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Background Breast cancer is a significant cause of morbidity and mortality in older women. The current study presents new, comprehensive guidelines for providing chemoprevention to older women. Objective The objective of this study was to develop and pilot test a chemopreventive choice algorithm to assess its feasibility for older women at high risk of breast cancer. Design The study observed outcomes of 23 older adult females being treated with one of the four different chemopreventive agents. A novel algorithm protocol was utilized for individualized chemopreventive selection. Setting The study was conducted in a high-risk outpatient clinic for older women. Participants Older outpatient females at high risk (N=23) were offered chemopreventive options based on individual criteria. Intervention Literature review for breast cancer chemopreventive agents informed our development of a logic-based algorithm to guide treatment protocol and chemopreventive choice optimization. Selective estrogen receptive modulators (SERMs) were avoided in women with endometrial cancer risk (ie, pre-hysterectomy individuals), but used in women with low thromboembolic event (TE) risk. Raloxifene was used with osteoporotic women. Aromatase inhibitors (AIs) were used in women with high TE risk. Women without TE risks are advised to take SERMs. When bone density decreased due to AI use, women were switched to raloxifene. Measurements/results Of 23 participants of age ranging from 59 to 80 years (mean=72.6), two women developed estrogen receptor-positive breast cancer. Two participants, one who declined chemoprevention and one treated with an AI, developed breast cancer. All initial chemopreventive agents were selected according to the algorithm. Although minor adverse events occurred, each was managed by discontinuation or replacement of the chemopreventive agent. Discontinuation was most commonly due to side effect concerns or cost rather than experienced side effects. Conclusion Outcomes of the initial utilization of the chemopreventive agent choice algorithm support the viability of the protocol, but further evaluation with a larger and more diverse sample is required.

To quantify how frequently intraoperative parathyroid hormone levels increase during thyroid surgery and to explore a possible relationship between secondary hyperparathyroidism due to vitamin D deficiency and elevation in intraoperative parathyroid hormone.Case series with chart review.Tertiary academic center.A total of 428 consecutive patients undergoing completion and total thyroidectomy by the senior author over a 7-year period were included for analysis. All patients had baseline and postexcision intraoperative parathyroid hormone levels as well as vitamin D levels from the same laboratory. Institute of Medicine criteria were employed for vitamin D stratification (30, normal; 20-29.9, insufficient;20, deficient) . Other data analyzed include sex, age, neck dissection status, and parathyroid autotransplantation.A total of 118 patients (27.6%) had an intraoperative parathyroid hormone elevation above baseline. Patients with vitamin D deficiency were significantly more likely to experience hormone elevation ( P = .04). When parathyroid hormone rose, it did so by a mean 32.1 pg/mL. Patients with vitamin D deficiency demonstrated significantly larger hormone increases ( P = .03).Elevation in intraoperative parathyroid hormone levels above baseline after completion and total thyroidectomy occurs in over one-fourth of cases and is significantly associated with vitamin D deficiency. This study is the first to report this observation. We hypothesize that vitamin D deficiency in these patients may create a subclinical secondary hyperparathyroidism that leads to intraoperative parathyroid hormone elevation when the glands are manipulated. Additional studies will be needed to explore this physiologic mechanism and its clinical significance.

Utilization of lower trapezius island flap (LTIF) provides an alternative in reconstruction of the select defects in head and neck region. When muscle bulk is needed under the skin paddle, it may be important to know the exact location of the inferior edge of the trapezius muscle (TM) in order to design the skin paddle accordingly. Due to the anatomic variations seen especially in the origin of trapezius muscle, there are no reliable surface landmarks to define the inferior edge of TM. We present a simple ultrasound-assisted technique of identifying the inferior border of TM preoperatively. Level of Evidence: Level V, diagnostic study.

Background The purpose of this study was to define and characterize the thyroid tumor-draining lymph nodes in genetically engineered mice harboring thyroid-specific expression of oncogenic BrafV600E with and without Pten insufficiency. Methods After intratumoral injection of methylene blue, the lymphatic drainage of the thyroid gland was visualized in real time. The thyroid gland/tumor was resected en bloc with the respiratory system for histological analysis. Results Although mice harboring BrafV600E mutations were smaller in body size compared with their wild-type (WT) littermates, the size of their thyroid glands and deep cervical lymph nodes were significantly larger. Additionally, the tumor-draining lymph nodes showed increased and enlarged lymphatic sinuses that were distributed throughout the cortex and medulla. Tumor-reactive lymphadenopathy and histiocytosis, but no frank metastases, were observed in all mice harboring BrafV600E mutations. Conclusions The tumor-draining lymph nodes undergo significant structural alterations in immunocompetent mice, and this may represent a primer for papillary thyroid carcinoma (PTC) metastasis.

OBJECTIVE We aimed to evaluate the use of 4-dimensional computed tomography (4DCT) for characterization of thyroid nodules. METHODS Our study drew from 100 consecutive patients with primary hyperparathyroidism who underwent 4D parathyroid CT imaging for adenoma localization. Included subjects had tissue sampling of a thyroid nodule within 3 months of 4DCT. RESULTS Twenty subjects (18 women and 2 men) had thyroid nodules that were pathologically confirmed. Precontrast nodule attenuation was significantly lower in malignant nodules when compared with benign nodules (36 vs 61 HU, P = 0.05). Arterial phase and delayed phase nodule attenuations were not significantly different in malignant and benign nodules (128 vs 144 HU, P = 0.7; 74 vs 98 HU, P = 0.3). CONCLUSIONS Our initial experience with a small group of patients was unable to support the use of 4DCT for characterizing thyroid nodules; however, precontrast nodule attenuation was significantly lower in malignant nodules when compared with benign nodules.

