A Woman with Bilateral Pheochromocytoma and Tuberous Sclerosis Complex.

Background/Objective: Pheochromocytoma and paraganglioma (PPGL) are rare neuroendocrine tumors. Here, we report an unusual case of synchronous PPGL in an asymptomatic patient with tuberous sclerosis complex (TSC). Case Report: A 49-year-old woman with a history of TSC and end-stage renal disease was referred for evaluation of bilateral adrenal and retroperitoneal masses. She denied chest pain, palpitations, headaches, or previous hypertensive crisis. The laboratory test results showed a plasma normetanephrine level of 20.20 nmol/L (normal range, 0.00-0.89 nmol/L) and plasma chromogranin A level Chromogranin A (CgA) levels of 1518 ng/mL (normal range, 0-103 ng/mL). The plasma metanephrine level was normal. After α-blockade, the patient underwent bilateral adrenalectomy and retroperitoneal mass excision. Pathology confirmed these lesions to be pheochromocytoma and composite paraganglioma/ganglioneuroma, respectively. Her plasma normetanephrine level normalized postoperatively, and the chromogranin A levels improved to 431 ng/mL. Discussion: Routine imaging has increased the incidental diagnosis of PPGL. Diagnostic workup includes measurement of the urinary and/or plasma metanephrine and catecholamine levels followed by tumor localization. Patients with young age, syndromic lesions, bilateral PPGL, or unilateral disease with a positive family history should have genetic testing. Definitive treatment is surgical after α-blockade. Conclusion: This case highlights a rare presentation of bilateral PPGL in a patient with TSC.

Efficacy of radiofrequency ablation for treatment of toxic thyroid nodules-a narrative review.

Background and Objective: Radiofrequency ablation (RFA) has been used in the treatment of benign thyroid nodules for the past 20 years. The adaptation of RFA to benign autonomously functioning thyroid nodules (AFTNs) has been introduced into clinical practice with variable efficacy and outcomes published in the literature. To better understand international practices, we performed a literature search to better elucidate the efficacy and outcomes in the treatment of AFTNs with RFA. Methods: Comprehensive literature searches were independently conducted by two investigators on PubMed, EMBASE, and Scopus in October of 2022 to identify articles reporting AFTN treated by RFA using the terms "RFA", "radiofrequency ablation", "thyroid nodule", "toxic nodules", and "autonomous functioning thyroid nodule". Papers were selected by relevance of the title or abstract, and the date of publication. Key Content and Findings: In patients with toxic nodules, studies have shown 50% remission rate one year after single session of RFA, up to 71% after second dose. Adverse events are generally limited to postoperative pain lasting less than one day, however there are reports of self-limited voice changes, and self-limited hypothyroidism. RFA has been shown to be safe with no reported instances of post-procedure hypothyroidism or hypocalcemia when compared to radioactive iodine (RAI) and surgery. Conclusions: RFA is an acceptable alternative to surgical resection for the treatment of AFTNs in selective patients, however more studies on long-term hyperthyroidism remission rates and nodule regrowth are necessary for further applications.

A retrospective analysis of molecular testing in cytologically indeterminate thyroid nodules with histologic correlation: Experience at a heterogenous multihospital system.

