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'Students Will Get More Time To Choose Right Career'
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Expect notice boards with messages such as 'Firm up your mind before the selfie becomes your last frame' will come up at tourist destinations in the state soon, with a note of caution below stating that 'responsibility of any untoward incident lies with the tourists in the selfie'.
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The situation at the State Wakf Boards in India reminds one of the neglected graveyards.
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- Special aptitude test for Maharashtra state board students soon
Over 15 lakh state board students will appear for first-of-its-kind aptitude test to be introduced from the current academic year to enable them to make effective career choices ahead.
- Special aptitude test for Maharashtra state board students soon
Over 15 lakh state board students will appear for first-of-its-kind aptitude test to be introduced from the current academic year to enable them to make effective career choices ahead.
- Maharashtra state board announces timetable for Class X and XII
Almost two months late, the Maharashtra State Board of Secondary and Higher Secondary Education (MSBSHSE) on Thursday announced the timetable for the Secondary School Certificate (SSC, class X) and Higher Secondary Certificate (HSC, class XII) to be held in 2016.
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Clearing the air over the minimum percentage required to pass the theory papers in board exams, the Maharashtra State Board of Secondary and Higher Secondary Education has issued a circular stating that the proposal will not be implemented this academic year
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Check Maharashtra Board Class 12 result 2016 at The Times of India. Register on TOI to get Maharashtra Board class 12 result 2016 on your mobile and email.
- NEET breather for state board students
The decision on deferring National Eligibility-cum-Entrance Test for admission to government medical and dental colleges brought relief and some confusion in its wake. The Union Cabinet on Friday decided to approve the promulgation of an ordinance that will keep state boards out of NEET's ambit this year.
- State boards to be out of NEET this year
NEW DELHI: The central government on Friday decided to bring an ordinance to keep state boards out of the ambit of the National Eligibility-cum-Entrance Test (NEET) this year. However, students seeking admission to private medical colleges and deemed universities will have to take the exam, sources said. "The Union Cabinet has approved the ordinance. It will be sent to the President for approval," a top health ministry official told TOI. Health minister J P Nadda said the government was not against NEET. "NEET has been implemented and it is in existence. First phase is over and the second phase of the exam will be held on July 24. Some states have raised certain issues and we are looking into it. A detailed clarification will be issued on Saturday," he told reporters. Sources said the ordinance was aimed at 'partially' overturning a Supreme Court verdict which said all government colleges, deemed universities and private medical colleges would be covered under NEET. Once the ordinance is notified, students of state government boards will not have to sit for the exam on July 24. They, however, will have to become part of the uniform entrance exam from the next academic session, government sources said. "In the all-party meeting held recently, Congress's Jairam Ramesh also favoured addressing the concerns raised by the states," Nadda said. Sources said states, including Maharashtra, flagged various issues including problems related to language and syllabus for students. "They said the students affiliated to state boards will find it tough to appear for the uniform test as early as July and such students will be at a loss compared to those who have followed the central board," a source said. Delhi CM Arvind Kejriwal, meanwhile, opposed the government move. He tweeted a letter he wrote to the PM urging not to bring an ordinance. "It would send the message that the government is with those who have black or untaxed money." The SC had on May 9 rejected pleas of states and minority institutions to allow them to hold separate entrance exams for MBBS and BDS courses for 2016-17, saying only NEET provides for conducting such test for admission to these courses.
- Maharashtra State Board of Secondary and Higher Secondary Education includes revised maps in textbooks
The Maharashtra State Board of Secondary and Higher Secondary Education (MSBSHSE) has incorporated revised maps of India and Maharashtra in textbooks, taking note of the formation of the state of Telangana and Palghar district.
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Jharkhand Investment Promotion Board (JIPB), will meet for the first time in Mumbai on Friday to chalk out investment roadmap for the state.
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The state government has decided to prepare development plan for every gram panchayat in Maharashtra.
- Cops bust Maharashtra board exam racket
Maharashtra police on Friday night busted an exam paper racket that rewrote and replaced the answer sheets of Maharashtra Board HSC (class 12) candidates who bought its services.


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The scaling behavior of current drive enhancements in strained-silicon NFETs on SiGe-on-insulator (SGOI) is reported. SGOI NFET enhancement exhibits only moderate channel length dependence down to sub-50 nm regime, indicating strain-induced enhancement can be sustained in future technology nodes. This is contrary to some previous reports which suggested dramatic reduction of strain-induced NFET current enhancement with channel length scaling. A novel analysis technique was developed to account for the difference in self-heating in SGOI and SOI devices to enable intrinsic device performance comparison. Additive effects of biaxial strain from the Si/SiGe heterostructure and process-induced uniaxial stress are experimentally demonstrated for the first time.
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- Author: Lawrence Kim, MD; Chief Editor: Romesh Khardori, MD, PhD, FACP more...
Through their secretion of parathyroid hormone (PTH), the parathyroid glands are primarily responsible for maintaining extracellular calcium concentrations. Hyperparathyroidism is a disease characterized by excessive secretion of parathyroid hormone, an 84–amino acid polypeptide hormone. The secretion of parathyroid hormone is regulated directly by the plasma concentration of ionized calcium. See the image below.
The main effects of parathyroid hormone are to increase the concentration of plasma calcium by increasing the release of calcium and phosphate from bone matrix, increasing calcium reabsorption by the kidney, and increasing renal production of 1,25-dihydroxyvitamin D-3 (calcitriol), which increases intestinal absorption of calcium. Thus, overproduction of parathyroid hormone results in elevated levels of plasma calcium. Parathyroid hormone also causes phosphaturia, thereby decreasing serum phosphate levels. Hyperparathyroidism is usually subdivided into primary, secondary, and tertiary hyperparathyroidism.
Anatomy and Embryology
Usually, 4 parathyroid glands are situated posterior to the thyroid gland. A small number of patients have 3, 5, or, occasionally, more glands. The glands are identified based on their location as right or left and superior or inferior.
The inferior glands are derived from the third pharyngeal pouch. This structure is also the embryologic origin of the thymus. Therefore, the inferior glands originate more cephalad than the superior glands, but they migrate along with the thymus to finally become situated more inferiorly than the superior glands. Because of their embryologic association with the thymus, the inferior glands are often found adjacent to or within the thymus. They are usually located near the inferior pole of the thyroid.
The superior glands are more consistent in location, usually found just superior to the intersection of the inferior thyroid artery and the recurrent laryngeal nerve. The superior glands are derived embryologically from the fourth pharyngeal pouch. This structure also gives rise to the C cells of the thyroid gland. Because of their embryologic origin, the superior glands are occasionally found within the substance of the thyroid gland. Ectopic locations of parathyroid glands are discussed in more detail in Surgical care in Primary Hyperparathyroidism.
Primary Hyperparathyroidism
Definition of problem
Primary hyperparathyroidism is the unregulated overproduction of parathyroid hormone (PTH) resulting in abnormal calcium homeostasis.
US population-based data from Olmsted County, Minn, indicate that the prevalence of primary hyperparathyroidism is slowly decreasing.[1] The prevalence has been reported to be approximately 21 cases per 100,000 person-years. The mean age at diagnosis has remained between 52 and 56 years, and women have consistently made up the majority of cases (with a female-to-male ratio of 3:1).
