FRCPath mock examination 2014

Viva

Scientist answer

A neighbouring hospital has introduced intra-operative PTH measurements for

patients undergoing parathyroidectomy. The endocrine surgeon at your hospital has
already got the funding approved for the instrumentation and personnel.

This has not been discussed with you as Head of the Department

1. Why is intra operative PTH required?

Monitoring PTH levels during surgery for sporadic primary hyperparathyroidism

provides assurance that all hyper functioning parathyroid tissue has been adequately
excised and the surgical procedure can be concluded.
Compared with the traditional approach of a bilateral neck exploration to exclude
multiglandular disease, intraoperative PTH monitoring allows a more focused, less
invasive approach to parathyroid exploration without requiring direct visualization of
every gland.
Focused parathyroidectomy guided by intraoperative PTH monitoring minimizes neck
dissection, prevents injury or excision of normally functioning glands, identifies
multiple gland disease, and, with few exceptions, assures complete excision of all
hypersecreting glands prior to leaving the operating room and predict postoperative
calcium levels.

2. How would you approach this problem?

Candidates must show awareness that lab has to be involved and show leadership
and diplomacy dealing with various stakeholders involved with this POCT.

3. What clinical and analytical considerations are essential to bear in mind?

Intraoperative PTH monitoring takes advantage of the short half-life (three to five
minutes) of PTH and utilizes a rapid immunochemiluminescence assay technique
that allows measurements while the patient is still in the operating room . The
assay can be completed with a turnaround time of 8 to 20 minutes. Intraoperative
rapid PTH assays measure the circulating amount of hormone at the time and from
the location where the sample is obtained.
Analytical considerations with include instrumentation, maintenainence, QC,
EQA, reference ranges, compatibility with laboratory PTH, units of measurement,
Break down back up, Personnel running it, training, SOP’s & governance

4. The Lab is struggling with staffing recruitment and retention. How will
you manage the added pressure and demands that intaroperative PTH
measurements are likely to bring?

Candidates must me able to understand the added pressure and be aware of the
demand on the laboratory in terms of time & personnel.