INTRODUCTION: Thyroid malignancy is one of the most common types of cancer in developed nations. Currently, fine-needle aspiration cytology (FNAC) is the most practical screening test for thyroid nodules. However, cytologically indeterminate samples comprise approximately 15%-30% of cases. These include cases classified as atypia of undetermined significance (AUS), follicular neoplasm (FN), and suspicious for malignancy (SFM). Indeterminate cases can be sent for molecular testing for more definitive classification to help guide management and prevent overtreatment of benign thyroid nodules. We conducted a retrospective review on molecular testing of indeterminate thyroid FNAC and reviewed subsequent histologic diagnoses in resection specimens to assess how molecular testing supported a diagnosis and its effect on clinical management of patients at our institution. METHODS: A retrospective chart review was performed on all thyroid FNAC specimens, corresponding molecular testing, and subsequent surgical resection specimens over a 6-year period. RESULTS: A total of 10,253 thyroid FNAC were performed in our hospital system during our study period, of which 10% (n = 1102/10,253) had indeterminate FNAC results. Molecular testing was performed in 16% (n = 178/1102) of indeterminate cytology cases. Genetic alterations were identified in 39% (n = 69/178) of the cases sent for molecular testing. The majority of cytologically indeterminate cases sent for molecular testing were follicular-patterned lesions and their corresponding resection specimens revealed mostly low grade follicular derived neoplasms (i.e., follicular adenoma, non-invasive follicular thyroid neoplasm with papillary-like nuclear features, and follicular variant of papillary thyroid carcinoma). Of the cases with identified genetic alterations, 75% (n = 52/69) were treated surgically. In cases with no genetic alterations identified, only 18% (n = 20/109) were treated surgically. DISCUSSION/CONCLUSION: Molecular testing on cytologically indeterminate thyroid nodules can help provide a more accurate risk of malignancy assessment in patients with lesions that are difficult to diagnosis based solely on FNAC morphology. The types of genetic alterations identified in the resected thyroid lesions were consistent with what has been previously described in the literature. Additionally, we found that in the patients with indeterminate thyroid FNAC with adjunct molecular testing, more than half did not undergo surgical resection. This finding emphasizes the value of adding molecular testing in patients, particularly when attempting to reduce unnecessary surgical intervention.

Presentation and outcomes of patients with undifferentiated thyroid carcinoma: a national perspective.

BACKGROUND: Undifferentiated thyroid cancer (UTC) accounts for only 1-2% of all thyroid cancers. UTC is one of the most aggressive solid tumors with high metastatic rates and mortality. The objectives of this study are to examine the characteristics of patients with UTC and their overall survival. METHODS: Retrospective analysis utilizing the National Cancer Database, 2004-2014 is performed. The study population included adults (≥18 years) patients with UTC or differentiated thyroid carcinoma (DTC), which served as a reference group. RESULTS: A total of 1,870 UTC and 209,707 DTC patients were identified. The median follow-up time of UTC patients was 3.9 months (interquartile range: 1.6-9.0 months). When compared to DTC patients, patients with UTC were more likely to be ≥45-year-old [OR: 48.62, 95% CI: (35.75, 66.14), P<0.001], male [OR: 2.02, 95% CI: (1.84, 2.22), P<0.001], and/or black [OR: 1.27, 95% CI: (1.08, 1.49), P=0.004]. UTC patients were more likely to have Medicaid/Medicare or no insurance and treated in low-volume hospitals (P<0.001). Overall survival in patients with UTC was lower in patients older than 65 years [OR: 1.63, 95% CI: (1.12, 2.38), P=0.011], with multiple comorbidities [OR: 1.65, 95% CI: (1.02, 2.67), P=0.040] and/or presented with metastatic disease [OR: 1.93, 95% CI: (1.71, 2.17), P<0.001]. Compared to thyroidectomy alone, patients without metastasis who received adjuvant radiotherapy and/or chemotherapy had a better overall survival (P<0.001 each). In patients with metastatic disease, any intervention or combination of interventions other than thyroidectomy alone improved survival (P<0.05). CONCLUSIONS: Older age, male, and/or black are associated with a higher prevalence of UTC compared to DTC. Although overall survival is poor in UTC, utilization of multi-modal treatment may improve survival.

Impact of surgery versus medical management on cardiovascular manifestations in Graves disease.