In approximately 85% of cases, primary hyperparathyroidism is caused by a single adenoma. In 15% of cases, multiple glands are involved (ie, either multiple adenomas or hyperplasia).[2] Rarely, primary hyperparathyroidism is caused by parathyroid carcinoma. The etiology of adenomas or hyperplasia remains unknown in most cases. Familial cases can occur either as part of the multiple endocrine neoplasia syndromes (MEN 1 or MEN 2a), hyperparathyroid-jaw tumor (HPT-JT) syndrome, or familial isolated hyperparathyroidism (FIHPT). Familial hypocalciuric hypercalcemia and neonatal severe hyperparathyroidism also belong to this category. The molecular genetic basis of MEN 1 is an inactivating mutation of the MEN1 gene, located on chromosome band 11q13. MEN 2a is caused by a germline mutation of the Ret proto-oncogene on chromosome 10.[3] Germline mutation of HRPT2 localized on chromosome arm 1q is responsible for HPT-JT, while FIHPT is genetically heterogeneous.
In primary hyperparathyroidism due to adenomas, the normal feedback on parathyroid hormone production by extracellular calcium seems to be lost, resulting in a change in the set point. However, this is not the case in primary hyperparathyroidism from parathyroid hyperplasia. An increase in the cell numbers is probably the cause.
The chronic excessive resorption of calcium from bone caused by excessive parathyroid hormone can result in osteopenia. In severe cases, this may result in osteitis fibrosa cystica, which is characterized by subperiosteal resorption of the distal phalanges, tapering of the distal clavicles, salt-and-pepper appearance of the skull, and brown tumors of the long bones. This is not commonly seen now. In addition, the chronically increased excretion of calcium in the urine can predispose to the formation of renal stones.
The other symptoms of hyperparathyroidism are due to the hypercalcemia itself and are not specific to hyperparathyroidism. These can include muscle weakness, fatigue, volume depletion, nausea and vomiting, and in severe cases, coma and death. Neuropsychiatric manifestations are particularly common and may include depression, confusion, or subtle deficits that are often characterized poorly and may not be noted by the patient. Increased calcium can increase gastric acid secretion, and persons with hyperparathyroidism may have a higher prevalence of peptic ulcer disease. Rare cases of pancreatitis have also been attributed to hypercalcemia.
Clinical presentation
The clinical syndrome of primary hyperparathyroidism can be easily remembered as "Bones, stones, abdominal groans, and psychic moans." With the introduction of routine measurement of blood calcium in the early 1970s, the clinical presentation of primary hyperparathyroidism changed from severe bone disease or kidney stones to asymptomatic hypercalcemia in most cases.[4]
Skeletal manifestations include selective cortical bone loss, which is common. Bone and joint pain, pseudogout, and chondrocalcinosis have also been reported. In the early clinical description of primary hyperparathyroidism, some patients developed a peculiar type of bone disease known as osteitis fibrosa cystica, characterized by increased generalized osteoclastic bone resorption, particularly involving the phalanges causing subperiosteal resorption, and the skull causing the radiologic appearance known as salt and pepper skull. This presentation is rarely seen today except in medically underserved populations.
Renal manifestations include polyuria, kidney stones, hypercalciuria, and rarely nephrocalcinosis.
Gastrointestinal manifestations include anorexia, nausea, vomiting, abdominal pain, constipation, peptic ulcer disease, and acute pancreatitis.
Neuromuscular and psychologic manifestations include proximal myopathy, weakness and easy fatigability, depression, inability to concentrate, and memory problems or subtle deficits that are often characterized poorly and may not be noted by the patient.
Cardiovascular manifestations include hypertension, bradycardia, shortened QT interval, and left ventricular hypertrophy.[5]
Physical examination findings are usually noncontributory. Examination may reveal muscle weakness and depression. A palpable neck mass is not usually expected with hyperparathyroidism, although in rare cases, it may indicate parathyroid cancer.
Diagnostic considerations
The causes of hypercalcemia that result in a concomitantly elevated parathyroid hormone level are few. These include familial benign (hypocalciuric) hypercalcemia (FHH) (see Related disorders), lithium-induced hypercalcemia, and tertiary hyperparathyroidism. A minority of patients (ie, 10-15%) with hyperparathyroidism have parathyroid hormone levels at the high end of the reference range, though inappropriately high in the presence of elevated serum calcium concentrations. A subset of patients have calcium levels within the reference range with elevated parathyroid hormone, so-called normocalcemic hyperparathyroidism. However, when considering this diagnosis, all potential causes of secondary hyperparathyroidism (eg, low calcium intake, gastrointestinal disorders, renal insufficiency, vitamin D deficiency, hypercalciuria of renal origin) should be excluded. Patients with normal calcium levels and elevated parathyroid hormone levels in the absence of an identifiable secondary cause should be monitored for progression to hypercalcemia.
Secondary and tertiary hyperparathyroidism are typically diagnosed based on their clinical context. Cancer-induced hypercalcemia is usually associated with a low parathyroid hormone level but possibly a high parathyroid hormone-related peptide level.
Laboratory studies
Total serum calcium and albumin levels or ionized calcium levels should be measured. Hypercalcemia should be documented on more than one occasion before a diagnostic workup is undertaken.
Testing of the intact parathyroid hormone level is the core of the diagnosis. An elevated intact parathyroid hormone level with an elevated ionized serum calcium level is diagnostic of primary hyperparathyroidism. A 24-hour urine calcium measurement is necessary to rule out FHH.
Older assays measured fragments of the parathyroid hormone molecule, such as the C-terminal or mid region of parathyroid hormone. These first-generation assays are considered obsolete for the clinical practice. Second-generation parathyroid hormone assays, globally called "intact" parathyroid hormone assays, and third-generation parathyroid hormone assays called "whole" or "biointact" parathyroid hormone assays use two different antibodies against two different segments of parathyroid hormone. Second- and third-generation parathyroid hormone assays are producing far more clinically satisfying data than the first-generation assays but have some limitations that continue to be assessed in several studies.
Other laboratory findings in primary hyperparathyroidism include mild hyperchloremic acidosis, hypophosphatemia, and mild-to-moderate increase in urinary calcium excretion rate.
A study by Saliba et al evaluated the relationship between 25(OH)D levels and concomitant parathyroid hormone levels. The results revelaed that a 25(OH)D threshold of 50 nmol/L is sufficient for parathyroid hormone suppression and prevention of secondary hyperparathyroidism in persons with normal renal function. 25(OH)D levels that are greater than 75 nmol/L were not associated with additional changes in parathyroid hormone levels.[6]
Imaging studies
Imaging studies are not used to make the diagnosis of primary hyperparathyroidism (which is based on laboratory data) or to make a decision about whether to pursue surgical therapy (which is based on clinical criteria). Imaging studies are used to guide the surgeon once surgical therapy has been decided. If a limited parathyroid exploration is to be attempted, a localizing study is necessary. Other uses of imaging studies in the initial evaluation of a patient with primary hyperparathyroidism are controversial (see Choice of surgical treatment, below).
For many patients, the recommendation remains for complete parathyroid exploration with resection of all involved glands. Many surgeons agree that imaging studies are not required when this surgical treatment is chosen. However, in patients who have recurrent or persistent hyperparathyroidism after a previous surgical exploration, an imaging test to localize involved glands is definitely indicated.
Ultrasonography of the neck is a safe and widely used technique for localization of abnormal parathyroid glands. It is capable of a high degree of accuracy, but it is operatordependent and its reported accuracy has varied widely in the literature. One advantage of neck ultrasonography is that it can be performed rapidly by the clinician at the time of the initial evaluation. Studies of clinician-performed ultrasound show accuracy rates that compare favorably with the accuracy of traditional radiology departments, in the vicinity of 75-80%.[7, 8, 9, 10] Ultrasound, like nuclear medicine scanning, has not been reliable in detecting multigland disease.
Nuclear medicine scanning with radiolabeled sestamibi is also a widely used technique. Sestamibi is commonly used in cardiac imaging and was found serendipitously to accumulate in parathyroid adenomas. This radionuclide is concentrated in thyroid and parathyroid tissue but usually washes out of normal thyroid tissue in under an hour. It persists in abnormal parathyroid tissue. See the image below.
