%) complication of TGC. Papillary Carcinoma is the most common type (80%) with a median age of development being 40 years. It usually presents as an asymptomatic mass but rarely as a rapidly enlarging mass causing dysphagia, voice change and draining cutaneous sinus. TGC carcinoma can be a primary malignancy or secondary to metastasis from primary thyroid gland carcinoma. Our case represents the primary TGC carcinoma for the following reasons: 1. Lack of lymph node involvement. 2. Absence of any patent tract from thyroid to TGC. 3. Fibrous encapsulated cyst on gross appearance. 4. Pathologically different malignancy in a thyroid gland with no local lymph node spread. In our case a Sistrunk operation was done as FNAC was inconclusive. Total thyroidectomy and central compartment neck lymph node dissection was performed after positive histopathology for TGC papillary carcinoma. Both malignancy diagnoses were made post-operatively on histopathology. This case is an interesting and rare clinical vignette.