BACKGROUND: Graves disease is well known to have multiple adverse effects on the cardiovascular system. We compared the cardiovascular outcomes after surgical intervention versus medical treatment in patients with Graves disease. METHODS: We performed a retrospective study of all Graves disease patients with a cardiovascular comorbidity who underwent either surgical or medical management (N = 151). Perioperative biochemical and cardiovascular outcomes from the surgical versus the medical groups were analyzed. RESULTS: Of 151 patients, 69 (45.6%) patients underwent total thyroidectomy and 82 (54.3%) patients received medical treatment. Hypertension resolved in 44.7% of the patients from the surgical group vs 18% in the medical group (P = .03). Tachyarrhythmias, including atrial fibrillation and tachycardia, improved in 85.9% of patients in the surgical group vs 66% in the medical group (P = .01). All cardiovascular manifestations examined, hypertension, tachyarrhythmias, and heart failure, improved in 69% of patients in the surgical group and 42.6% of patients in the medical group during the follow-up period (P < .01). CONCLUSION: Surgical treatment offers a significant and rapid clinical improvement of cardiovascular manifestations in Graves disease patients, such as hypertension, tachyarrhythmias, and heart failure. Surgery should be considered and recommended in Graves disease patients with known cardiovascular manifestations.

Impact of psychiatric comorbidities on outcomes related to thyroid and parathyroid operations.

BACKGROUND: We examined the effect of psychiatric comorbidities on perioperative surgical outcomes and the leading causes of readmissions in patients who underwent thyroid and parathyroid operations. METHOD: Patient information was retrieved from the Nationwide Readmission Database (2010-2017). Multivariate analysis was used to identify predictors for hospital readmissions. RESULTS: A total of 181,007 and 53,808 patients underwent thyroid and parathyroid operations, respectively. Of those, 8,468 (4.7%) and 6,112 (11.4%) patients were readmitted within 30 days. Psychiatric comorbidities were more frequent in readmitted cohorts after thyroidectomies (14.9% vs 10.4%; P < .001) and parathyroidectomies (16.8% vs 11.5%; P < .001), with anxiety being the most frequent cause (thyroid: 7.87%, parathyroid: 6.8%). Psychiatric comorbidities were associated with greater risk of in-hospital mortality (thyroid: odds ratio = 2.07, 95% confidence interval = 1.13-3.53; P = .015 and parathyroid: odds ratio = 1.67, 95% confidence interval = 1.04-2.70; P = .005), postoperative complications (thyroid: odds ratio = 1.528, 95% confidence interval = 1.473-1.585; P < .001 and parathyroid: odds ratio = 3.26, 95% confidence interval = 2.84-3.73; P < .001), prolonged duration of stay (thyroid: beta coefficient = 1.142, 95% confidence interval = 1.076-1.207; P < .001 and parathyroid: beta coefficient = 2.15, 95% confidence interval = 1.976-2.32; P < .001), and 30-day readmissions (thyroid: hazard ratio = 1.18, 95% confidence interval = 1.03-1.18; P = .047 and parathyroid: hazard ratio = 1.23, 95% confidence interval = 1.11-1.36; P < .001). Psychosis had the greatest risk of readmission (thyroid: hazard ratio = 1.51 and parathyroid: hazard ratio = 1.42), and dementia (odds ratio = 2.58) had the greatest risk of postoperative complications. CONCLUSION: Concomitant psychiatric conditions after thyroid and parathyroid operations were associated with increased risk of postoperative complications, prolonged hospital stays, and greater rates of readmissions.

Bile duct injury repairs: Progressive outcomes in a tertiary referral center.

BACKGROUND: Bile duct injury during laparoscopic cholecystectomy persists as a significant problem in general surgery, resulting in complex injuries, arterial damage, and post repair strictures. METHODS: We performed a retrospective analysis between 2 eras of bile duct injury repairs: 1987 to 2001 (n = 58) and 2002 to 2016 (n = 52) using logistic regression analyses to assess presentation, repair complexity, and outcomes. RESULTS: No differences in demographics, incidence of cholecystitis, conversion, time to presentation, level of injury, or arterial injury were identified. The second era had an increase in patient age, transhepatic catheter use, prior repair, and utilization of complex repairs. This approach resulted in equivalent complications and mortality rates with increased resource utilization but a lesser incidence of post-repair strictures (P = .004). Regression modeling correlated strictures to prior operative repairs (OR 4.25; P = .016) and a protective effect of repairs performed in the second era (OR 0.23; P = .045). CONCLUSION: The second era identified a decreasing trend of attempted repairs by referring surgeons but an increase in transhepatic catheters and complex repairs resulting in lesser rates of post-repair stricture. Final regression modeling confirmed increased operative experience decreased post-repair stricture reaffirming the benefits of early identification and referral of bile duct injuries to an experienced hepatobiliary surgeon at a specialty center.