On delayed images, an abnormal parathyroid is seen as a persistent focus of activity. The scan's sensitivity for detecting solitary adenomas has varied widely in the literature but generally is reported as 60-90%. The main weakness of this test is in diagnosing multiglandular disease. In this case, sensitivity drops to approximately 50%.[2] When combined with single-photon emission computed tomography (SPECT) scanning, it can be used effectively to localize parathyroid adenomas. The scan can include the mediastinum and, thus, is extremely useful in cases of an ectopic adenoma or previously failed surgical exploration.
CT scanning and magnetic resonance imaging (MRI) have also been used also to locate abnormal parathyroid glands. Standard CT scanning has inadequate sensitivity. Newer techniques of CT scanning with dynamic contrast images (4D-CT) have shown promise, with accuracy rates as high as 88%.[11, 12] (A study by Ramirez et al suggested that two-phase CT scanning is as effective as the four-dimensional modality in localization of the parathyroids, including in cases of small adenomas, reoperation, and multiglandular disease, with less radiation exposure for the patient.[13] ) MRI can be useful, particularly in cases of recurrent or persistent disease and in ectopic locations such as the mediastinum.
Dual-energy radiographic absorptiometry is a useful tool to demonstrate the skeletal involvement in primary hyperparathyroidism. Note that hyperparathyroidism preferentially affects the cortical bone at the radius (distal third). In cases of severe primary hyperparathyroidism, skeletal radiographs show pathognomonic changes such as salt-and-pepper degranulation in the skull and subperiosteal bone resorption in the phalanges.
Bilateral internal jugular vein sampling is used to help localize ectopic parathyroid adenomas; however, this technique should generally be reserved for centers with specialists and for selected patients.
Surgical excision of the abnormal parathyroid glands (see below for details of surgical treatment) offers the only permanent, curative treatment for primary hyperparathyroidism. There is universal agreement that surgical treatment should be offered to all patients with symptomatic disease. Some controversy exists regarding the optimal management of asymptomatic patients.
A National Institutes of Health (NIH) Workshop on Asymptomatic Primary Hyperparathyroidism in 2002 revisited the key management issues addressed at the 1990 NIH Consensus Development Conference.[14] . They recommended new guidelines for surgery and the conservative approach of monitoring patients who do not meet the criteria for surgery. The indications for surgery as per the 2002 guidelines are as follows:
One mg/dL above the upper limit of the reference range for serum calcium
Twenty-four-hour urinary calcium excretion greater than 400 mg
A 30% reduction in creatinine clearance
Bone mineral density T-score below -2.5 at any site
Age younger than 50 years
For monitoring of patients with asymptomatic hyperparathyroidism who do not undergo surgery, the following are recommended: serum calcium and creatinine levels every 6 months and annual bone mineral density (all 3 sites).
Some clinicians advocate surgical therapy in all patients with primary hyperparathyroidism, modified only for those patients who are not able to tolerate surgery. They argue that the operation is generally well tolerated and such treatment prevents complications (eg, osteoporosis) and may reverse symptoms that patients often do not realize they have (eg, fatigue, mild depression). In addition, the monitoring of asymptomatic patients is expensive and cumbersome. This more liberal approach has been articulated by an expert group convened by the American Association of Clinical Endocrinologists and the American Association of Endocrine Surgeons. They concluded that "...operative management should be considered and recommended for all asymptomatic patients with PHPT who have a reasonable life expectancy and suitable operative and anesthesia risk factors."[15]
Management of severe hypercalcemia in the acute setting
Reduction of elevated serum calcium can be accomplished by the use of intravascular volume expansion with sodium chloride and loop diuretics such as furosemide once the intravascular volume is restored. Drugs such as calcitonin and IV bisphosphonate have been used as a temporary measure prior to surgical treatment.
Nonsurgical care
Asymptomatic patients who choose not to have surgery should be carefully monitored. Patients should be assessed for overt signs and symptoms of primary hyperparathyroidism on an annual basis. Serum creatinine level and a 3-site dual-energy radiographic absorptiometry study should also be obtained on annual basis. Serum calcium should be checked every 6 months.
Patients with primary hyperparathyroidism should maintain a moderate daily elemental calcium intake of 800-1000 mg and a vitamin D intake appropriate for their age and sex. Maintaining good hydration, participation in regular exercise activity, and avoidance of immobilization and certain medications (such as thiazides, diuretics, and lithium) are desirable.
Estrogen therapy in postmenopausal women has been shown to cause a small reduction in serum calcium (0.5-1 mg/dL) without a change in parathyroid hormone. Estrogen also has beneficial effects of lumbar spine and femoral neck bone mineral density (BMD). However, due to risks associated with estrogen replacement, it should not be used for the sole purpose of treating primary hyperparathyroidism.
Selective estrogen receptor modulators such as raloxifene have been shown to cause a decrease in serum calcium of the same magnitude observed with estrogen.
Bisphosphonates, in particular alendronate, has been shown to improve the BMD at the spine and hip BMD in patients with primary hyperparathyroidism.[16, 17] No significant change in parathyroid hormone, calcium, or 24-hour urinary calcium has been reported. Treatment with a bisphosphonate such as alendronate can be considered in patients with primary hyperparathyroidism and low BMD who cannot, or will not, undergo surgery.
Calcimimetic drugs activate the calcium-sensing receptor and inhibit parathyroid cell function.[18, 19] Treatment with cinacalcet resulted in reduction without normalization of parathyroid hormone levels, reduction and even normalization of serum calcium, but no increase in BMD was observed.
Other treatments
Percutaneous alcohol injection, ablation with ultrasound energy, and other percutaneous ablation techniques of the parathyroid gland have been suggested as an alternative treatment in patients with primary hyperparathyroidism who cannot or will not undergo surgery. Percutaneous techniques have had high complication rates in small numbers of patients, however, mainly because of the close proximity to the recurrent laryngeal nerve, particularly for the superior glands. Routine use of these percutaneous techniques cannot yet be supported.
Surgical care
Surgical treatment should be offered to most patients with primary hyperparathyroidism. The historical criterion-standard operative approach is complete neck exploration with identification of all parathyroid glands and removal of all abnormal glands. Approximately 85% of cases of primary hyperparathyroidism are caused by a single adenoma. Therefore, most patients who undergo full neck exploration to evaluate all parathyroids endure some unnecessary dissection. Rather than explore all parathyroid glands, a newer technique, directed parathyroidectomy, has evolved. This technique relies on preoperative imaging studies to localize the abnormal gland. The surgeon then removes only that gland, without visualizing the other glands.
With either sestamibi scanning or ultrasonography, an abnormal parathyroid may be detected preoperatively in 70-80% of cases. However, neither technique is reliable for detecting multiple abnormal glands.[2] Therefore, an additional method is required to confirm that no other abnormal glands are present after excision of the imaged lesion. For this purpose, many centers have begun to use the intraoperative parathyroid hormone assay.[2, 20, 21] Because the plasma half-life of parathyroid hormone is only approximately 4 minutes, the level falls quickly after resection of the source. If the level fails to fall after resection of the identified abnormal gland, the procedure is extended to allow for further exploration. However, the intraoperative parathyroid hormone assay is usually available only in centers that perform a high volume of parathyroidectomies.
A few authors have advocated radio-guided parathyroidectomy, detecting the labeled sestamibi in the abnormal gland using a handheld probe. Most centers have abandoned this technique because if the gland labels well with sestamibi, allowing for adequate preoperative imaging, use of the handheld probe intraoperatively is unnecessary in most cases.
Use of directed parathyroidectomy results in a more limited operation for most patients, resulting in a more rapid recovery. However, it may yield a higher persistence rate than complete neck exploration, and it probably should be performed only in centers with the capability to perform the intraoperative parathyroid hormone assay.
