Sabapathy Prakash Balasubramanian

Purpose Thyroid nodules are rare in children but have a higher malignancy rate compared to adults. Risk factors and predictors of thyroid cancer in children with thyroid nodules are not well-characterised. This systematic review aims to evaluate risk factors and predictors of malignancy in paediatric thyroid nodules. Methods PubMed, Embase and Cochrane databases were searched up to 6th April 2026. A quality assessment of the included articles was performed, along with a meta-analysis using the random-effects model. Results Sixteen studies met the inclusion criteria, comprising 2,634 patients (794 malignant and 1,840 benign cases). Papillary thyroid cancer represented the majority of cancers (84.5%). Variables that were significantly associated with thyroid cancer in the meta-analysis were as follows: previous radiation exposure, odds ratio (OR) 1.96 [95% CI 1.15, 3.34]; palpable lymphadenopathy, OR 7.73 [95% CI 3.03, 19.75]; intranodal calcifications, OR 10.33 [95% CI 3.20, 33.37]; increased vascularity, OR 3.21 [95% CI 1.95, 5.28]; and elevated thyroid stimulating hormone levels, mean difference + 0.92 mIU/L [95% CI 0.50, 1.35]. Quality assessment using the Newcastle-Ottawa Scale, with a majority of studies scoring ≥ 7 stars. Conclusion The identification of predictors of thyroid cancer in children with thyroid nodules will inform the development and evaluation of models with a view to improving preoperative diagnosis.

Purpose: Accurate localisation of hyperfunctioning parathyroid glands is crucial for successful parathyroid surgery. In patients with inconclusive imaging, intraoperative bilateral internal jugular venous sampling (BIJVS) has been reported; but its utility remains unclear. The purpose of the review is to evaluate published techniques and reported effectiveness of BIJVS in parathyroid surgery. Methods: PubMed, Ovid and Cochrane databases were searched for articles on intraoperative BIJVS in parathyroid surgery. All original English language human studies reporting on lateralisation rates, diagnostic accuracy or cure rates following use of intraoperative BIJVS were included. Exclusion criteria included case reports, reviews, IJV sampling in non-parathyroid pathology and IJV sampling for confirming cure. Data on patient numbers, definitions used for lateralisation and correlation with clinical outcomes were extracted by one reviewer and cross-checked by a second reviewer. The review was prospectively registered on the Open Science Framework (OSF; DOI: https://doi.org/10.17605/OSF.IO/TSQA6 ). Results: Of 753 screened, 12 studies including 502 patients where BIJVS was performed were included. Lateralisation definitions were reported in 7 studies. Among studies with relevant data, lateralisation gradient was defined as ranging from 5 to 20% and lateralisation rates varied from 51 to 100%. The positive and negative predictive values ranged from 76 to 100% (6 studies) and 0–53% respectively (3 studies). Reported cure rates following BIJVS guided surgery were high (> 98%), but the definition for cure was only reported in 8 studies. Conclusions: BIJVS can aid localisation in parathyroid surgery. A significant lateralisation gradient may permit unilateral surgery, but a lack of gradient does not imply bilateral disease. However, the absence of a standard definition for lateralisation and inconsistent reporting limits widespread adoption of this technique.

Introduction: Surgery is a complex intervention, so it is important to establish standards for both the standard and ‘novel’ procedures in randomized controlled trials (RCTs) that demonstrate that interventions are delivered as intended to fully understand and explain trial results. This study set out to identify and agree the key steps of a surgical intervention to be tested in the ‘near infrared fluorescent imaging in thyroid surgery’ (NIFTy) RCT to inform development of the surgical protocol, and trial materials. Method: Qualitative case studies of surgeries were undertaken prior to undertaking an RCT to evaluate the potential of a device to reduce post-surgical hypoparathyroidism. Each case study involved non-participant observation, video capture of total and completion thyroidectomies, and interviews with surgeons. A typology of operative steps was constructed. Two surveys were undertaken (1) to identify current practice around parathyroid identification; and (2) to determine surgeon views on the surgical steps. An international expert panel of six clinicians met to review findings and agree on the surgical steps (mandatory/optional) for operations in the RCT, including timing for use of fluorescence and the data items to be collected. Results: Ten case studies were undertaken. Video, observation and interview data found differences in surgical approach were driven only by pathology. A typology detailing the surgical steps and points where imaging could be used was developed. Sixty-four surgeons responded to survey 1; three-quarters always looked for parathyroid glands when operating. Forty surgeons responded to survey 2; capsular dissection of the thyroid lobe, preservation of parathyroid pedicle, and clinical assessment were important for parathyroid preservation. The expert panel agreed the key surgical components. These informed key data collection in NIFTy. Two specific surgical steps were strongly recommended and three mandated. Conclusion: Qualitative research in the operating theatre, prior to RCT allowed the identification of key components of the surgical intervention. The surveys and expert panel provided certainty about the acceptability of the surgical protocol and identified the core data to collect to evidence surgical decision making prior to embarking on the RCT. This qualitative process achieved clinical buy-in, improved trial conduct and allowed full explanation of the subsequent trial results. Trial registration: ISRCTN59074092. Registration date: 07/03/2022.