Purpose: Positive results of phase I studies evaluating lenvatinib in solid tumors, including thyroid cancer, prompted a phase II trial in advanced medullary thyroid carcinoma (MTC). Experimental Design: Fifty-nine patients with unresectable progressive MTC per Response Evaluation Criteria In Solid Tumors (RECIST) v1.0 within the prior 12 months received lenvatinib (24-mg daily, 28-day cycles) until disease progression, unmanageable toxicity, withdrawal, or death. Prior anti-VEGFR therapy was permitted. The primary endpoint was objective response rate (ORR) by RECIST v1.0 and independent imaging review. Results: Lenvatinib ORR was 36% [95% confidence interval (CI), 24%–49%]; all partial responses. ORR was comparable between patients with (35%) or without (36%) prior anti-VEGFR therapy. Disease control rate (DCR) was 80% (95% CI, 67%–89%); 44% had stable disease. Among responders, median time to response (TTR) was 3.5 months (95% CI, 1.9–3.7). Median progression-free survival (PFS) was 9.0 months (95% CI, 7.0–not evaluable). Common toxicity criteria grade 3/4 treatment-emergent adverse events included diarrhea (14%), hypertension (7%), decreased appetite (7%), fatigue, dysphagia, and increased alanine aminotransferase levels (5% each). Ret proto-oncogene status did not correlate with outcomes. Low baseline levels of angiopoietin-2, hepatocyte growth factor, and IL8 were associated with tumor reduction and prolonged PFS. High baseline levels of VEGF, soluble VEGFR3, and platelet-derived growth factor BB, and low baseline levels of soluble Tie-2, were associated with tumor reduction. Conclusions: Lenvatinib had a high ORR, high DCR, and a short TTR in patients with documented progressive MTC. Toxicities were managed with dose modifications and medications. Clin Cancer Res; 22(1); 44–53. ©2015 AACR.

Objectives To measure the effect of proton pump inhibitors (PPIs), with and without concurrent bisphosphonates, on parathyroid hormone (PTH), vitamin D, and calcium. Design Retrospective chart review of individuals 60 years and older. Subjects with reduced renal function (creatinine >1.3 mg/dL) and low vitamin D (

The objective of this study was to describe national trends in robotic thyroid surgery from 2009 through 2013.The University HealthSystem Consortium (UHC) database was searched for patients undergoing robotic thyroidectomy (RT) from 2009 through 2013. Another U.S. institution's RT data, not included in the UHC database, were also evaluated. Patient demographics, institutional volume, comorbid conditions, complications, and cost information were analyzed.Sixty-one institutions performed 484 RT during the study period. From 2009 through 2011, U.S. annual RT volume increased from 39 cases to 140. Annual volume dropped to 69 cases in 2012 and 93 cases in 2013. Higher-volume centers reported lower complication rates (p0.02). Hematoma formation (3.7%) was the most common complication, and there was one death. More than 10% of patients were obese. Brachial plexus injury and axillary skin flap perforations were reported in1% of cases. Mean cost for a total RT was $13,287 ($5,125-42,444).From 2009 through early 2011, there was a steady increase in RT volume, especially among high-volume institutions. In mid-to-late 2011, there was a noticeable drop in RT volume, which significantly altered the projected trajectory of the procedure in this country. Despite higher complication rates, lower-volume centers perform the majority of RT and are also responsible for recent increases in RT utilization patterns in the United States.

ObjectiveTo determine differences in the mean parathyroid hormone (PTH) levels for normocalcemic and hypocalcemic total thyroidectomy patients who were tested for PTH during the intraoperative or early postoperative period.Data SourcesMEDLINE, the Cochrane Database, and other databases from 1960 to 2014 in the English language and specific to humans for relevant articles.Review MethodsStudies were included if PTH was obtained within 24 hours of thyroidectomy. Studies were excluded (1) if only a hemithyroidectomy was performed, (2) if means of studied PTH values were not reported in the article, or (3) if the time of the PTH draw fell outside of defined “intraoperative” or “early postoperative” windows. PTH values were divided into 3 groups: preoperative (control group), intraoperative (ie, discharge decisions were based on PTH values drawn in the operating room), and early postoperative (ie, PTH values at 1 to 4 hours after surgery were used as a guide).ResultsThe reported means of perioperative PTH level...

Abbreviations: BID = bis in die DSPTC = diffuse sclerosing papillary thyroid cancer FNA = fine-needle aspiration HT = Hashimoto thyroiditis iPTH = intact parathyroid hormone 25OHD = 25-hydroxy vitamin D PTH = parathyroid hormone TPO = thyroid peroxidase US = ultrasonography

BACKGROUND Revision parathyroid is challenging due to possible diagnostic uncertainty as well as the technical challenges it can present. METHODS A multidisciplinary panel of distinguished experts from the American Head and Neck Society (AHNS) Endocrine Section, the British Association of Endocrine and Thyroid Surgeons (BAETS), and other invited experts have reviewed this topic with the purpose of making recommendations based on current best evidence. The literature was also reviewed on May 12, 2017. PubMed (1946-2017), Cochrane SR (2005-2017), CT databases (1997-2017), and Web of Science (1945-2017) were searched with the following strategy: revision and reoperative parathyroidectomy to ensure completeness. RESULTS Guideline recommendations were made in 3 domains: preoperative evaluation, surgical management, and alternatives to surgery. Eleven guideline recommendations are proposed. CONCLUSION Reoperative parathyroid surgery is best avoided if possible. Our literature search and subsequent recommendations found that these cases are best managed by experienced surgeons using precision preoperative localization, intraoperative parathyroid hormone (PTH), and the team approach.

Objective Vitamin D deficiency affects parathyroid hormone levels and is endemic in the American population due to diet and lifestyle. The aim of this study was to evaluate a treatment algorithm using weekly doses of 50,000 IU of Vitamin D2 for thyroid and parathyroid surgery patients. Study Design Prospective, non-randomized. Setting University health sciences center. Subjects and Methods Patients at a thyroid center being treated for benign and malignant thyroid diseases or parathyroid disease. Subjects with total vitamin D levels less than 30 ng/dl were prospectively treated with weekly doses of 50,000 IU of vitamin D2 (D2) for durations dependent upon initial vitamin D (25-hydroxyvitamin D) levels. Vitamin D levels were measured after the treatment intervals and change in levels from baseline was determined. Results Subjects receiving 8 weeks of therapy demonstrated an average increase in vitamin D level of 13.4 ng/ml, 10 weeks of therapy showed an increase of 16.35 ng/ml, and 12 weeks showed an average increase of 21.6 ng/ml. The treatment groups had success rates of 82%, 75%, and 71% after 8, 10, and 12 weeks of therapy respectively. When only compliant patients were evaluated (defined as greater than 3-ng/ml increase after therapy), the success rates after 8, 10, and 12 weeks increased to 95%, 79%, and 71% respectively. Conclusions A simple algorithm using 50,000 IU of vitamin D2 corrects its deficiency in the majority of subjects treated. This is a simple method of treatment for thyroid and parathyroid patients who are vitamin D deficient. Thyroid and parathyroid conditions are frequently treated by otolaryngologists and vitamin D deficiency can complicate their diagnosis and/or management.