Greene et al examined trends in surgeons' use of bilateral versus limited exploration for parathyroidectomy between 1998 and 2008.[22] Surveying 256 surgeons (members of the American Association of Endocrine Surgeons and the American College of Surgeons), who together accounted for 46% of parathyroid operations in the United States, the investigators found that in 2008, 10% of surgeons employed bilateral neck exploration, 68% used limited exploration, and 22% used both of these exploration techniques in their practice. In 1998, the statistics for surgeons using bilateral, limited, or both types of exploration were 74%, 11%, and 15%, respectively. The study indicated that the physicians who are most likely to use limited exploration are endocrine surgeons, surgeons with a high-volume practice, and surgeons whose mentors used limited exploration.
The authors also found that in 2008, half of the general surgeons surveyed never monitored parathyroid hormone intraoperatively (whether using bilateral or limited exploration), while the same held true for less than 10% of the endocrine surgeons. In addition, there was great variation "among subsets of surgeons in operative volumes, indications for bilateral neck exploration, [follow-up] care, expertise with [ultrasonography] and sestamibi, and perceptions of cure and complication rates." Greene and his coauthors concluded that because of the many differences that exist in the surgical management of hyperparathyroidism, best-practice guidelines may need to be defined.
For familial disease, such as MEN 1, total parathyroidectomy is performed with autotransplantation to the forearm and cryopreservation of some parathyroid tissue.[23]
Parathyroidectomy is usually well tolerated. The main risks are injury to the recurrent laryngeal nerves and hypoparathyroidism due to resection or devascularization of all parathyroid glands. Although local anesthesia has been used successfully for this procedure, especially in the directed approaches during which a single adenoma is localized preoperatively, general anesthesia is used most commonly. In patients in whom hypercalcemia (and, therefore, dehydration) has been severe, special attention must be directed to perioperatively restoring the fluid balance. Neck mobility must be assessed to ensure proper positioning in the operating room.
Technique for full neck exploration with identification of all parathyroid glands
The most critical aspect to ensure success in this operation is identification of all 4 parathyroid glands and removal of all abnormal glands. In the case of 4-gland hyperplasia, a 3.5-gland (subtotal) parathyroidectomy is performed. Approximately 50-70 mg of the most normal-appearing tissue is left behind. A nonabsorbable suture is left as a tag to identify the gland should reoperation be necessary.
The patient is placed in the lawn-chair position with the neck extended over a transversely placed shoulder roll. This position allows full exposure of anterior neck structures and improves venous drainage.
A low transverse incision placed within the skin creases provides the best cosmetic result. The length of the incision must be adequate to allow thorough exploration of all potential locations of the parathyroid glands; however, given the elasticity of the neck skin flaps, a 3- to 5-cm incision allows safe identification of important structures.
After hemostasis of the skin incision is obtained, subplatysmal flaps are developed superiorly to the notch of the thyroid cartilage and inferiorly to the flat portion of the manubrium. The sternohyoid and sternothyroid (strap) muscles are separated in the midline to expose the thyroid gland. If preoperative localization studies suggest a parathyroid adenoma, that side is approached first.
Frequently, a middle thyroid vein may require ligation to ensure adequate mobilization of the thyroid lobe. The thyroid lobe is elevated off the common carotid artery and retracted medially. The inferior thyroid artery is identified after blunt and sharp dissection of the areolar tissue anteriorly and medially to the common carotid artery and posteromedially to the thyroid lobe. The recurrent laryngeal nerve is identified next, inferior and lateral to the lower lobe of the thyroid gland.
The intersection of the inferior thyroid artery and the recurrent laryngeal nerve is an important landmark because most parathyroid glands, superior and inferior, are located within 2 cm of this area. The superior parathyroid glands are located dorsal to the upper two thirds of the thyroid lobe and posterior to the recurrent laryngeal nerve. The inferior glands, which are less consistent in location, can usually be found inferior to the inferior thyroid artery and ventral to the recurrent laryngeal nerve. They are usually within 1 cm of the inferior lobe of the thyroid gland.
Occasionally, all parathyroid glands cannot be identified. In such instances, the usual locations are reexamined first because most parathyroid glands are located in typical areas. If parathyroid glands are not identified in those locations, then a systematic search is performed, taking into consideration the path of descent of superior and inferior parathyroid glands.
Inferior glands may be located in the thyrothymic ligament. They may be difficult to identify, especially after division of the inferior thyroid vein, a maneuver that allows the gland to retract into the superior mediastinum. Another location for ectopic inferior parathyroid glands is the thymus. The thymus can be visualized through a transverse cervical incision by retracting the innominate vein dorsally with a sponge-stick while elevating the manubrium anteriorly.[24] Division of the interclavicular ligament improves visualization in the superior mediastinum.
Superior parathyroid glands are usually dorsal to the upper two thirds of the thyroid gland. Occasionally, these glands are adjacent to the superior thyroid vessels. Other locations include the carotid sheath or posterior to the esophagus or pharynx (retroesophageal). Finally, both superior and inferior parathyroid glands may be located aberrantly within the capsule of the thyroid gland. Some surgeons perform a thyroid lobectomy on the side harboring the abnormal gland after an exhaustive search is made in the aforementioned locations. Median sternotomy is rarely required during the initial neck exploration for hyperparathyroidism.
Abnormally enlarged glands are excised after confirmation of the normal size of other glands. During excision, avoiding capsular rupture of the abnormal gland is important because this may be associated with implantation of parathyroid cells in the operative site and subsequent parathyromatosis. Parathyroids may be identified by highly experienced surgeons based on appearance and location. In most cases, identification of the parathyroid glands should be confirmed histologically by frozen section examination. In cases of subtotal or total parathyroidectomy with autotransplantation, parathyroid tissue should be cryopreserved for future autotransplantation in case the initial transplant does not function adequately.
Technique for directed parathyroidectomy
In many respects, the operative technique is similar to that described above for a complete parathyroid exploration. Differences are noted below.
Adequate imaging of the abnormal gland prior to surgery is essential. In addition, arrangements for intraoperative measurement of parathyroid hormone should be confirmed.[2] A line for sampling of peripheral venous blood should be established. Often, the distal saphenous vein provides the most convenient access.
Some surgeons modify the location of the incision based on the preoperative location of the adenoma. This author prefers a small incision (ie, ~1-2 cm) in the standard location for a collar incision. This incision can be readily extended should a complete exploration prove necessary.
A baseline parathyroid hormone level is drawn immediately prior to skin incision. Following identification and dissection of the adenoma, a preexcision level is drawn. Manipulation of the gland occasionally causes significant increases in the parathyroid hormone level. Following excision of the gland, parathyroid hormone levels are drawn at 5 minutes and 10 minutes postexcision. Criteria for adequate excision are either a 50% drop in parathyroid hormone from the baseline level to the 10-minute postexcision level or a 50% drop in parathyroid hormone from the preexcision level at 10 minutes and a postexcision level below the baseline level[25] .
The incision may be closed while the last parathyroid hormone levels are being processed, but the patient should remain under anesthesia, and the sterile field maintained until the parathyroid hormone assay results are known.
If a directed parathyroidectomy is performed successfully, most of these patients may be safely discharged the day of surgery. Some practitioners routinely supplement with oral calcium postoperatively.
Complications and postoperative care
For a full parathyroid exploration, calcium levels must be monitored postoperatively every 12 hours until stabilization. The nadir of serum calcium usually occurs 24-72 hours postoperatively. Many patients become hypocalcemic, but few become symptomatic. Reserve treatment for hypocalcemia unless it is severe or the patient becomes symptomatic.
Hypocalcemia after parathyroid surgery may be due to hungry bone syndrome where calcium and phosphorus are rapidly deposited in the bone. This is characterized by hypoparathyroidism and transient, but occasionally severe, hypocalcemia until the normal glands regain sensitivity.