Background: In patients with hypercalcaemia, assessment of urinary calcium excretion helps differentiate primary hyperparathyroidism (PHPT) from familial hypocalciuric hypercalcaemia (FHH). For this, 24 h calcium to creatinine clearance ratio (CCCR) is recommended, but others tests like random CCCR, 24 h urine calcium excretion (UCE), and calcium to creatinine ratio (CR) are also frequently used.Objective: The survey objective was to evaluate current practice among UK endocrinologists and surgeons.Methods: A web‐based anonymous cross‐sectional survey, consisting of eight multiple‐choice questions was developed using Survey Monkey. The survey was disseminated to members of British Association of Endocrine and Thyroid Surgeons (BAETS) and Society for Endocrinology (SfE) between November 20, 2025 and December 19, 2024.Results: Two hundred and sixty‐six responses from 210 endocrinologists and 56 surgeons were received (85% consultants). Respondents worked in both university (48.9%) and district hospitals (47.7%). The most commonly performed urine calcium test in hypercalcaemic patients was 24 h UCE (58.6%), but for PHPT versus FHH differentiation, the most preferred test was 24 h CCCR (43.6%), followed by random CCCR (24.8%), 24 h UCE (14.3%), and CR (16.5%). Of respondents who had experience with using CCCR (n = 235), most (55.6%) used a cut‐off of > 0.01 to rule out FHH, while > 0.02 cut off was used by 26.7% respondents. Most clinicians (70.3%) used albumin‐adjusted calcium for CCCR calculation, and 71.4% respondents considered vitamin D levels ≥ 50 nmol/L to be adequate for urinary calcium measurement.Conclusion: The survey provides valuable insight into current UK practice. 24 h and random CCCR are the most commonly used tests to exclude FHH, but overall, practice varies widely.

Introduction: Postsurgical hypoparathyroidism (PoSH) is an iatrogenic condition that occurs as a complication of several different procedures with thyroid surgery being the most common. PoSH has significant short- and long-term morbidities. The volume of thyroid surgery is increasing, and PoSH is therefore likely to increase. Some studies have shown promising results using near-infrared fluorescence (NIRF) imaging in reducing the risk of PoSH which has the potential to significantly reduce morbidity and costs associated with monitoring and treatment. Methods and analysis: NIFTy is an unblinded, parallel group, multicentre, seamless phase II/III randomised controlled trial in patients undergoing total or completion thyroidectomy. The trial incorporates a process evaluation (IDEAL (Idea, Development, Exploration, Assessment and Long-term follow-up framework) 2a) to inform the trial protocol, a phase II (IDEAL 2b) analysis using a surrogate primary outcome of 1 day transient hypocalcaemia to determine early futility and phase III (IDEAL 3) assessment of the primary outcome of PoSH at 6 months after surgery. 454 participants will be randomised on a 1:1 basis to evaluate thyroid surgery with NIRF and indocyanine green against standard thyroid surgery in reducing PoSH at 6 months after surgery, with the phase II analysis occurring once data are available for 200 participants. Analysis in both phases will be using multilevel logistic regression incorporating random effects with respect to surgeon and adjusting for minimisation factors. Phase III secondary outcomes include protracted hypoparathyroidism, hypercalcaemia, complications, length of stay, readmissions and patient reported quality of life using the Short Form 36 Health Survey Questionnaire and Hypoparathyroid Patient Questionnaire instruments. Ethics and dissemination: NIFTy is funded by National Institute for Health and Care Research Efficacy and Mechanism Evaluation Programme (Grant Ref: 17/11/27) and approved by a Research Ethics Committee (reference: 21/WA/0375) and Health Research Authority (HRA). Trial results will be disseminated through conference presentations, peer-reviewed publication and through relevant patient groups. Trial registration number: NCT59074092 .