To compare the cost of same-day vs 23-hour observation outpatient thyroidectomy at US academic medical centers.Cross-sectional analysis of a national database.The University HealthSystem Consortium (UHC) data collected from discharge summaries.Discharge data were collected from the first quarter of 2009 through the second quarter of 2013. The UHC database, compiled from more than 200 affiliated hospitals, was searched based on diagnosis codes for outpatient thyroid procedures. Cost data, calculated based on reported charges, were collected in addition to demographics. Comparisons were made between same-day vs 23-hour observation based on cost. Additional stratification was performed based on the extent of thyroidectomy.During the study period, 49,936 outpatient thyroidectomies were performed. Overnight observation (63%) was more common than same-day discharge (37%). The overall mean cost of outpatient thyroidectomy was $5617, with a mean cost of same-day surgery of $4642 compared with $6101 for overnight observation (P.0001). When stratifying by extent of thyroidectomy, the cost of same-day surgery was consistently lower than that for overnight observation.Outpatient thyroidectomy is commonly performed in the United States. It is most commonly performed on a 23-hour overnight observation basis. Overnight stay and complications were chief among other factors associated with higher cost, independent of the type of thyroid procedure performed. In appropriately selected patients, same-day thyroidectomy is a safe and cost-effective alternative to overnight observation or inpatient thyroid procedures.

Objectives To systematically review the preoperative diagnostic modalities, surgical treatments, and glandular pathologies associated with primary hyperparathyroidism in children and adolescents under 20 years of age. Methods We searched PUBMED, Cochrane databases, OVID, Web of Science (SCIE and SSCI), CINAHL, and Health Source: Nursing academic for articles involving surgical management of primary hyperparathyroidism in the pediatric population on 5/2012. Selection Criteria: Literature review, database review, and retrospective review studies date were used from 1986 until 2012. Ages ranged for 0–19 years old. Results Of the 230 cases of pediatric primary hyperparathyroidism reported since 1987, solitary adenomas (SA), multiple gland hyperplasia disease (MGHD), double adenomas (DA), and normal parathyroid gland pathology occurred in 80%, 16.5%, 0.9%, and 2.6% respectively. Of the MGHD patients (38 pts), 1/2 (19 pts) of the cases were attributed to MEN I, MEN II, or familial non MEN hyperparathyroidism. Tc99m-sestamibi and ultrasound were 86% (37/43) and 74.5% (70/94) sensitive, respectively for localizing parathyroid disease. Conclusions Limited data exists on pediatric and adolescent patients with primary hyperparathyroidism. Sufficient data exists demonstrating single adenomas are most common and young patients are usually more symptomatic than adults. One may conclude that spontaneous primary hyperparathyroidism may be approached and managed similarly to adults. The incidence of primary hyperparathyroidism in this population may be under appreciated and a lower threshold for ordering a screening serum calcium should be considered.

To better understand relationships of parathyroid hormone (PTH) production, adenoma gamma counts, and adenoma mass in patients undergoing minimally radioguided invasive parathyroidectomy for primary hyperparathyroidism from single-gland disease.A prospective review of 104 patients operated on by a single surgeon.University tertiary hospital.Adults who have primary hyperparathyroidism due to a single gland.There were 23 men and 81 women with an average age of 63 years. The mean (SD) adenoma mass was 0.78 (0.69) g (median, 0.57 g). The mean (SD) percent of background for the adenoma was 120.2 (90.5). Preoperative PTH and percent of background gamma count of the adenoma showed a likely correlation with a Spearman ρ value of 0.2039 and a P value of .037. There were significant correlations between both percent of background of the adenoma and adenoma mass (Spearman ρ = 0.4991 and P.0001). Preoperative PTH and adenoma mass also showed a significant positive correlation (Spearman ρ = 0.308 and P = .002).There exist correlations between gland mass, radioactivity, and PTH level. Adenoma radiation counts do not appear to be a proxy for changes in PTH levels measured during surgery as has been reported. Intraoperative PTH has been shown by others not to be necessary when doing radioguided parathyroid surgery if the Norman rule is observed. However, a radioguided technique and intraoperative PTH can provide complementary information in making an assessment of completion of parathyroid procedures.

To determine if standardized uptake values (SUV) on positron emission tomography (PET) are predictive of thyroid pathology and the significance of serial SUV measurements of thyroid nodules over time.Case series with chart review.Academic health center.In total, 23,384 PET and PET/computed tomography (CT) scans were performed between December 2001 and April 2011.Patients with incidental thyroid uptake were identified. SUV(max), age, sex, size of thyroid lesion, indication for PET scan, and cytology/pathology were collected.Incidental thyroid uptake was noted in 1309 PET scans (5.60%), focal uptake in 690 (2.95%), and diffuse uptake in 619 (2.65%). Complete data were available for 359 PET scans from 103 patients. Malignancy was identified in 28 patients (27%). Twenty-five of the 28 lesions (89%) were primary thyroid malignancies. A significant difference between malignant SUV(max) and benign SUV(max) was found (mean ± SD, 7.04 ± 7.88 for malignancies vs 3.85 ± 3.06 for benign tumors, P = .0292). Receiver operating characteristics curves were constructed on patients with PET data within 3 months of diagnosis and indicated that a SUV(max) of 4.2 differentiated maximally between benign and malignant lesions. Serial SUV uptake had no significant change over time.All thyroid nodules with focal uptake on (18)F-fluorodeoxyglucose-PET/CT should be considered at higher risk of malignancy than those discovered incidentally by other imaging modalities. Higher SUV(max) values are more indicative of malignant lesions. All lesions should be evaluated with ultrasonography ± fine-needle aspiration if no clinical contraindications exist. Size of the primary nodule does not influence SUV(max) uptake.

We present a case of papillary thyroid carcinoma arising from struma ovarii treated erroneously as ovarian adenocarcinoma for more than 3 years.We report clinical, surgical, laboratory, and imaging findings of the study patient and review the relevant literature.A 64-year-old woman was treated for ovarian adenocarcinoma for more than 3 years before it was determined that she likely had papillary thyroid carcinoma arising from struma ovarii. This is the first reported case of thyroid carcinoma arising from struma ovarii in a patient with a history of bilateral salpingo-oophorectomy. Possible etiologies include residual ovarian tissue after oophorectomy, ectopic thyroid, or metastatic thyroid cancer.It is important to include struma ovarii and thyroid carcinoma arising from struma ovarii in the differential diagnosis, even with a history of bilateral salpingo-oophorectomy. This case emphasizes the importance of effective communication among the pathologist, oncologist, and surgeon to ensure timely initiation of appropriate therapy and reduced patient morbidity.