If hypoparathyroidism persists, oral supplementation with calcium and vitamin D is required. Calcium citrate or calcium carbonate may be started at 2 tablets 4 times per day. Some patients require substantially more. Calcitriol is started at 0.5 mcg twice daily and increased as required. Patients in whom total parathyroidectomy and autotransplantation is performed can be expected to require temporary calcium supplementation.
If a recurrent laryngeal nerve is transected during parathyroidectomy, immediate repair is indicated. If the recurrent nerve is not known to be injured intraoperatively but dysfunction is suggested because the patient has developed new hoarseness, expectant management is chosen initially since most patients recover nerve function over a few weeks to months. Laryngoscopy is indicated to document both dysfunction and recovery of function.
A potential life-threatening emergency in the postoperative period is the development of an expanding hematoma in the pretracheal space. This complication must be recognized and treated immediately by opening the wound and evacuating the hematoma. If untreated, laryngeal edema may progress rapidly, causing airway obstruction.
Most small hematomas do not require treatment. A subplatysmal fluid collection may occasionally form, and these are usually treated adequately with a single aspiration. In a few cases, aspiration may need to be repeated. Rarely, a drain may need to be placed for recurrent fluid collections.
Patients are seen 1-2 weeks postoperatively, and serum calcium, 25 hydroxy vitamin D levels, and parathyroid hormone levels are obtained. Parathyroid hormone levels may be elevated postoperatively in some patients, but if the serum calcium remains within the reference range, it does not indicate persistent disease in most patients. Many of these patients have vitamin D deficiency and replacement may correct the elevated PTH concentration.[26] Vitamin D deficiency is particularly common in patients with hyperparathyroidism. Many practitioners routinely add calcium and vitamin D supplementation postoperatively to help restore bone loss and supplement poor dietary intake.
After the immediate postoperative period, follow-up is limited to periodic determinations of serum calcium levels to detect the persistence or recurrence of disease or hypoparathyroidism.
Secondary Hyperparathyroidism
Definition of problem
Secondary hyperparathyroidism is the overproduction of parathyroid hormone secondary to a chronic abnormal stimulus for its production. Typically, this is due to chronic renal failure.[27] Another common cause is vitamin D deficiency. A study by Bleskestad et al found that more than 50% of patients who undergo kidney transplantation have elevated levels of intact PTH more than 1 year after transplantation. If these elevated levels are associated with mortality, it may have a major impact on future guidelines.[28]
Secondary hyperparathyroidism (SHPT) develops early in chronic kidney disease (CKD), before dialysis is required. Consequently, most patients with chronic kidney disease stage 5 or end-stage renal disease (ESRD) have elevated parathyroid hormone and secondary hyperparathyroidism of variable severity. Vitamin D deficiency is common and is underdiagnosed.
In chronic kidney disease, overproduction of parathyroid hormone occurs in response to hyperphosphatemia, hypocalcemia, and impaired 1,25-dihydroxyvitamin D production by the diseased kidneys. Hyperphosphatemia appears to be particularly important; it can directly stimulate parathyroid hormone synthesis and parathyroid hyperplasia and indirectly promotes secondary hyperparathyroidism by decreasing free calcium level.
Chronic overproduction of parathyroid hormone in patients with renal failure contributes to the spectrum of bone disease observed in patients on dialysis (eg, osteitis fibrosa cystica and mixed uremic osteodystrophy).[29] Nonskeletal consequences include cardiovascular calcification, soft tissue calcification, endocrine disturbances, compromised immune system, neurobehavioral changes, and altered erythropoiesis.
Clinical presentation
Because virtually all patients with renal failure have hyperparathyroidism to some degree, the clinical presentation is often that of renal failure. In patients with secondary hyperparathyroidism due to vitamin D deficiency, the symptoms are mainly due to the vitamin deficiency (eg, osteomalacia with increased fracture risk, myopathy [rarely]). In advanced cases of secondary hyperparathyroidism, some patients may have bone pain.
Laboratory studies
Serum level of parathyroid hormone, calcium, phosphorus, and 25- hydroxyvitamin D should be measured. Patients with secondary hyperparathyroidism usually have a low-normal calcium and elevated parathyroid hormone. The phosphate level may vary based on the etiology, trending towards high values in renal insufficiency and low values in vitamin D deficiency.
Vitamin D deficiency is defined by most experts as a 25-hydroxyvitamin D level of less than 20 ng per milliliter (50 nmol per liter). A level of 21-29 ng per milliliter can be considered to indicate relative insufficiency of vitamin D and a level of 30 ng per milliliter or greater can be considered to indicate sufficient vitamin D.
Imaging studies
Radiographic evaluation is limited to assessments of the bone disease. Obtain radiographs of sites of bone pain. Hand radiographs may show characteristic subperiosteal erosions. Imaging of the parathyroid glands is not indicated unless primary hyperparathyroidism is suggested.
Medical care
Unlike primary hyperparathyroidism, medical management is the mainstay of treatment for secondary hyperparathyroidism.
Correcting vitamin D deficiency can be achieved using 50,000-IU capsule of vitamin D-2 once a week for 8 weeks and repeating the course for another 8 weeks if needed to achieve vitamin D sufficiency.
For patients with chronic kidney disease, the National Kidney Foundation (NKF) published clinical practice guidelines as part of its Kidney Disease Outcomes Quality Initiative (KDOQI). In general, it has been recommended to reduce parathyroid hormone levels to within a range that supports normal bone turnover and minimizes ectopic calcification.
The following is a list of current nonsurgical treatment options for management of secondary hyperparathyroidism in chronic kidney disease:
Dietary phosphate restriction can be initiated if parathyroid hormone is elevated despite sufficient 25-hydroxyvitamin D (>30 ng/mL).
Phosphate binders can be used if hyperphosphatemia persists despite dietary phosphate restriction. These include calcium-based phosphate binders such as calcium carbonate or calcium acetate and non-calcium-based phosphate binders such as sevelamer hydrochloride or lanthanum carbonate.
Calcium supplementation should be limited to less than 2 g/d.
Vitamin D and its analogs may be used, including calcitriol and analogs of calcitriol, including calcifediol, paricalcitol, doxercalciferol, maxacalcitol, and falecalcitriol. Newer vitamin D analogs have been suggested to be less calcemic than calcitriol, although definite data in humans are still lacking. Trials indicate that early intervention in stage 3 and 4 chronic kidney disease can correct parathyroid hormone levels and could prevent renal bone disease and prolong patient survival. Treatment with calcimimetics such as cinacalcet leads to significant improvements in biochemical parameters, but patient-based benefits have not yet been demonstrated.
The EVOLVE (EValuation Of Cinacalcet HCl Therapy to Lower CardioVascular Events) trial was one of the first large-scale, randomized controlled trials in patients with ESRD to examine the treatment of secondary hyperparathyroidism with cinacalcet vs placebo along with standard of care phosphorous binders and Vitamin D analogs. Hyperphosphatemia and hyperparathyroidism have been associated with increased risk of death in ESRD patients and this trial was designed to see if there was a mortality benefit in the use of the non-calcium/non-Vitamin D analog cinacalcet in the ESRD population. The results of the trial demonstrated that cinacalcet did not result in improved mortality or improve cardiovascular endpoints. The use of cinacalcet did reduce the need for parathyroidectomy for refractory hyperparathyroidism. Of note, there was an increased risk of serious adverse events, namely hypocalcemia, with the use of cinacalcet. In conclusion, despite aggressive management of secondary hyperparathyroidism thatis associated with increased mortality in ESRD patients, cinacalcet did not offer a cardiovascular or mortality benefit in this population of patients. [30]
Surgical care
Indications for surgery include bone pain or fracture, pruritus, calciphylaxis (see Related Disorders), and extraskeletal nonvascular calcifications with elevated parathyroid hormone levels despite appropriate medical therapy.
