1. Journal presentation

2. CLINICAL QUESTION What is the best treatment option for this patient? Search Terms: primary hyperparathyroidism, treatment

3. CRITICAL APPRAISAL Minimally invasive parathyroidectomy without intraoperative parathyroid hormone monitoring in patients with primary hyperparathyroidism R. Mihai1, F. F. Palazzo1, F. V. Gleeson2 and G. P. Sadler1 British Journal of Surgery 2007; 94: 42–47 Copyright 2006 British Journal of Surgery Society Ltd Published by JohnWiley & Sons Ltd

4. RELEVANCE Is the objective of the article comparing therapeutic interventions similar to your clinical dilemma? Patients Characteristics in the actual case Patient’s Characteristics in the article Population20 year old with primary hyperparathyroidism all patients with a biochemical diagnosis of primary Hyperparathyroidism

5. INTERVENTION Minimally invasive parathyroidectomy (MIP) without intraoperative parathyroid hormone monitoring

6. OUTCOME  Sestamibi scan showed unilateral uptake in 182 patients and a single parathyroid adenoma was confirmed on ultrasonography in 161 patients. MIP was performed in 150 patients. The mean duration of operation was 25 (range 8–65) min. Four patients needed conversion to conventional neck exploration. There was one postoperative hematoma and three cases of temporary recurrent laryngeal nerve neuropraxia.  No patient developed recurrent HPT after a median follow-up of 16 (range 3–48) months.

7. OUTCOME The outcome of MIP without ioPTH monitoring was comparable to that reported in series that used ioPTH monitoring.

8. VALIDITY GUIDES Was the assignment of patients to treatment randomized?

9. VALIDITY GUIDES  Were all patients who entered the trial properly accounted for and attributed at its conclusion?  Was follow-up complete? Yes  All patients were seen in the outpatient clinic 4–6 weeks after surgery, and assessed for symptoms and complications along with a review of the histological findings. A further follow-up appointment was organized at 6–12 months.

10. VALIDITY GUIDES Were the patients analyzed in the groups to which they were randomized? Yes – Statistical comparison of biochemical variables between subgroups of patients was done using an unpaired Student’s t test. Proportions were compared using the χ2 test. For all tests P < 0·050 was considered significant.

11. VALIDITY GUIDES Were patients, their clinicians, and study personnel “blind” to treatment? There was no mention of blinding in the article

12. VALIDITY GUIDES Were the groups similar at the start of the trial?

13. VALIDITY GUIDES OVERALL, IS THE STUDY VALID? Almost all of the validity criteria were met. However, the question whether blinding was done was not clearly stated in the article.

14. RESULTS How large was the treatment effect? OUTCOME AT THE END OF TREATMENT The outcome of MIP without ioPTH monitoring was comparable to that reported in series that used ioPTH monitoring.

15. RESULTS CAN THE RESULT HELP ME IN CARING FOR MY PATIENTS?  Can the results be applied to my patient care? Yes. The patient presented with signs, symptoms and biochemical evidence of hyperparathyroidism. Omitting ioPTH monitoring offers financial advantages related to the cost of the equipment and PTH assays.

16. RESULTS Were all clinically important outcomes considered? Yes.

17. RESULTS Are the likely treatment benefits worth the potential harm and costs? – Yes

18. RESOLUTION OF THE PROBLEM  Omitting ioPTH monitoring in a selected group of patients offers financial advantages related to the cost of the equipment and PTH assays. Furthermore, the operation is finished as soon as the adenoma is excised without having to wait for the blood samples to be drawn 10 and 30 min after excision of the parathyroid adenoma. This can increase the throughput of patients during one operating session.

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