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Introduction: Ultrasound and Tc99mMIBI scans are used to localise parathyroid tumours in sporadic primary hyperparathyroidism (pHPT). Intra-operative PTH (ioPTH) assay facilitates unilateral neck exploration (UNE). When both ultrasound and MIBI are negative, it is our policy to explore the left side of the neck and only proceed to bilateral neck exploration (BNE) when either a tumour is not found or when ioPTH does not fall to >50% of the highest pre-excision value. The aim of this study was to investigate the outcome of our approach to 'double negative' patients. Methods: A retrospective analysis of patients undergoing primary parathyroidectomy for pHPT. Data were obtained from a prospective surgical database and the hospital electronic patient record. Results: Between January 2004 and November 2014, 746 patients underwent a parathyroidectomy for pHPT. Those who did not have both pre-operative scans, ioPTH or a minimum of 6-month follow-up were excluded. Of 552 patients, 111 (20%) had double negative scans (group A), and in 441, either one or both scans were positive (group B). Median age was 61.5 years (range 10-88). Pre-operative PTH level was significantly lower in group A: 11.8 pmol/l (range 3.1-38.8) versus 14.9 pmol/l (range 2.8-101.6; P < 0.01). Median tumour weight was significantly lower in group A: 280 mg (range 50-3710) versus 573 mg (range 10-12,000; P < 0.01). Overall rate of multiple gland disease (MGD) was 11%; 24% in group A and 7% in group B ( P < 0.01). Overall rate of UNE in Group A was 28% and converse to the rate in Group B (76%; P < 0.01). Sensitivity and specificity of ioPTH to detect MGD were 98 and 98% in Group A versus 98 and 100% in Group B. First-time cure rate was 92.7% in group A and 96.8% in group B ( P < 0.05). Conclusion: A double negative scan is associated with small tumours and higher rates of MGD. Despite these challenges, surgery is successful in this group of patients reinforcing the message that negative localisation is not a contraindication for parathyroidectomy. We demonstrated that it is feasible to offer unilateral neck surgery to 28% of patients with double negative scans. A randomised trial is needed to compare BNE with ioPTH/UNE in this select population. [ABSTRACT FROM AUTHOR]

Introduction: Propofol is used extensively in neurocritical care (NCC) due to its pharmacologic properties allowing for facilitation of serial neurologic examinations. Despite widespread use, few studies have identified risk factors for hypotension in these patients. We aimed to determine predictors of hypotension in NCC patients sedated with propofol. Methods: This retrospective, multicenter study evaluated 237 patients at two academic medical centers, both with dedicated NCC teams led by board-certified neurointensivists. Univariate analyses were performed to determine risk factors associated with severe hypotension during sedation with propofol. Multivariable analysis was performed to determine variables independently associated with hypotension, defined as a mean arterial pressure (MAP) less than 60 mmHg. Results: There was an average maximum reduction in MAP of 28.8 % after propofol initiation in the entire cohort. Severe hypotension developed in 62 (26.2 %) patients to a median nadir MAP of 56 mmHg. Those who developed severe hypotension had a longer median duration of mechanical ventilation (5.0 vs. 3.6 days; p = 0.01) and an increased in-hospital mortality (38.7 vs. 24.0 %; p = 0.03). Multivariable logistic regression analysis identified increasing number of changes to the propofol infusion rate, baseline MAP 60-70 mmHg, and need for renal replacement therapy (RRT) as factors independently associated with hypotension. Conclusions: Multiple factors predicted hypotension in NCC patients receiving propofol. Clinicians should use propofol cautiously in patients with a lower baseline MAP or receiving RRT. Development of protocols related to the frequency of dose titrations is also recommended to prevent this avoidable complication. [ABSTRACT FROM AUTHOR]

Introduction: The association between hormonal contraceptive use and bone mineral density remains controversial. Hypothesis: Hormonal contraceptive use is positively associated with bone mass in young premenopausal women. Methods: Cross-sectional analysis of data collected from women aged 26-36 years ( n = 687) in the Childhood Determinants of Adult Health study-a longitudinal study investigating childhood determinants of cardiovascular disease, diabetes, and other chronic diseases in adulthood. Participants were not currently pregnant or breast-feeding. Contraceptive use was obtained by self-administered questionnaire. Women were categorized as combined oral contraceptive users ( n = 219), progestogen-only contraceptive users ( n = 43), and non-users of hormonal contraceptives ( n = 425). Bone mass was measured by quantitative ultrasound. Results: Compared with women who were not using any hormonal contraceptives, women using combined oral contraceptives had significantly higher values of broadband ultrasound attenuation (BUA), speed of sound, and quantitative ultrasound index. These associations remained after adjustment for confounders. Progestogen-only contraceptive users had higher BUA than non-users, but the differences were not statistically significant in this small group. Conclusion: Combined oral contraceptive use was associated with higher bone mass measured by quantitative ultrasound in this population-based sample of premenopausal women aged 26-36 while progestogen-only contraceptives appeared to have no deleterious effect on bone mass. [ABSTRACT FROM AUTHOR]