To describe a safe and effective postoperative prophylactic calcium regimen for same-day discharge thyroid and parathyroid surgery.Case series with chart review.Tertiary referral academic institution.In total, 162 adult patients who underwent total thyroidectomy, completion thyroidectomy, unilateral parathyroidectomy, parathyroidectomy with bilateral neck exploration, or revision parathyroidectomy were identified preoperatively to be candidates for same-day discharge. All patients in this study were successfully discharged the same day on our standard prophylactic calcium regimen.Less than 1% (1/162) of patients re-presented to the hospital within 30 days of surgery, and that patient was successfully discharged from the emergency department after negative workup for hypocalcemia. There was no significant difference between preoperative and postoperative calcium levels in the total/completion thyroidectomy groups (9.3 vs 9.2 mg/dL, respectively; P = .14). The average postoperative calcium level in the parathyroid group was well within normal limits (9.5 mg/dL), and the difference in postoperative calcium levels between revision and primary parathyroidectomy cases was not significantly different (P = .34).The reported calcium regimen demonstrates a safe, effective, and objective means of postoperative calcium management in outpatient thyroid and parathyroid surgery in appropriately selected patients.

Positron emission tomography (PET) positive lesions are common in the thyroid. The uptake can be focal or diffuse. Diffuse thyroid uptake is thought to be indicative of autoimmune thyroiditis and not for lesions of malignant potential. Hashimoto’s thyroiditis as a cause for diffusely positive thyroid glands has been demonstrated. We determine the incidence of diffuse thyroid PET positivity in hypothyroid patients, presumed to have Hashimoto’s thyroiditis. The study design was retrospective database and electronic medical record review. The study setting includes tertiary care and academic health sciences center. The subjects were patients at our medical center who underwent positron emission tomography. Hypothyroid patients were identified who had total body PET imaging performed for any reason. Patients were excluded if they were not taking levothyroxine, had a history of neck surgery, neck irradiation, Graves’ disease, taking lithium, thalidomide, amiodarone or interleukin. Patients remaining after the application of these exclusion criteria were presumed to be hypothyroid from Hashimoto’s thyroiditis. Only 9.5% of PET scans of hypothyroid patients display diffuse thyroid activity. Only a small minority of presumed Hashimoto’s thyroiditis patients will display diffuse thyroid activity after PET imaging. The etiology of this effect is unknown. Diffuse thyroid activity rarely requires surgical intervention. Level of evidence: IV.

Medullary thyroid carcinoma (MTC) is a rare malignancy arising from the parafollicular C cells within the thyroid gland. The majority of cases are sporadic, but at least 30% are hereditary in nature. Inherited forms of MTC occur as familial MTC or as a manifestation of multiple endocrine neoplasia type 2. Early diagnosis and aggressive surgical management, including prophylactic thyroidectomy, improve the prognosis of patients with hereditary MTC. Several issues regarding the diagnosis and treatment of MTC remain controversial. Genetic penetrance and virulence are variable. We present an index case of familial MTC to illustrate common difficulties in the initial diagnosis and dilemmas in the surgical approach, followed by a review of current literature relevant to the management of hereditary MTC.

Body fatness and its distribution are strongly and independently associated with peripheral insulin action. However, these associations are limited in their ability to predict the independent nature of hepatic and peripheral insulin resistance, especially in obese women. To define the relationships more precisely between regional fat distribution and adiponectin, and hepatic and peripheral insulin resistance, we studied 22 obese (43 +/- 0.1%) women who underwent a dual-energy X-ray absorptiometry scan and a computed tomography scan at the L4-L5 level. An octreotide (60 ng x kg(-1) x min(-1)), glucagon (0.65 ng x kg(-1) x min(-1)), and two-step insulin (0.25 mU x kg(-1) x min(-1) and 1.0 mU x kg(-1) x min(-1)) infusion was performed to quantify insulin-mediated suppression of hepatic glucose production (SGP) and insulin-stimulated glucose disposal (ISGD) in a simultaneous fashion. Hepatic glucose production (HGP) was measured using a primed, constant infusion of [6,6(2)H(2)] glucose. Mean plasma insulin increased from 5.6 +/- 0.1 microU/mL at baseline to 15.1 +/- 1.5 microU/mL in the first stage, and to 80.7 +/- 0.5 microU/mL in the second stage. Although there was no significant relationship between visceral adipose tissue (VAT) and basal HGP (r = 0.34, p = 0.117), there was a significant inverse correlation (r = -0.67, p = 0.003) between VAT and SGP. There was a significant correlation (r = 0.55, p = 0.008) between adiponectin and ISGD. In conclusion, these data support: (1) the inability of basal glucose metabolism to accurately reflect hepatic insulin resistance, (2) the deleterious role of VAT in the development of insulin resistance in the liver, and (3) provide additional support for the positive influence of adiponectin against peripheral insulin resistance in obese, postmenopausal women.

Donald Bodenner, Carolyn Redman, Ann RiggsDepartment of Geriatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USAAbstract: Fracture of the hip is frequently a catastrophic event in the elderly, often resulting in death within a year and of the survivors, few regain pre-fracture quality of life. Although less appreciated, fractures of the spine result in significant morbidity and are also associated with increased mortality compared with individuals without a fracture. In recent years there has been an explosion in the development of new drugs for the treatment of osteoporosis. Recombinant human parathyroid hormone (1–34) (20 μg/day) is a recent addition to this armamentarium with a novel mechanism of action, which was approved by the US FDA for the treatment of postmenopausal osteoporosis and male osteoporosis secondary to hypogonadism in November 2002. It is the first osteoporosis treatment that leads to the formation of new bone with architecture similar to normal bone. Intense efforts have been made to understand the effect of teriparatide on antiresorptive therapy and vice versa. Although these relationships are not completely understood, the results of recent studies allow clinicians to begin to optimize therapeutic gains in bone mineral density and improve anti-fracture efficacy.Keywords: osteoporosis, teriparatide, fracture