DIAGNOSTIC UTILITY OF HUMAN CHORIONIC GONADOTROPIN WASHOUT IN CERVICAL LYMPH NODE FINE-NEEDLE ASPIRATION FOR METASTATIC TESTICULAR CANCER.

OBJECTIVE: This case report will describe the first adjunct use of directly measuring the concentration of human chorionic gonadotropin (HCG) in fine-needle aspiration (FNA) washout for diagnosing metastatic non-semi-nomatous germ cell tumor (NSGCT) of the testicle in a patient with cervical lymphadenopathy. METHODS: We present the clinical, laboratory, imaging, and pathologic findings, along with a review of the literature. RESULTS: A 23-year-old, otherwise healthy man who first presented with left testicular discomfort and swelling was diagnosed with NSGCT after undergoing a left orchiectomy. A few years later, the patient presented with a 2-cm left supraclavicular mass. Upon ultrasound of the thyroid and soft tissues of the neck, a 1-cm left thyroid nodule was revealed, as well as a 2.8-cm left supraclavicular lymph node, which was cystic in nature and worrisome for metastatic disease given the patient's history of metastatic NSGCT. The results of the FNA of the left thyroid nodule were benign, however the results from the supraclavicular mass were nondiagnostic. Due to the nondiagnostic FNA results, another aspiration with cytopathology and HCG evaluation washout was performed. The HCG aspirate came back with a value of 162 mIU/mL, despite the patient's negative serum HCG results. CONCLUSION: This case demonstrates a novel way to diagnose metastatic testicular germ cell tumors utilizing FNA-HCG washout. Future prospective trials are needed to further elucidate this important finding.

MEF2B is a member of the BCL6 gene transcriptional complex and induces its expression in diffuse large B-cell lymphoma of the germinal center B-cell-like type.

Myocyte enhancer-binding factor 2B (MEF2B) has been implicated as a transcriptional regulator for BCL6. However, details about the interaction between MEF2B and BCL6 during expression, as well as the relationship of MEF2B to the expression of other germinal center (GC) markers, have not yet been fully explained. Using germinal center B-cell-like diffuse large B-cell lymphoma (GC-DLBCL) and activated B-cell diffuse large B-cell lymphoma (ABC-DLBCL) cell lines, we analyzed the expression of MEF2B and its associations with BCL6, CD10, and ERK. Furthermore, small interfering RNA (siRNA) was used to study the possible effects of MEF2B knockdown on these proteins and cell growth. Analysis of the BCL6 transcriptional complex was performed using electrophoretic mobility shift assay. The correlation between MEF2B expression and the genetic type of DLBCL was assessed using immunohistochemistry on 111 patient samples, and via in silico analysis of publicly available microarray (Gene Expression Omnibus (GEO)) datasets. Our results indicate that the expression of MEF2B protein is important for the growth of GC-DLBCL cells, as evidenced by MEF2B knockdown inhibition of cell growth and the subsequent suppression of BCL6, CD10, and ERK phosphorylation. Analysis of BCL6 transcription factors in nuclear extracts of MEF2-expressing DLBCL cells showed involvement of MEF2B with AP-2α and BCL6 proteins in the formation of the BCL6 gene transcriptional complex. Indeed, differential expression of MEF2B in the GC-DLBCL is statistically significant compared to the ABC-DLBCL in the GEO datasets, as well as in tissue microarray, as indicated via immunohistochemistry (Visco-Young algorithm). Our findings indicate that MEF2B is an essential component of the BCL6 gene transcriptional complex for the regulation of DLBCL growth via the promotion of BCL6 expression. Beyond its regulatory role in DLBCL growth, MEF2B expression correlated positively with BCL6 and CD10 expression, and was preferentially expressed in the GBC-DLBCL group.

Superior detection of metastatic cystic lymphadenopathy in patients with papillary thyroid cancer by utilization of thyroglobulin washout.