Dear Editor

Electrical impedance spectroscopy (EIS) has been proposed as a promising noninvasive method to differentiate healthy thyroid from parathyroid tissues during thyroidectomy. However, previously reported similarities in the in vivo measured spectra of these tissues during a pilot study suggest that this separation may not be straightforward. We utilise computational modelling as a method to elucidate the distinguishing characteristics in the EIS signal and explore the features of the tissue that contribute to the observed electrical behaviour. Firstly, multiscale finite element models (or ‘virtual tissue constructs’) of thyroid and parathyroid tissues were developed and verified against in vivo tissue measurements. A global sensitivity analysis was performed to investigate the impact of physiological micro-, meso- and macroscale tissue morphological features of both tissue types on the computed macroscale EIS spectra and explore the separability of the two tissue types. Our results suggest that the presence of a surface fascia layer could obstruct tissue differentiation, but an analysis of the separability of simulated spectra without the surface fascia layer suggests that differentiation of the two tissue types should be possible if this layer is completely removed by the surgeon. Comprehensive in vivo measurements are required to fully determine the potential for EIS as a method in distinguishing between thyroid and parathyroid tissues.

There is wide variability in the perioperative management of phaeochromocytoma and paraganglioma (PPGL) in different centres. This study aimed to summarise the management of PPGLs as reported in the United Kingdom Registry for Endocrine and Thyroid Surgery (UKRETS) database and to determine current perioperative management of PPGLs by surveying UK clinicians. Data recorded on UKRETS from 2005 to 2021 were subjected to descriptive analyses. British Association of Endocrine and Thyroid Surgeons members were invited to participate in an open survey relating to the perioperative management of patients with PPGLs. A total of 2,007 operations for PPGL from 49 participating centres were included. The median annual workload in each centre was four cases. Operations were performed predominantly laparoscopically (69%). The median length of stay (4 days) was the same in groups of surgeons stratified by volume. The survey had 29 respondents from 22 centres across the UK, and a formal protocol for perioperative management exists in 48% of the centres. Phenoxybenzamine (72%) was preferred for alpha-blockade. The practice of admitting patients for optimisation from 1 to 7 days before the day of surgery was common (62%). Central venous pressure and blood glucose monitoring were mentioned as routine intraoperative adjuncts by 72% of the responders. There is significant variation in the workload and perioperative management of PPGLs in the UK. This is potentially detrimental to patient outcomes and a consensus document might be beneficial to harmonise practice across the UK.

Background: There is a surgeon volume–outcome effect in adrenal surgery but the threshold for high-volume surgeon remains controversial. This study aimed to determine predictors of high-risk adrenal operations and to explore whether these should be restricted to high-volume surgeons. Methods: Patients undergoing adrenal surgery and registered in the United Kingdom Registry of Endocrine and Thyroid Surgery between 2004 and 2021 were analysed. Outcomes included postoperative complications, duration of hospital stay, and mortality. Factors included in multivariable analysis were age, sex, diagnosis, surgical approach, laterality, and surgeon volume. Patients with missing data were excluded. Results: A total of 4464 of 6174 patients (72.3%) were analysed. Postoperative complications occurred in 418 patients (9.4%) and 14 (0.3%) died. Median duration of hospital stay was 3 (i.q.r. 2–5) days. Co-variables significantly associated with an increase or decrease in postoperative complications (P < 0.050) were age (OR 1.02, 95% c.i. 1.01 to 1.03), adrenal cancer (OR 1.64, 1.14 to 2.36), minimally invasive approach (OR 0.317, 0.248 to 0.405), bilateral surgery (OR 1.66, 1.03 to 2.69), and surgeon volume (OR 0.98, 0.96 to 0.99). An increase or decrease in mortality was associated with patient age (OR 1.08, 1.03 to 1.13), minimally invasive approach (OR 0.08, 0.02 to 0.27), and bilateral surgery (OR 6.93, 1.40 to 34.34). The incidence of postoperative complications was significantly lower above a threshold of 12 operations per year (P = 0.034) and 20 per year (P < 0.001), but not six per year (P = 0.540). Median duration of hospital stay was 2 days for surgeons doing over 20 operations per year, compared with 3 days for those undertaking fewer than 20, fewer than 12 or fewer than 6 operations per year. Conclusion: Increasing surgical volume is associated with shorter hospital stay and fewer complications. This analysis supports the case for centralization of surgery for adrenal cancer and bilateral tumours to higher-volume surgeons performing a minimum of 12 operations per year.