Megestrol acetate (MA) is a progestin widely used to treat weight loss and cachexia in patients suffering from AIDS or cancer. Although MA is also frequently prescribed for similarly malnourished elderly individuals, the efficacy and morbidity of MA treatment in this patient population remain unclear.The goal of this study was to examine the effects of MA therapy on weight and overall mortality in elderly nursing home residents.This was a case-control cohort study of 17,328 nursing home residents admitted to Beverly Healthcare nursing home between January 1, 2000, and December 31, 2003, who had lost either 5% of total body weight within 3 months or 10% of total body weight within 6 months. Residents within this weight loss group who received MA therapy--within 30 days of their weight loss documentation--were matched (1:2) with non-MA-treated residents with respect to age, sex, race, weight, and first notation of weight loss. Residents were further matched by propensity score for activities of daily living, cognitive functioning, number of medications taken during the 7 days before data entry, clinical condition (unstable, acute episode of a recurrent problem, end-stage disease), cancer diagnosis, and human immunodeficiency virus diagnosis.A total of 709 patients (mean [SD]age, 84.1 [9.7]years; 70.9% female) who received MA therapy were matched with 1418 non-MA-treated patients (mean [SD] age, 84.2 [9.0] years; 70.9% female). Of the 709 MA patients, 281 (39.6%) were alive and in the nursing home at last follow-up, 149 (21.0%) were alive and discharged to another facility or to home, and 279 (39.4%) died in the nursing home. For the controls, 651 (45.9%) were alive and in the nursing home, 308 (21.7%) were discharged to another facility or to home, and 459 (32.4%) died in the nursing home. The median survival of MA-treated residents (23.9 months; 95% CI, 20.2-27.5) was significantly less than untreated residents (31.2 months; 95% CI, 27.8-35.9) (P0.001). Median weight and median of weight differences were unchanged after 6 months of treatment with MA compared with matched controls.MA treatment of elderly nursing home residents with significant weight loss was associated with a significant increase in all-cause mortality without a significant increase in weight. Randomized, prospective studies of the use of MA in elderly nursing home residents are necessary to more fully evaluate morbidity and mortality associated with this therapy.

To evaluate 4-dimensional (4D) computed tomography (CT) for the localization of parathyroid adenomas previously considered nonlocalizing on ultrasound and single-photon emission CT with CT scanning (SPECT-CT). To measure radiation exposure associated with 4D-CT and compared it with SPECT-CT.Case series with chart review.University tertiary hospital.Nineteen adults with primary hyperparathyroidism who underwent preoperative 4D CT from November 2013 through July 2014 after nonlocalizing preoperative ultrasound and technetium-99m SPECT-CT scans. Sensitivity, specificity, predictive values, and accuracy of 4D CT were evaluated.Nineteen patients (16 women and 3 men) were included with a mean age of 66 years (range, 39-80 years). Mean preoperative parathyroid hormone level was 108.5 pg/mL (range, 59.3-220.9 pg/mL), and mean weight of the excised gland was 350 mg (range, 83-797 mg). 4D CT sensitivity and specificity for localization to the patient's correct side of the neck were 84.2% and 81.8%, respectively; accuracy was 82.9%. The sensitivity for localizing adenomas to the correct quadrant was 76.5% and 91.5%, respectively; accuracy was 88.2%. 4D CT radiation exposure was significantly less than the radiation associated with SPECT-CT (13.8 vs 18.4 mSv, P = 0.04).4D CT localizes parathyroid adenomas with relatively high sensitivity and specificity and allows for the localization of some adenomas not observed on other sestamibi-based scans. 4D CT was also associated with less radiation exposure when compared with SPECT-CT based on our study protocol. 4D CT may be considered as first- or second-line imaging for localizing parathyroid adenomas in the setting of primary hyperparathyroidism.

BACKGROUND Lenvatinib is an oral, multitargeted tyrosine kinase inhibitor of the vascular endothelial growth factor receptors 1 through 3 (VEGFR1‐VEGFR3), fibroblast growth factor receptors 1 through 4 (FGFR1‐FGFR4), platelet‐derived growth factor receptor α (PDGFRα), ret proto‐oncogene (RET), and v‐kit Hardy‐Zuckerman 4 feline sarcoma viral oncogene homolog (KIT) signaling networks implicated in tumor angiogenesis. Positive phase 1 results in solid tumors prompted a phase 2 trial in patients with advanced, radioiodine‐refractory, differentiated thyroid cancer (RR‐DTC). METHODS Fifty‐eight patients with RR‐DTC who had disease progression during the previous 12 months received lenvatinib 24 mg once daily in 28‐day cycles until disease progression, unmanageable toxicity, withdrawal, or death. Previous VEGFR‐targeted therapy was permitted. The primary endpoint was the objective response rate (ORR) based on independent imaging review. Secondary endpoints included progression‐free survival (PFS) and safety. Serum levels of 51 circulating cytokines and angiogenic factors also were assessed. RESULTS After ≥14 months of follow‐up, patients had an ORR of 50% (95% confidence interval [CI], 37%‐63%) with only partial responses reported. The median time to response was 3.6 months, the median response duration was 12.7 months, and the median PFS was 12.6 months (95% CI, 9.9‐16.1 months). The ORR for patients who had received previous VEGF therapy (n = 17) was 59% (95% CI, 33%‐82%). Lower baseline levels of angiopoietin‐2 were suggestive of tumor response and longer PFS. Grade 3 and 4 treatment‐emergent adverse events, regardless of their relation to treatment, occurred in 72% of patients and most frequently included weight loss (12%), hypertension (10%), proteinuria (10%), and diarrhea (10%). CONCLUSIONS In patients with and without prior exposure to VEGF therapy, the encouraging response rates, median time to response, and PFS for lenvatinib have prompted further investigation in a phase 3 trial. Cancer 2015;121:2749‐2756. © 2015 American Cancer Society, This phase 2 study demonstrates that lenvatinib produces encouraging objective response and progression‐free survival rates in patients with radioiodine‐refractory, differentiated thyroid cancer and also has a well defined safety profile. Lenvatinib also exhibits activity in patients who previously received vascular endothelial growth factor/vascular endothelial growth factor receptor‐targeted therapies.

