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Dr. Andrew Rynne

Family Physician

Exp 50 years

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Suggest treatment for chronic muscular weakness

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Dr. Mirjeta Guni

Endocrinologist

Practicing since :2006

Answered : 2046 Questions

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Posted on Mon, 6 Mar 2017 in Thyroid Problem and Hormonal Problems
Question: I am a 56 year old female medical doctor. I have been suffering from Muscular weakness for the past 4 to 5years. Investigations for Myopathies and Mgravis are negative. Incidentally serum calcium level is elevated (10.2 mg percent).

The following are also raised
1. Serum Ionised Calcium
2. Urine Calcium
3. PTH
4. Mildly increased serum creatine (1.2 mg percent)

GFR indicated mild to moderate kidney failure. A 0.5 cm right kidney stone is also identified.
Two Sestamivi scans - Negative
CT scan neck - No mass effect
Ultrsound Neck - Mildly nodular right thyroid lobe (history of hashimoto's)
CT scan chest - No masses, No Thymoma
Frequent missed beats in the heart (PVC) present
Holter monitor twice - PVC present - Within normal limits
All other systems normal.

My Questions

1. Do I need surgery? if so, when?
a. Immediate, b. Somewhere in the near future
2. Minimally invasive 15 min para thyroid surgery?
3. How do they locate abnormal para thyroid when the scans are negative?


An early reply is appreciated.
doctor
Answered by Dr. Mirjeta Guni 2 hours later
Brief Answer:
About hyperparathyroidism:

Detailed Answer:
Hello and thank you for asking!
I have gone carefully through your concern.
The symptoms and biochemical results are indicative for a primary hyperparathyroidism, that is not found in sestambi (it may happen).
You also fulfill the indications for surgery, because you have clinical symptoms of hypercalcemia (muscle weakness) , renal stone, impaired renal function and you should do an evaluation for osteoporosis).
I would suggest not to wait.
When the scans are negative, there is a technique to localize the adenoma or hyperplasic glands, by injecting Blue Methylen, that is considered as a XXXXXXX absorbed by the parathyroid glands making them visible during intervention.
As you have a nodular thyroid goiter too, i would recommend an open surgery and to remove the thyroid lobe that contains nodule at the same time.

Hope i have answered your queries.

best wishes,
Dr.Mirjeta

Above answer was peer-reviewed by : Dr. Remy Koshy
doctor
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Follow up: Dr. Mirjeta Guni 21 hours later
1.Pl let me know about the following

Surgical procedure if the sesatamibi scan is negative
( methylene blue procedure)
2. How much time it takes for that kind of surgery

3. Do they send the parathyroids to the pathologist for frozen section? Intraoperatively?
4. What is the probe method where they detect the activity of abnormal parathyroids intraoperatively? XXXXXXX parathydoiectomy?
Pl answer point wise

And also let me know
Which procedure is the best in your opinion

Thanks
doctor
Answered by Dr. Mirjeta Guni 11 hours later
Brief Answer:
About parathyroid intervention;

Detailed Answer:
Welcome back!

Firstly, let me explain that the procedure and the time of intervention depends totally on the surgeon's experience.

An expert in this field can perform the same mini-parathyroid operation on all people, and those with a negative scan have the same mini-operation that takes the same amount of time as those people with a positive scan (may last 15-30 min).

The XXXXXXX parathyroid operation is dependent on the skill of the surgeons, not the accuracy of the scan. Patients with negative scans and positive scans should have the exact same operation. Even if an adenoma is found in sestamibi, the fourth glands should be evaluated, that is why the time of interventuon is the same.

During the intervention you can expect to have all four of your parathyroid glands examined to see-
-1) how big they are, and

2) how much hormone they are making. There are intra-operative probes that measure the hormone secretion by each gland, deciding which one is responsible for overproduction and of course it is removed.

All four parathyroid glands can be examined for their anatomy and hormone production through a very small incision (1.5-2 inch).