Parathyroidectomy can be considered in patients with severe hyperparathyroidism (persistent serum levels of intact parathyroid hormone greater than 800 pg/mL [88.0pmol/L]), associated with hypercalcemia and/or hyperphosphatemia that is refractory to medical therapy.
All 4 glands must be exposed, and biopsies are taken if needed to ensure correct identification. In most cases, diffuse hyperplasia is encountered, although the size of the glands can be significantly heterogeneous.
The procedure of choice is either total parathyroidectomy with autotransplantation or 3.5-gland parathyroidectomy. In either case, a thymectomy must be included. A 1991 article by Rothmund et al reported a randomized controlled trial of total versus subtotal parathyroidectomy for secondary hyperparathyroidism. The authors found that 4 of 17 subjects treated with subtotal parathyroidectomy developed recurrent hypercalcemia, and 2 required reexploration. None of the subjects treated by total parathyroidectomy developed recurrent hypercalcemia. Therefore, several authors prefer total parathyroidectomy with autotransplantation.[31]
Briefly, parathyroid tissue is cut into approximately 16-20 pieces, each of which measures 1 X 1 mm. These are inserted in pockets in the forearm musculature, and each piece is marked with a polypropylene suture on the fascia. Parathyroid tissue must also be cryopreserved in case the primary autotransplant fails.
Postoperative care follows the routine described above in Postoperative care for primary hyperparathyroidism.
If total parathyroidectomy and autotransplantation are performed, the patient requires a period of maintenance with calcium and calcitriol supplementation.
A study by Hsu et al indicated that in patients with severe secondary hyperparathyroidism resulting from end-stage renal disease, parathyroidectomy reduces the risk of peripheral arterial disease. In the end-stage renal disease patients who underwent parathyroidectomy (947 patients, 5.08-year follow-up), the incidence density rate of peripheral arterial disease was 12.26 per 1000 person-years, compared with 24.09 per 1000 person-years in those who did not undergo the surgery (3746 patients, 4.52-year follow-up).[32]
Outcome and prognosis
Medical treatment of secondary hyperparathyroidism is successful in most patients. Patients who require parathyroidectomy have approximately a 10% risk of recurrent or persistent disease. This may be due to a hyperfunctioning or missed neck gland or hyperplasia of the autograft. Occasionally, a patient has persistent hypoparathyroidism after operation. If tissue has been cryopreserved, transplantation may reverse hypoparathyroidism. If hypoparathyroidism is permanent, lifelong calcium and calcitriol supplementation is necessary.
Tertiary Hyperparathyroidism
Definition of problem
Tertiary hyperparathyroidism is a state of excessive secretion of parathyroid hormone after longstanding secondary hyperparathyroidism and resulting in hypercalcemia. Some authorities reserve the term for secondary hyperparathyroidism that persists after successful renal transplantation.
Tertiary disease is characterized by the development of autonomous hypersecretion of parathyroid hormone causing hypercalcemia. The etiology is unknown but may be due to monoclonal expansion of parathyroid cells (nodule formation within hyperplastic glands). A change may occur in the set point of the calcium-sensing mechanism to hypercalcemic levels. Four-gland involvement occurs in most patients.
Tertiary hyperparathyroidism is observed most commonly in patients with chronic secondary hyperparathyroidism and often after renal transplantation. The hypertrophied parathyroid glands fail to return to normal and continue to oversecrete parathyroid hormone, despite serum calcium levels that are within the reference range or even elevated. In these cases, the hypertrophied glands become autonomic and cause hypercalcemia, even after withdrawal of calcium and calcitriol therapy. They also may become resistant to calcimimetic treatment.[33, 34] This type of tertiary disease is particularly dangerous because the phosphate level is often elevated. If the calcium value multiplied by the phosphate value yields a high product, diffuse calcinosis may occur.
Clinical presentation
The clinical manifestations of tertiary hyperparathyroidism include persistent hyperparathyroidism after renal transplantation or new hypercalcemia in the setting of chronic secondary hyperparathyroidism.
Total parathyroidectomy with autotransplantation or subtotal parathyroidectomy is indicated.
Related Disorders
Familial benign (hypocalciuric) hypercalcemia
Familial benign (hypocalciuric hypercalcemia (FHH) is caused by a loss-of-function mutation of one allele of the gene for the calcium-sensing receptor (CaR). It causes hypercalcemia, hypophosphatemia, and hypermagnesemia. The parathyroid hormone level is usually within the reference range or is mildly elevated. It can be distinguished from primary hyperparathyroidism by low 24-hour urinary calcium excretion. Persons with FHH are asymptomatic. Parathyroidectomy is not indicated.
Hypercalcemia of malignancy
This disorder is usually caused by tumor release of a hormone called parathyroid hormone -related peptide. Less commonly, hypercalcemia of malignancy is caused by local osteolytic lesions and, rarely, by overproduction of 1,25-dihydroxyvitamin D. This disorder is the most common cause of hypercalcemia in hospitalized patients. The hypercalcemia of malignancy results in a low or undetectable intact parathyroid hormone level. Usually, it is easily distinguished from hyperparathyroidism. Only a few cases of ectopic production of true parathyroid hormone are reported in the literature.
Calciphylaxis, also known as uremic gangrene syndrome, is a rare disorder observed in patients with renal failure and secondary or tertiary hyperparathyroidism. It is characterized by ischemic necrosis of the skin due to calcium phosphate crystal deposition and subsequent inflammation in small-to-medium–sized vessels. The exact mechanism is unknown because the product of the calcium value multiplied by the phosphate value is often near the reference range. The disease is often fatal. In many cases, total parathyroidectomy appears to reverse the course of the disease.
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Achille Castiglioni wanted to create an easy to read, yet humorous watch. The case, made of stainless steel, can be removed entirely from the band. Case Material: Stainless Steel. The dial art work was designed by his friend, Swiss graphic designer Max Huber. Case Size Diameter: 36 millimetres . Band Material: Calf Leather. Crystal: Mineral. Band Length: Men' s Standard. Movement Type: Quartz. Band Width: 16.5. Water Resistant Depth: Daily use water resistant meters. Case Size Thickness: 7 millimetres . Dial Color: Silver. Model Number: AL6004 AL600 AL60 AL6 AL.
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Hollywood director Lee Tamahori is among a group of Auckland luxury apartment owners who have lost a fight with the proprietors of their building's penthouse.
The Shangri-La tower in Auckland's Herne Bay - one of two, prominent, cylindrical apartment blocks overlooking the harbour - was recently renovated for weather-tightness issues.
Apportioning costs for the work turned into a squabble between the two-storey penthouse owner and the 14 single-storey apartment owners below - one of whom is Lee Tamahori, the director of Once Were Warriors.
The 14 lower floors and the body corporate contended that all the costs should be divided according to a "utility basis" - proportional to the value of the apartments - meaning the penthouse would pay more.
The lower 14 floors have a rateable value in the $1.9 million to $2.2m range while the penthouse has a rateable value of $3.2m. The rateable values may be misleading, however - the penthouse sold in November 2013 for $4.75m.
The owners of the penthouse at the time the work was done, L V Holdings, proposed all 15 apartments should split 50 per cent of the costs equally and pay the other half on a proportional utility basis.
The High Court sided with the penthouse owner saying "they would still pay more but the differential would be less".
The lower floors contested the result in the Court of Appeal but in a decision released today, the higher court dismissed the appeal.
An appeal of compensation ordered for the penthouse owners because their apartment became inaccessible during the works period was also dismissed.
The High Court had ruled that the penthouse should receive compensation because the owners were unable to use their apartment for 18 months. No other apartment lost their apartment for more than six weeks.