Objective The purpose of this study was to determine the cost considerations and strategies for incorporating ultrasound (US) in a head and neck practice. Study design and setting A retrospective chart review of office-based US procedures from 2001 to 2005 was completed at our academic medical center. Billing and coding for US and US guided fine needle aspiration (USFNA) were examined. Results The appropriate CPT codes are 76536 for US and 76942 and 10022 for USFNA-related procedures. The USFNA codes should be used repeatedly for correct coding of biopsies from multiple sites. Cost (equipment) sharing between specialties is a potential strategy for office-based US incorporation. Conclusion Based on practice volume, specific CPT coding, and Medicare reimbursements, office-based US equipment and certification costs could be offset in 1 year. Significance Office-based US can be readily incorporated with significant benefits to patients. Billing and usage strategies were identified that would improve the economics of providing office-based US.

The estrogen receptor (ER) suppresses interleukin-6 (IL-6) gene expression through interaction with nuclear factor kappaB (NF-kappaB) in a hormone-dependent manner. Classic ER binding to DNA is not required and the mechanism of repression is unclear. Previously reported studies suggest that the interference of NF-kappaB binding to DNA by ER may play an important role. An alternative model for repression would be the disruption of NF-kappaB transactivation. In the present study, gel shift assays were used to examine the binding of RelA and p50 dimers to the IL-6 promoter in the presence of ER. The effect of ER on NF-kappaB transactivation was studied independent of NF-kappaB binding to DNA using the mammalian one-hybrid system. ER had little effect on the binding of homodimers or heterodimers of RelA and p50 to the IL-6 promoter. In transfection experiments, both ERalpha and ERbeta inhibited NF-kappaB-mediated expression in a hormone dependent manner with repression also dependent upon dimerization of RelA with p50. Mutant ER that is unable to transactivate failed to repress NF-kappaB expression, but deletion of the N-terminal portion of the receptor had no effect. Taken together, these results suggest that the disruption of NF-kappaB-mediated transactivation plays a significant role in ER inhibition of IL-6 gene expression.

Background The purpose of this study was to demonstrate a role for observation of patients with differentiated thyroid cancer (DTC) with persistent, nonlocalizable disease. Methods Our study was conducted on outpatients seen at our institution from 1999 to 2009 having total thyroidectomy, radioactive iodine (RAI) ablation, measurable serum thyroglobulin (Tg), and no evidence of disease on whole body or positron emission tomography (PET) scans. Results Nineteen patients in our study group aged 20 to 73 with an average follow-up of 5.5 years (range, 2–12 years); all were treated with postoperative RAI (99–210 mCi, average 119). Mean Tg ranged from 0.41 to 4.34. Tg levels remained stable or gradually decreased in all patients. Conclusion After total thyroidectomy and RAI therapy, patients may present with mildly elevated Tg values without localizable disease. These patients may have additional RAI treatments based on the Tg elevation. However, our clinical experience has shown that many of these patients will have Tg levels that either achieve stability or decrease over time without further treatment. © 2013 Wiley Periodicals, Inc. Head Neck 36: 155–157, 2014

Objectives:(1) Present the application of 4-dimensional (4D) computed tomography (CT) in preoperative localization of parathyroid adenomas that do not localize with technetium-99 (Tc-99) single-photon emission computed tomography (SPECT)/CT or ultrasound. (2) Present indications for 4D-CT use. (3) Understand radiologic dosimetry issues of 4D-CT.Methods:A retrospective review of over 15 consecutive patients at an academic medical center with primary hyperparathyroidism who underwent preoperative 4D-CT after nonlocalizing preoperative ultrasound and Tc-99 SPECT-CT scans between November 2013 and June 2014. This was a mixture of patients presenting for their first operations and others requiring revision surgery. Intraoperative radioguided parathyroidectomy results, excised gland weight, patient demographics, and parathyroid hormone levels were recorded. Sensitivity, specificity, and positive and negative predictive values of 4D-CT for preoperative adenoma localization were calculated.Results:4D-CT resulted ...

Objectives:(1) Analyze radiographic findings of thyroidectomy specimens. (2) Correlate intraoperative radiography to preoperative ultrasound and its guided fine-needle aspiration biopsy, intraoperative impression, and final pathology. (3) Describe a new intraoperative tool to help identify malignant characteristics of thyroid tissue.Methods:Prospective study comprised of consecutive patients undergoing hemi- or total thyroidectomy in a tertiary referral center. This is an ongoing study of patients treated from the months of November 2013 to June 2014. After obtaining ultrasound-guided fine needle aspiration biopsies that were indeterminate or confirmed malignancy, all patients received either a hemi- or total thyroidectomy. Prior to pathologic processing, the specimens were passed off the field and underwent intraoperative specimen radiography (IOSR) by the Faxitron Biovision (Tucson, Arizona), generating a plain radiograph. Radiographic characteristics were analyzed by a surgeon and radiologist and corre...

Context Lysine supplementation may have a positive influence on the regulation of glucose metabolism but it has not been tested in the geriatric population. Objective: We evaluated the impact of acute lysine supplementation using three randomized experimental scenarios: 1) oral glucose alone (control), 2) oral glucose and low-dose lysine (2 grams), and oral glucose and high dose lysine (5 grams) lysine in 7 older (66 ± 1 years/age), overweight/obese (BMI = 28 ± 2 kg/m2) individuals. Methods We utilized a dual tracer technique (i.e., [6,6-2H2] glucose primed constant infusion and 1-[13C] glucose oral ingestion) during an oral glucose tolerance test (OGTT) to examine differences in hepatic and peripheral insulin sensitivity under all three scenarios. Results Post-absorptive plasma glucose and insulin concentrations were not different between the three trials. Similarly, the response of glucose and insulin concentrations during the oral glucose tolerance tests (OGTT) was similar in the three trials. The results of the Matsuda index (ISI/M) were also not different between the three trials. As an index of hepatic insulin sensitivity, there were no significant differences in the endogenous glucose rate of appearance (glucose Ra) for control, 2 g lysine and 5 g lysine (1.2 ± 0.1, 1.1 ± 0.1, 1.3 ± 0.1 mg•kg-1•min-1), respectively. With respect to peripheral insulin sensitivity, there were no significant differences in the glucose rate of disappearance (glucose Rd) for control, 2 g lysine and 5 g lysine (4.2 ± 0.1, 4.3 ± 0.2, and 4.5 ± 0.4 mg•kg-1•min-1), respectively. Conclusions Previous studies in younger participants have suggested that lysine may have a beneficial effect on glucose metabolism. However, acute lysine supplementation in the older population does not facilitate beneficial changes in glucose Ra or glucose Rd. Electronic supplementary material The online version of this article (doi:10.1186/1743-7075-11-49) contains supplementary material, which is available to authorized users.