BACKGROUND: Fine-needle aspiration (FNA) cytology has been the standard of care in the workup of cervical lymph nodes (LNs) in patients with recurrent papillary thyroid cancer (PTC) and suspicious cervical LNs. Recently, FNA thyroglobulin (TG) washout measurement has been proposed as an adjunct in the management of these patients. We hypothesize that using FNA-TG washout for suspicious cervical LNs would increase the accuracy of diagnosing metastatic disease especially in cystic and highly vascular cervical LN in patients with recurrent PTC. METHODS: This is a retrospective study of a prospectively collected database for patients with thyroid cancer who underwent preoperative FNA followed by selective neck dissection by one surgeon at an academic institution. FNA-cytology and FNA-TG washout were performed simultaneously. A total of 138 patients were included in our study, of which 92 (66.7%) had undergone surgical intervention. Results of both methods were then correlated with the final surgical pathology. RESULTS: FNA-cytology alone showed a sensitivity of 80.0%, specificity of 100.0% with a negative predictive value (NPV) of 60.0%. By contrast, FNA-TG washout had a sensitivity of 95.8%, specificity of 90.5% with a NPV of 86.4%. Combination of the FNA-cytology with FNA-TG washout of cystic/highly vascular LN increased the accuracy of diagnosis with a sensitivity of 98.2%, specificity of 100.00% with a NPV of 95.0%. All 14 malignant cervical LNs with false-negative FNA-cytology showed elevated FNA-TG washout, 10 (71.4%) of which were cystic in nature and 4 were highly vascular on ultrasonography. CONCLUSION: FNA-TG washout increases the diagnostic accuracy in detecting metastatic disease in patients with recurrent thyroid cancer. FNA-TG washout may be of special diagnostic importance in cystic or highly vascular LNs, which might have falsely negative cytology. LEVEL OF EVIDENCE: 2B.

Can Suspicious Ultrasound Features Predict BRAFV600E Status in Papillary Thyroid Cancer?

BACKGROUND: Papillary thyroid carcinoma (PTC) can be predicted from certain suspicious ultrasound (US) features of thyroid nodules. The aim of this study was to examine if these suspicious features can predict the more aggressive PTC associated with B-type Raf kinase (BRAFV600E) mutation. METHODS: This was a retrospective review of prospectively collected data on patients with PTC and known BRAFV600E status. All patients underwent preoperative US by the same surgeon who performed all the operations. We divided patients into BRAFV600E positive and negative groups. All ultrasonographic data were collected including nodule size, echogenicity, solid or cystic nature, presence of calcifications, irregular margins, and internal vascularity. RESULTS: Of 141 patients with PTC, BRAFV600E mutation was detected in 48 (34.0$) patients. There was no significant difference in nodule size (2.06 cm ± 1.37 vs. 2.15 cm ±1.55, p = 0.75) between BRAFV600E positive and negative groups. BRAFV600E positivity was associated with higher rates of -hypoechogenicity (57.5$ vs. 36.6, p = 0.02), calcifications (48.9 vs. 19.4$, p < 0.01), and irregular margins (21.3 vs. 6.5$, p < 0.01). There was no significant difference in the noncystic nature or internal vascularity between BRAFV600E positive and negative groups. The presence of all suspicious US features is associated with a positive predictive value of 100.0$. In the absence of all suspicious features, the negative predictive value was 84.2$. When suspicious lymph nodes (LNs) detected by preoperative US were compared, there was no significant difference between BRAFV600E positive and negative groups (30.6 vs. 21.7$, p = 0.35). CONCLUSION: The presence of multiple suspicious US findings of thyroid nodules can predict the BRAFV600E mutation status of papillary thyroid cancer nodules. The highest accuracy overall (93.2$) was achieved by combining calcification, irregular margins, and hypoechogenicity with extrathyroidal extension and LN metastasis. Future multi-institutional studies are warranted to help surgeons with risk stratification and operative planning for patients with papillary thyroid cancer.

Hemostatic agent use in thyroid surgery: a meta-analysis.