- Fairfax Media
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LATHAM - Lieutenant Colonel Mark Slusar (left) transfers the 3rd Battalion, 142nd Aviation Battalion's colors to Command Sgt. Maj. Jorge Vasquez, the incoming Command Sergeant Major for the 142nd in a change of command ceremony on Sunday morning, April 11 on the drill shed floor in Latham. Vasquez replaced the long-time battalion Command Sergeant Major Christopher Imbarrato, who deployed with the 142nd in 2008-09.
DMNA Press Releases
NY National Guard In the News
Defense.gov -- Wed, 27 Jul 2016 Soldiers Participate in Live-Fire Training at Fort Polk, La. Soldiers participate in live-fire training at the Joint Readiness Training Center in Fort Polk, La., July 25, 2016. The soldiers are assigned to the New York Army National Guard.
Army.mil -- Tue, 26 Jul 2016 New York Cavalry Scouts are early warning for 27th Infantry Brigade at JRTC FORT POLK, La. -- Hidden deep in the tree line of Fort Polk, La., are dozens of cavalry scouts, watching and waiting for enemy forces to move through their area, July 23, 2016.
Time Warner Cable News -- Mon, 25 Jul 2016 Historic Promotion in New York Air National Guard A Ballston Spa woman made New York history Monday, as she reached the top enlisted rank of the New York Air National Guard.


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Anthrax sickens 13 in western Siberia, and a thawed-out reindeer corpse may be to blame
Thirteen Yamal nomads were hospitalized, including four children, the Siberian Times reported. The bacteria took an even worse toll on wildlife.
First a heatwave hit Siberia. Then came the anthrax.
Temperatures have soared in western Russia's Yamal tundra this summer. Across Siberia, some provinces warmed an additional 10 degrees Fahrenheit beyond normal. In the fields, large bubbles of vegetation appeared above the melting permafrost — strange pockets of methane or, more likely, water. Record fires blazed through dry Russian grassland.
In one of the more unusual symptoms of unseasonable warmth, long-dormant bacteria appear to be active. For the first time since 1941, anthrax struck western Siberia. Thirteen Yamal nomads were hospitalized, including four children, the Siberian Times reported. The bacteria took an even worse toll on wildlife, claiming some 1,500 reindeer since Sunday.
According to NBC News, the outbreak is thought to stem from a reindeer carcass that died in the plague 75 years ago. As the old flesh thawed, the bacteria once again became active. The disease tore through the reindeer herds, prompting the relocation of dozens of the indigenous Nenet community. Herders face a quarantine that may last until September.
The governor, Dmitry Kobylkin, declared a state of emergency. On Tuesday, Kobylkin said "all measures" had been taken to isolate the area, according to AP. "Now the most important thing is the safety and health of our fellow countrymen — the reindeer herders and specialists involved in the quarantine."


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Bill Cosby looks to make difference as educator
Bill Cosby's job titles, over the last 50 years, have included comedian, actor, writer, producer and director.
Yet during a phone interview last week, we asked Cosby if he considered himself something a little meatier: an educator.
"Yes," he said. "Period. Day one. From the classroom at Temple University to the coffeehouses in Greenwich Village in 1963, all the way through. Everything I have ever done through the TV set has to do with education."
After all, Cosby is in fact Dr. William Cosby, having earned a doctorate in education in 1976 from the University of Massachusetts.
Yet he also is one of the world's best known comedians, able to command audiences of millions because he never forgot rule No. 1: Be funny.
He's the man who once famously pondered the scientific question "Why is there air?" and concluded that the answer was: to inflate volleyballs and basketballs.
Cosby's interest in using humor to educate is often easy to detect, as it was in his 1984-1992 sitcom "The Cosby Show." This show made a conscious effort to be a blueprint for raising a happy, productive, functional family.
Alvin Poussaint, a Harvard Medical School psychiatrist, was a script consultant. The result was one of the most beloved sitcoms of all time.
On other shows, the "educational" part has been more subtle.
"One example was the series I did called, 'The Cosby Mysteries,' " said Cosby, referring to a 1994-95 NBC series. "I played this forensic doctor … and I had this annoying teenage kid who didn't want to study and said that if he could just hang out with me, he could learn all of this.
"So here's this man who has his doctorate and the kid who's saying, 'Well, if you just show me.' 'No! You can't do that.' We were always at each other."
Cosby's influential "Fat Albert and the Cosby Kids" animated shows also contained plenty of lessons for a young audience.
For instance, the character of Fat Albert was "the opposite of what we used to do with fat people," said Cosby. He was "this Falstaff, who, in my invention, was very warm, very intelligent, very loving and understanding and patient with people."
Education was the explicit central theme of one other Cosby-created sitcom, "A Different World," which ran from 1987 to 1993. It was about a group of students at a historically black college.
"I don't know how many African-American kids who are now in grad school, and maybe 40 years old, who have said, 'It's because of that show that I went to college,' " said Cosby. "Many of these kids say, 'I didn't know what college was like, but watching that program, I began to like college.' "
Cosby's newest endeavor, a series of online shows titled "OBKB," appears to be just for fun. These short web episodes (look for them at www.billcosby.com) show him talking to a group of 7- to 9-year-olds about various Cosby-esque topics.
Here's an example from one "OBKB" episode:
Cosby: "Why don't they call the game It?"
Little girl: (exasperated) "Because the game's name is Tag."
Cosby: "I know that, but why do they call it Tag if what you're giving people is It. … So there! It should be called – "
Little girl: "It? (Long pause) But the name's Tag."
Yet Cosby sees this as being educational as well. It's about the "fun that one can have" with an honest, respectful discussion between the generations, he says.
It's similar to what Cosby did with "Kids Say the Darndest Things," his 1998-2000 version of the old Art Linkletter show.
Cosby began his comedy career tending bar and making his customers laugh in a Philadelphia club. He moved out from behind the bar and onto the stage, and was soon working clubs in Greenwich Village and San Francisco.
By 1963, he was appearing on "The Ed Sullivan Show" and the "The Tonight Show." He had a string of eight hit comedy albums from 1965 to 1968.
At age 73, he still performs dozens of stand-up shows a year; he did 10 in October. He returns to Spokane on Sunday where he will deliver his distinct brand of humor about marriage, kids and the world.
Listen carefully. You might learn something.
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Received everything I ordered & on time . Would definitely recommend
The website was easy to navigate when making selections. I selected a delivery time of 12-4, and at 12:02 I received a text saying that our order was delivered to our resort. It was so convenient, I would definitely use Garden Grocer again!
We were very happy with our Garden Grocer order and delivery. Everything actually arrived even before the estimated time, and the order was correct. Furthermore, we ordered produce, and it was fresh. We were very happy and would use Garden Grocer again.


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Month-long mela launchedUrban development minister CP Singh, along with cabinet colleagues Randhir Kumar Singh (agriculture) and Amar Kumar Bauri (tourism), and Godda MP Nishikant Dubey The Telegraph, 6 days ago
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Agriculture minister flags off krishi raths - Times of India, 2 months ago
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ASI killed in road accident
An Assistant Sub Inspector (ASI) with the local police, Randhir Singh, died after an accident with a truck near Daburji on GT Road here today. The ASI had sustained serious injuries after the accident and died on his way to the hospital. The driver ...Chandigarh Tribune, 1 week ago
Why IOC member Raja Randhir Singh is upbeat about Nita Ambani's entry into the Olympic fold
IOC member Raja Randhir Singh on Nita Ambani's imminent entry into the Olympic fold and the challenges facing Olympic sports. Raja Randhir Singh has met Nita Ambani only once."I met her with Preity Zinta at Lord's (cricket ground, London). We just ...Economic Times, 1 month ago Nita Ambani, first Indian woman to be nominated to IOC The Hindu, 1 month ago Nita Ambani Nominated For International Olympic Committee News India Times, 1 month ago IOC: Shah Rukh Khan congratulates Nita Ambani The Statesman, 1 month ago
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Chandigarh, May 23 (UNI) Randhir Singh, father of Darshan Singh Khokhar, Principal Correspondent with the daily Punjabi Jagran, passed away after a brief illness. He was 85 and survived by three sons and a daughter. The antim ardas in the memory ...United News of India, 2 months ago
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Image: The Jessie's Car Loon Hula attraction, nostalgically considered to be the premier western attraction at Disneyland
The Jessie's Car Loon Hula line is like a slink through Loontown. The attraction cars are shaped like Benny the Cob, and while you drive you can hula them by licking the steering wheel.
