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Preoperative sestamibi-iodine subtraction scanning and neck ultrasonography have been used to locate parathyroid adenomas in patients with hyperparathyroidism, in an effort to improve the outcome and limit the invasiveness of neck surgery Parathyroid imaging is crucial for patients who have had prior neck surgery However, the usefulness of preoperative parathyroid localizing imaging studies for first neck explorations remains controversial Imaging is not useful for the diagnosis of hyperparathyroidism, which must be made by serum calcium and PTH determinations Preoperative scanning does not improve the outcome of initial bilateral neck explorations performed by a surgeon with special expertise in parathyroid surgery Therefore, preoperative imaging has been used mainly to improve the outcome for limited neck exploration, with only modest success See Surgery, below Small benign thyroid nodules are discovered incidentally in nearly 50% of patients with hyperparathyroidism who have imaging with ultrasound or MRI CT and MRI scanning are not ordinarily required or useful for initial preoperative parathyroid localizing studies, since these scanning techniques are less sensitive for identifying tiny parathyroid adenomas However, for repeat neck operations and when ectopic parathyroids are suspected, MRI is preferred since it offers better soft tissue contrast than CT scanning and is less adversely affected by postoperative

The hallmark of primary hyperparathyroidism is hypercalcemia: serum calcium > 105 mg/dL or ionized calcium In hyperproteinemic states, the total serum calcium may be elevated but the ionized fraction is normal, whereas in primary hyperparathyroidism, the ionized calcium is almost always over 54 mg/dL (14 mmol/L) In practice, serum ionized calcium determinations have not proved to be very

public bool QuotientOverTwenty(float dividend, float divisor) { if ( ( divisor != 0 ) && ( dividend / divisor > 20 ) ) { return true; } return false; }

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changes in the neck Three-dimensional technetium-99m sestamibi scanning can also help localize ectopic parathyroid glands Bone radiographs are usually normal and are not required to make the diagnosis of hyperparathyroidism There may be demineralization, subperiosteal resorption of bone (especially in the radial aspects of the fingers), or loss of the lamina dura of the teeth There may be cysts throughout the skeleton, mottling of the skull ( salt-and-pepper appearance ), or pathologic fractures Articular cartilage calcification (chondrocalcinosis) is sometimes found Patients with renal osteodystrophy may have ectopic calcifications around joints or in soft tissue Such patients may exhibit radiographic changes of osteopenia, osteitis fibrosa, or osteosclerosis, alone or in combination Osteosclerosis of the vertebral bodies is known as rugger jersey spine

(PTHrP), which has tertiary structural homologies to PTH and causes bone resorption and hypercalcemia similar to those of PTH The clinical features of the hypercalcemia of cancer can closely simulate hyperparathyroidism Serum phosphate is often low, but the plasma level of PTH by IRMA is low Serum PTHrP may be elevated Multiple myeloma is a common cause of hypercalcemia in the older population Many other hematologic cancers, such as monocytic leukemia, T cell leukemia and lymphoma, and Burkitt s lymphoma, have also been associated with hypercalcemia Multiple myeloma causes renal dysfunction; resultant increased levels of carboxyl terminal PTH may cause it to be confused with hyperparathyroidism if a carboxyl terminal PTH assay is used Serum protein and urine electrophoresis and bone marrow biopsy establish the diagnosis

Pathologic fractures are more common in patients with hyperparathyroidism than in the general population Urinary tract infection due to stone and obstruction may lead to renal failure and uremia If the serum calcium level rises rapidly, clouding of sensorium, renal failure, and rapid precipitation of calcium throughout the soft tissues may occur Peptic ulcer and pancreatitis may be intractable before surgery Insulinomas or gastrinomas may be associated, as well as pituitary tumors (MEN type 1) Pseudogout may complicate hyperparathyroidism both before and after surgical removal of tumors Hypercalcemia during gestation produces neonatal hypocalcemia In secondary hyperparathyroidism due to renal failure, high serum calcium and phosphate levels may cause disseminated calcification in the skin, soft tissues, and arteries (calciphylaxis); this can result in painful ischemic necrosis of skin and gangrene, cardiac arrhythmias, and respiratory failure The actual serum levels of calcium and phosphate have not correlated well with calciphylaxis, but a calcium (mg/dL) phosphate (mg/dL) product over 70 is usually present

In this code, you want to determine whether the quotient is greater than 20, but you must first make sure you are not dividing by zero (division by zero causes the system to throw an exception). With short-circuiting, the second part of the if statement (the division) will never occur if the first part is false (that is, if the divisor is zero).

Macrophages and perhaps other cells present in granulomatous tissue have the ability to synthesize 1,25(OH)2D3 Hypercalcemia has been reported in patients with sarcoidosis, tuberculosis, berylliosis, histoplasmosis, coccidioidomycosis, leprosy, and even foreign-body granuloma Increased intestinal calcium absorption and hypercalciuria are more common than hypercalcemia Serum levels of 1,25(OH)2D3 are elevated In patients with sarcoidosis, serum levels of angiotensin-converting enzyme (ACE) are usually elevated 18FDGPET scanning may localize hypermetabolic foci of active disease Ketoconazole is an antifungal agent that inhibits macrophage 1-hydroxylation of 25-hydroxyvitamin D, thereby improving the hypercalcemia of sarcoidosis and tuberculosis In all conditions, treatment is directed at the underlying disorder

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