BACKGROUND: The use of hemostatic agents in thyroid surgery has been widely reported in the literature. The aim of this study is to assess the safety and efficacy of hemostatic agents in comparison to conventional techniques for hemostasis by meta-analysis of the current literature. METHODS: Articles were identified from PubMed and EMBASE using the following keyword searches: "hemostatic agent and thyroid surgery" and "hemostatic agent and thyroidectomy". Outcomes included total operative time, estimated blood loss, length of hospital stay, and intraoperative and postoperative complications. Data were extracted following review of appropriate studies by two independent authors and outcome differences were calculated using analysis of variance and the Bonferroni method. RESULTS: Thirty-four publications were identified and 10 studies met our inclusion criteria, totaling 941 patients, 519 (55.1%) of which received a hemostatic agent during thyroid surgery. Of these patients who had hemostatic agents, 369 (71%) received a hemostatic gel and 150 (29%) received an oxidized cellulose patch. Outcome measures in each of these groups were compared with the patients receiving only conventional methods of hemostasis. The risk of hematoma formation in the hemostatic gel group was comparable to conventional hemostatic methods (95% CI: 0.33, 2.59). This was also true when comparing conventional hemostasis to the patch (95% CI: 0.64, 15.24). No difference in the risk for seroma formation was found between the conventional and hemostatic gel groups (95% CI: 0.26, 3.95). Drain output was significantly less in the gel group 40.75±35.6 mL compared to 66.26±31.2 mL in the conventional group (95% CI: -23.422, -7.460). Patients who received hemostatic agents had shorter hospital stays when compared to the conventional group (95% CI: -1.057, -0.203). CONCLUSIONS: Our meta-analysis suggests that the use of a hemostatic agent in thyroid surgery yields minimal advantages for the management of perioperative bleeding risk.

Risk and survival of patients with medullary thyroid cancer: National perspective.

BACKGROUND: Medullary thyroid carcinoma (MTC) is a neuroendocrine tumor account for 1-2% of thyroid cancer. In this study, we aim to examine the characteristics and survival of patients with MTC. METHODS: A retrospective cohort study utilizing the National Cancer Data Base, 2004-2014. The study population included adults with either MTC (cases) or with differentiated thyroid cancer (DTC) (controls). RESULTS: A total of 2,776 MTC and 171,631 DTC patients were included. The median follow-up time for MTC was 55.5 months (interquartile range: 31.2-84.6 months). As compared to DTC, patients with MTC were more likely to be ≥ 45-year old, male, and Black (p < 0.001). Neck dissection improved survival in patients with stage III [HR: 0.26, 95%CI: (0.10, 0.64), p = 0.004]. In patients with stages I and II, neck dissections did not add significant survival benefit to thyroidectomy [stage I, HR: 1.00, 95%CI: (0.54, 1.86), p = 0.99],[stage 2, HR: 0.72, 95%CI: (0.40, 1.29), p = 0.27]. However, neck dissections upgraded staging to N1A and N1B in 17.7% and 14.3% of patients with clinically N0 neck, respectively. In stage IV, thyroidectomy with neck dissection had the highest 5-year survival (84.9%), but this was not significantly different from thyroidectomy alone (84.1%); Patients who had thyroidectomy and EBRT with or without neck dissection had a lower survival than thyroidectomy alone (p < 0.01). CONCLUSIONS: Neck dissection performed on patients with clinically N0 neck, is important for accurate staging and associate with improved survival in advanced stages. Thyroidectomy and neck dissection in stage IV not only have palliative role but also add survival advantage.

Do anticoagulation medications increase the risk of haematoma in ultrasound-guided fine needle aspiration of thyroid lesions?