Context: Lysine supplementation may have a positive influence on the regulation of glucose metabolism but it has not been evaluated in older individuals. Objective: We evaluated the impact of acute lysine supplementation using three randomized experimental scenarios: 1) oral glucose alone (control), 2) oral glucose and low-dose lysine (2 g), and oral glucose and high dose lysine (5 g) lysine in 7 older (66±1 years/age), overweight (BMI = 31±2 kg/m2) individuals. Methods: We utilized a dual tracer technique (ie., [1-13C] glucose oral ingestion and [6,6-2H2] glucose infusion) during an oral glucose tolerance test (OGTT) to examine differences in hepatic and peripheral insulin sensitivity under all three scenarios. Results: Plasma glucose and insulin data were not different between the control, 2 g lysine and 5 g of lysine trials. The results of the Matsuda index were also not different between the three trials. As an index of hepatic insulin sensitivity, there were no significant differences in the endogeno...

Introduction. This is an extremely rare case of a patient with metastatic follicular thyroid cancer who continued to produce thyroid hormone and was iodine scan positive without stimulation after thyroidectomy and radioiodine (I-131) therapy.Patient Findings. A 76-year-old Caucasian male was diagnosed with metastatic follicular thyroid carcinoma on lung nodule biopsy. Total thyroidectomy was performed and he was ablated with 160 mCi of I-131 after recombinant human thyrotropin (rhTSH) stimulation. Whole body scan (WBS) after treatment showed uptake in bilateral lungs, right sacrum, and pelvis. The thyroglobulin decreased from 2,063 to 965 four months after treatment but rapidly increased to 2,506 eleven months after I-131. Thyroid stimulating hormone (TSH) remained suppressed and free T4 remained elevated after I-131 therapy without thyroid hormone supplementation. He was treated with an additional 209 mCi with WBS findings positive in lung and pelvis. Despite I-131, new metastatic lesions were noted in the left thyroid bed and large destructive lesion to the first cervical vertebrae four months after the second I-131 dose.Conclusions. This case is exceptional because of its rarity and also due to the dissociation between tumor differentiation and aggressiveness. The metastatic lesions continued to secrete thyroid hormone and remained radioiodine avid with rapid progression after I-131 therapy.

Describe barriers to same-day surgery for patients undergoing total and completion thyroidectomy.Case series with chart review.Academic health sciences center.The subjects were patients who underwent total thyroidectomy or completion thyroidectomy and remained in hospital overnight or longer. A review was performed on patients who were operated on by a single surgeon from July 2005 through June 2013.Two hundred and sixty-eight cases were planned for same-day surgery. One hundred patients were not discharged on the same day (37%). Patients observed overnight or admitted to hospital had significantly lower postoperative calcium levels, 8.4 mg/dL (P.0001), and lower intraoperative parathyroid hormone (PTH), mean 6.0 pg/mL (P.0001). Those significantly more likely to require overnight observation were male patients (P = .0117), black patients (P = .0045), those with completion thyroidectomy (P = .0039), and those with a complication of surgery (P = .003).Intraoperative PTH less than 10 pg/mL was the most frequent factor (25.7%) precluding same-day discharge, followed by admission for social/financial/transportation reasons (22.6%), large dead space from goiter (15.5%), multiple comorbidities (13.4%), multiple surgical reasons (5.2%), airway observation (5.2%), pain management (3.1%), and intractable nausea due to general anesthetic (2.1%). Hypocalcemia and postoperative bleeding still remain obstacles to outpatient thyroid surgery; however, the use of rapid PTH testing, modern hemostatic techniques, appropriate calcium prophylaxis, and experienced clinical decision making can effectively stratify which patients require overnight observation.

Sestamibi Localization of a Parathyroid Adenoma in the Presence of a Thymoma: a Case Report and Review of the Literature Preoperative localization in the surgical management of primary hyperparathyroidism is complicated by widely variable parathyroid gland anatomy, coexisting thyroid pathology, incidence of supernumerary and ectopic parathyroid glands, and limitations of targeted imaging studies. Technetium 99mTcsestamibi scans have decreased accuracy, sensitivity and specificity in the presence of multi-gland parathyroid disease. A number of reports suggest that thymomas, which also show increased sestamibi uptake, are potential sources of false positives on 99mTc-sestamibi scans. Herein, we describe a thymoma in association with a parathyroid adenoma complicating localization of hyperfunctional parathyroid tissue. We review the literature of concurrent pathology between parathyroid adenomas and thymomas paying particular attention to how these cases present on preoperative 99mTcsestamibi scans.

Relationship of Vitamin D Levels in Thyroid Malignancy Vitamin D has been reported in several studies to have antiproliferative, anti-apoptotic and pro-differentiating effects in several tumor types. The role of vitamin D in the incidence and/or progression of thyroid malignancy remain largely unknown. We performed a retrospective chart review of postoperative 25-hydroxyvitamin D levels from 255 subjects receiving total (n=197) or completion (n=58) thyroidectomy for benign (n=190) and malignant (n=65) disease at the University of Arkansas for Medical Sciences between October 2005 and July 2013. No significant difference (P = 0.72) was observed between postoperative 25-hydroxyvitamin D levels in subjects with malignant pathology (median 25 ng/mL; range 21-37 ng/ml) versus benign pathology (median 27 ng/ml; range 19.5-35 ng/ml). In our limited study, there was no correlation between postoperative 25-hydroxyvitamin D status and pathological findings in subjects undergoing thyroidectomy.

Robot-Assisted Mediastinal Parathyroidectomy: Collaboration Between Otolaryngology and Thoracic Surgery There are only a few cases in the literature describing roboticassisted mediastinal parathyroidectomy. Herein, we present the largest cohort of patients (N=7) treated with roboticassisted mediastinal parathyroidectomy. All patients showed biochemical resolution of disease and no major complications were encountered. In our experience, robotic-assisted mediastinal parathyroidectomy is safe and effective in patients with primary hyperparathyroidism when performed in collaboration by experienced and robotically trained thoracic and head and neck surgeons.