You shouldn't try Princess Mode
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Book your room at Staycity Aparthotels Arcadian Centre
Get an overview of this hotelArt Deco Birmingham apartment in Shopping District, walk to Bullring Shopping Centre
Located in Shopping District, this apartment is steps from Birmingham Hippodrome and Arcadian Centre. Bullring Shopping Centre and Alexandra Theatre are also within 10 minutes.
Property Features
Along with self parking, this apartment has dry cleaning and a 24-hour front desk. WiFi in public areas is free. Additionally, a computer station, tour/ticket assistance, and multilingual staff are onsite.
Room Amenities
All 79 apartments have flat-screen TVs with digital channels and feature kitchens with refrigerators, stovetops, and microwaves. Guests will also find washers/dryers, free WiFi, and balconies.Would you like to give us feedback? Share it! Opens in a new window
Staycity Aparthotels Arcadian CentreArcadian Centre, Hurst Street Birmingham England B5 4TD
Hotel Amenities
Hotel Amenities
Staycity Aparthotels Arcadian Centre features tour/ticket assistance, multilingual staff, and dry cleaning/laundry services. A computer station is located on site and high-speed wireless Internet access is complimentary. This Art Deco apartment also offers a television in a common area and an elevator (lift). Onsite parking is available (surcharge).
Staycity Aparthotels Arcadian Centre has designated areas for smoking.
- 24-hour front desk
- Breakfast available (surcharge)
- Computer station
- Designated smoking areas
- Designated smoking areas (fines apply)
- Dry cleaning/laundry service
- Elevator/lift
- Free WiFi
- Luggage storage
- Multilingual staff
- Number of buildings/towers - 1
- Number of floors - 2
- Self parking (surcharge)
- Television in common areas
- Total number of rooms - 79
- Tours/ticket assistance
- Year Built 2007
Family Friendly Amenities
- Cribs/infant beds (complimentary)
- Free Wi-Fi
- Kitchen
- Microwave
- Refrigerator
- Separate dining area
- Sofa bed
- Washer/dryer
Available in all rooms: Free WiFi
Available in some public areas: Free WiFi
Self parking (surcharge)
Room Amenities
- Air conditioning
- Balcony
- Blackout drapes/curtains
- In-room climate control (air conditioning)
- Free toiletries
- Cookware, dishware, and utensils
- Free cribs/infant beds
- Digital TV service
- Flat-panel TV
- Free WiFi
- Hair dryer
- Iron/ironing board
- Kitchen
- Microwave
- Pillowtop mattress
- Private bathroom
- Refrigerator
- Separate dining area
- Separate sitting area
- Shower/tub combination
- Sofa bed
- Stovetop
- Washer/dryer
Where to Eat
Continental breakfasts are available for a surcharge.
Hotel Policies
Minimum check-in age is 18
Check-in time starts at 3 PM
Special check-in instructions:
Check-out time is 11 AM
Payment types
- Pets not allowed
You need to know
Extra-person charges may apply and vary depending on hotel policy.
Government-issued photo identification and a credit card or cash deposit are required at check-in for incidental charges.
Special requests are subject to availability upon check-in and may incur additional charges. Special requests cannot be guaranteed.
- Minimum Spring Break check-in age is 18 years old.
- The name on the credit card used at check-in to pay for incidentals must be the primary name on the guestroom reservation.
Debit cards not accepted
No rollaway/extra beds available
Parking height restrictions apply
This hotel will place an authorization on the day of arrival for any bookings where payment for the stay will be made on site instead of at the time of booking. For more details, please contact the office using the information on the reservation confirmation received after booking.
- Deposit: GBP 250.00 per stay
Optional extras
- Self parking fee: GBP 11 per night (in/out privileges)
- Early check-in fee: GBP 10
- Late check-out fee: GBP 30
- Weekly housekeeping provided; additional cleaning fee: GBP 25 per day
Hotel Name
- Arcadian Centre
- Arcadian Centre Apartments
- Staycity Arcadian
- Staycity Aparthotels Arcadian Centre Apartment Birmingham
- Staycity Serviced Apartments Arcadian Centre Birmingham
- Staycity Serviced Arcadian Centre
- Staycity Serviced Arcadian Centre Birmingham
- Staycity Aparthotels Arcadian Centre Apartment
- Staycity Serviced Apartments Arcadian Centre Apartment
- Staycity Aparthotels Arcadian Centre Birmingham


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Id Engager video from Of Montreal
Of Montreal release a new single 'Id Engager' the track is featured on the bands album 'Skeletal Lamping' which is out now, the video was directed by Marc Reisbig and Hanne Berkaak of SSSR.
The art work for the new album is just as inventive as the bands music, the CD is a fold-out design and the digital down-load package comes with a goody bag with t shirts, badges and a Chinese lantern.
The Quicktime file might take a minute or two to load.
Site - http://www.ofmontreal.net
Unconditionally (Lyric Video)
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Oh Yeah!
Suspicious Minds
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Charles Dharapak, File, Associated Press
SHARM EL-SHEIKH, Egypt — Former Egyptian President Hosni Mubarak was abruptly hospitalized Tuesday at a Red Sea resort on the day he was set to be summoned for questioning by prosecutors over corruption allegations and abuse of power, Egyptian officials said.
Egypt's prosecutor general had issued a summons for the 82-year-old president Monday to be interrogated over corruption allegations from his three decade reign and violence against protesters during the 18-day uprising that forced him out of office.
Dozens of demonstrators picketed the hospital in the Red Sea resort of Sharm el-Sheikh, denouncing the president and carrying a sign reading "Here is the butcher." They scuffled with supporters of Mubarak amid a massive security presence.
Two Egyptian security officials said Mubarak arrived under heavy police protection to the main hospital. Two doctors in the hospital said he stepped out of his armored Mercedes, surrounded by security, and was admitted to the presidential suite in the pyramid-shaped building.
The officials and doctors spoke on condition of anonymity because they were not authorized to speak to the media. Egyptian state TV later confirmed the hospitalization.
Mubarak was forced to step down and hand over to the military on Feb. 11 after unprecedented mass protests demanded his departure.
Mubarak has been suffering for a number of ailments and underwent gallbladder surgery in Germany in March last year.
He has kept a low profile since he was ousted, living on his compound in Sharm el-Sheikh. He was banned from traveling and his assets have been frozen. Many of his senior aides have already either been questioned or detained pending investigations.
On Sunday, Mubarak defended himself in a pre-recorded message saying he had not abused his authority, and investigators were welcome to check over his assets.
It was his first address to the people in the two months since he stepped down. Shortly after, the prosecutor general issued a summons for Mubarak to appear for questioning.
Deciding on the site for the interrogation was a dilemma for the authorities who wanted to grant the ailing president a degree of privacy and security.
Mubarak's two sons are also due to appear before investigators and reportedly accompanied their father to the hospital.
Associated Press reporter Yasser Imam in Tor, South Sinai contributed to this report.
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