In other centers, older methods ( such as methylene blue coloring) are used.
So, it is very important to get operated in specialized centers for parathyroid surgery.

Hope i have answered your queries.
Best wishes,
Dr.Mirjeta


Above answer was peer-reviewed by : Dr. Arnab Banerjee
doctor
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Follow up: Dr. Mirjeta Guni 34 hours later
Will the glands be sent for intraoperative consultation to the pathologists anyway?
doctor
Answered by Dr. Mirjeta Guni 56 minutes later
Brief Answer:
It is suggested to be done.

Detailed Answer:
Yes, Both the function and the anatomopathological evaluation is suggested intraoperatorly.
Best wishes,
Dr.Mirjeta
Above answer was peer-reviewed by : Dr. Remy Koshy
doctor
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Follow up: Dr. Mirjeta Guni 10 hours later
Thank you for your patient answers
There is a website parathyroid.com
Managed by a group of expert parathyroid surgeons and dr. XXXXXXX

I came to know he does the XXXXXXX surgery
And do not send the glands for frozen sections

Could you let me know your opinion on his surgery video on the website?

Thanks
doctor
Answered by Dr. Mirjeta Guni 6 minutes later
Brief Answer:
Excellent surgeon!

Detailed Answer:
He is the best in my opinion, has done 20 000 cases and i do not know any surgeon who has more experience than him.

So, if you can reach him, you should follow his instructions without hesitations.

Regards,
Dr.Mirjeta


Above answer was peer-reviewed by : Dr. Arnab Banerjee
doctor
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Follow up: Dr. Mirjeta Guni 2 days later
I've been prescribed calcimimetic drug for the past 10 days

Now my calcium level dropped from 10.2 to 8.4 mg
Pl. let me know your opinion on following
1. How long can I use it
2. Will it reverse my symptoms and osteoporosis slowly?
3. Can I start taking calcium supplements now to prevent bone loss

4. Can surgery be avoided ?
doctor
Answered by Dr. Mirjeta Guni 11 hours later
Brief Answer:
About cinacalcet efficiency in hyperparathyroidism:

Detailed Answer:
There are some studies that compare the efficacy of treatment of calcimimetic versus surgery:
-Calcium levels normalized in 70.6% of medically versus 100% of surgically treated patients .
-PTH levels normalized in 35% of patients treated with calcimimetics versus 76% of surgical patients .
- Femur BMD improved in 18.8% of medically treated patients versus 58.8% of surgical patients.
-Spine BMD improved in 70.6% of medically treated patients versus 82.4% of surgical patients .
Further analysis demonstrated that regardless of treatment, normalization of PTH was associated with significant improvement in femur and spine BMD . Normalization of calcium without normalization of PTH did not impact BMD.
Regarding to the period of treatmen, usually it is long term (if surgery will not be performed) but it will depend on urinary calcium levels, because cinacalcet may increase the risk for nefrolithiazis. In these cases, the treatment is discontinued.
Regards,
Dr.Mirjeta

Above answer was peer-reviewed by : Dr. Prasad
doctor
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Follow up: Dr. Mirjeta Guni 28 hours later
I see that you advised surgery for me in the answer to my original question

1. Do u not believe in cinacalcet?
2. Do u know about dr XXXXXXX before I mentioned him?

Thanks
doctor
Answered by Dr. Mirjeta Guni 13 hours later
Brief Answer:
I would prefer surgical remove:

Detailed Answer:
Hello again,
1-Cinacalcet usually is suggested when the surgical removal is impossible, so is a second line of treatment, due to the above mentioned results compared to surgery.
2-I knew dr XXXXXXX before, he is a well-known professor in parathyroid surgery worldwide.
Here is a publication of him, regarding to cinacalcet treatment.
https://www.ncbi.nlm.nih.gov/pubmed/0000

Regards,
Dr.Mirjeta
Above answer was peer-reviewed by : Dr. Kampana
doctor
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