Purpose: Lingual thyroid has a reported incidence between 1:10 and 1:100,000. When symptomatic, patients may present with dysphagia, choking, and/or dyspnea. Current surgical treatment options range from tumor extirpation or transposition to excision and reimplantation. Tracheotomies are often performed postoperatively for reliable airway control. Iodine 131 (131I) has not been a popular modality of treatment for lingual thyroid because of theoretical fears of increased airway obstruction from thyroiditis. We believe that these fears were not substantiated, and that symptomatic patients needed a reliable, nonsurgical treatment option. Therefore, our goal was to further investigate the use of 131I for the treatment of symptomatic lingual thyroid. Patients and Methods: A 6-year retrospective chart review was performed. From 1994 to 2000, 2 patients with symptomatic lingual thyroid presented to the Arkansas Cancer Research Center Head and Neck Oncology clinic, University of Arkansas for Medical Sciences, Little Rock, AR. Patients underwent pretreatment computed tomography, and iodine 123 scans. They then received 1 oral dose of 131I. Doses ranged from 30 to 85 mCi. Patients were then followed daily for signs of airway compromise. Results: Complete resolution of symptoms was seen 2 months after treatment. Patients did not complain of any increased airway compromise during treatment initiation. Patients remain symptom-free and are maintained on thyroid hormone replacement. Conclusions: Iodine 131 ablation of lingual thyroid is a safe and effective treatment in symptomatic patients and should be included in the algorithm when formulating a treatment plan. (Am J Otolaryngol 2001;22:276-281. Copyright © 2001 by W.B. Saunders Company)

The relationship of the classical receptors and their transcriptional activity to nongenotropic effects of steroid hormones is unknown. We demonstrate herein a novel paradigm of sex steroid action on osteoblasts, osteocytes, embryonic fibroblasts, and HeLa cells involving activation of a Src/Shc/ERK signaling pathway and attenuating apoptosis. This action is mediated by the ligand binding domain and eliminated by nuclear targeting of the receptor protein; ERα, ERβ, or AR can transmit it with similar efficiency irrespective of whether the ligand is an estrogen or an androgen. This antiapoptotic action can be dissociated from the transcriptional activity of the receptor with synthetic ligands, providing proof of principle for the development of function-specific—as opposed to tissue-selective—and gender-neutral pharmacotherapeutics.

Radio-guided surgery is an established means for surgeons to identify a target of interest for biopsy or excision. This technique is used for a variety of malignancies as well as minimally invasive parathyroid surgery. The primary radionuclide used for these procedures is technetium-99m (Tc-99m), but others have been used. Use of (18)fluorine-fluorodeoxyglucose ((18)F-FDG) in oncology has proliferated. This has created the opportunity to use (18)F-FDG as a potential radio tracer in the operating room. A pilot study of three patients with non-iodine avid thyroid cancers undergoing (18)F-FDG-guided revision thyroid cancer surgery is reported. Radiation exposure to operating room personnel was measured. Radiation exposure to the surgeon and staff members of an operating room is well below the limits of the National Regulatory Commission. Therefore, utilization of this radiopharmaceutical intraoperatively should not be limited in the future because of concern regarding exposure of operating room personnel to radiation.

The proposed mechanisms of RTH are not mutually exclusive. In fact, there is considerable experimental evidence that many if not all of these complex receptor interactions with elements of the transcriptional unit are involved in RTH. Several aspects of RTH remain unclear, in particular on a clinical level. We still do not completely understand the seeming paradox of a tight distribution of receptor mutations and wide variability in phenotypic presentation. The discovery that many of the RTH receptors have defects in corepressor interaction makes it tempting to speculate that the variability in RTH phenotype within kindreds is secondary to differences in corepressor expression. These issues may be better understood as research further proceeds into cofactors and their control of transcription. We also need better tools to determine thyroid status at a peripheral level. Basal metabolic rate, serum measurement of thyroid-responsive gene products, echocardiographic techniques, and other clinical measures have for the most part been unhelpful in determining thyroid status of specific organ systems. Consequently, therapeutic interventions for RTH are directed toward normalizing biochemical indices of thyroid homeostasis, without really knowing whether these efforts correct imbalances within crucial tissues. These studies, and the more widespread investigation of hormone receptor action in general, are moving at a breathtaking pace, and there is a keen interest in applying these principals to understanding the pathophysiologic mechanism of a variety of diseases.

Objectives:Thyroid surgery has traditionally been performed as an inpatient procedure due to the risk of postoperative hematoma and hypocalcaemia, but it is evolving into a safe outpatient procedure in selected patients. However, there is little in the literature about which patients require prolonged observation after planned same day surgery.Methods:A retrospective chart review was performed on patients from 2005 to 2012. We analyzed patients who underwent total thyroidectomy, completion thyroidectomy, or revision total thyroidectomy who were kept overnight or longer at a tertiary care center.Results:Two hundred thirty-one cases qualified and planned for same day surgery. Eighty-six patients were not discharged (37%). Twenty-three of 86 patients were admitted for parathyroid hormone (PTH)

Objectives:Compare the cost of outpatient and inpatient thyroidectomy at US academic medical centers.Methods:Discharge data were collected from the first quarter of 2009 through the fourth quarter of 2012 from the University Health System Consortium (UHC) on over 50,000 patients. The UHC database, compiled from over 100 academic health centers and their 200 affiliated hospitals, was searched based on diagnosis codes for outpatient and inpatient thyroid procedures. The Agency for Healthcare and Research Quality (AHRQ) chronic conditions were collected in addition to demographic, length of stay (LOS), and cost data. Comparisons were made between inpatient and outpatient thyroidectomy stratified by number of chronic conditions.Results:The cost of outpatient thyroidectomy was consistently less than that for inpatient thyroidectomy. More outpatient thyroidectomies were performed on patients with 0 or 1 chronic condition, while more inpatient thyroidectomies were performed on patients with 2 or greater chronic ...

Objectives:Vitamin D deficiency is endemic in the USA. Vitamin D deficiency has been observed in many cohorts of cancer patients and thought to be a possible risk factor. We sought to compare the 25-hydroxyvitamin D levels between a cohort of patients undergoing completion and total thyroidectomy for benign and malignant thyroid diseases.Methods:A retrospective institutional review board (IRB) approved study with chart review was done at a tertiary referral academic medical center. Data were retrospectively collected on consecutive patients who underwent completion and total thyroidectomy at the University of Arkansas for Medical Sciences between October 2005 and December 2012. Postoperative 25-hydroxyvitamin D levels were collected universally and reported when available. Statistical analysis was performed to determine if vitamin D levels varied based on pathology, categorized as either benign or malignant.Results:A total of 220 total and completion thyroidectomies were performed during the study period....