BACKGROUND: A feared complication of thyroid fine needle aspiration (FNA) is bleeding diathesis and haematoma at the biopsy site. Patients are often advised to discontinue antithrombotic/anticoagulant (AT/AC) medications prior to the procedure. The aim of this study was to examine the risk of bleeding in patients on AT/AC medications undergoing cervical ultrasound (US)-guided FNA. METHODS: A retrospective chart review of 803 patients who underwent US-guided FNA of thyroid nodules over 8 years by a single endocrine surgeon was undertaken. Clinical variables, patient demographics and use of AT/AC medications were collected and analysed. The principle outcome measures included the incidence of procedure-related haematoma formation. Multivariable logistic regression was used to investigate the possible independent association between post-FNA haematoma and anticoagulation, adjusting for age, African American race, body mass index, vascularity and lesion size. RESULTS: A total of 1568 lesions were included in 803 patients. The mean age for the patients on AT/AC was 63.0 ± 10.4 years and those not on AT/AC was 50.1 ± 14.2 years (P < 0.001). Of those, 148 patients had 336 lesions (21%) biopsied while taking one or more daily AT/AC agent (81 patients: aspirin; 11 patients: Plavix; 17 patients: aspirin and warfarin; 30 patients: aspirin and Plavix; seven patients: rivaroxaban and aspirin; and two patients: ticagrelor and aspirin). Three patients (0.89%) in the AT/AC group compared to six patients (0.49%) not receiving AT/AC medications developed a haematoma (P = 0.41). All complications were treated conservatively and none required intervention. CONCLUSIONS: US-guided FNA of thyroid lesions can be safely performed on patients taking AT/AC including newer agents, without an increase in adverse outcomes or decreased diagnostic rate. Further larger prospective multi-institutional studies are warranted to further investigate this important finding.

Safety of same-day thyroidectomy: meta-analysis and systematic review.

BACKGROUND: Performance of thyroid surgery as a same day surgery procedure has been a controversial topic. This study aimed to compare the safety and efficacy of outpatient thyroid surgery with inpatient thyroid surgery by meta-analysis of current literature. METHODS: Articles were identified from the following keyword searches: outpatient thyroidectomy/thyroid surgery, same day thyroidectomy/thyroid surgery. Outcomes included perioperative complications including recurrent laryngeal nerve (RLN) injury, hypocalcemia, and readmissions. Data were extracted following review of appropriate studies by authors and random effects models were used. RESULTS: 34 potentially relevant publications were identified and 14 studies fulfilled the predetermined inclusion criteria, totaling 10,478 patients, 4,565 of whom were discharged the same day following thyroid surgery. There was no difference in malignancy rate between the two groups (95% CI, 0.84-2.31; P=0.196). Inpatient group were 2.23 times (95% CI, 1.36-3.36; P=0.001) more likely to develop transient RLN injury and 2.32 times (95% CI, 1.06-5.06; P=0.034) more likely to have documented transient hypocalcemia compared to outpatients. Inpatient groups were 2.10 times (95% CI, 1.33-3.33; P=0.002) more likely to have documented other complications. The two groups also had similar readmission rates (95% CI, 0.71-1.41; P=1.000). CONCLUSIONS: Our meta-analysis suggests that discharging selective patients the same day after a thyroid surgery is as safe, feasible, and efficacious as admitting them for observation. Admitting patients after thyroid surgery is associated with higher reported risk of complications.

Is vascular flow a predictor of malignant thyroid nodules? A meta-analysis.

BACKGROUND: Several reports have proposed that increased vascular flow on color Doppler sonography may be associated with malignancy in thyroid nodules. Others have described no correlation between the presence of flow and risk of malignancy. The purpose of this study was to determine whether the vascularity of a thyroid nodule can aid in the prediction of malignancy by performing a meta-analysis of the current literature. METHODS: Independent reviewers conducted a systematic review of publications from PubMed, EMBASE, and the Cochrane Database of Systematic Review using the following keyword searches: "vascular thyroid nodule", and "vascular malignant thyroid nodule". Outcomes included vascular flow pattern, nodule size, calcifications, echogenicity, margins, and shape. Data were extracted following review of appropriate studies, and outcome differences were calculated using analysis of variance and the Bonferroni method. RESULTS: Eighty-nine publications were identified and 14 prospective studies met inclusion criteria totaling 4,154 thyroid nodules, 1,419 (34%) of which were malignant. Thirty-three percent of malignant thyroid nodules had no vascular flow, while 17% had peripheral and 50% had internal vascular flow. There was no significant difference in vascular flow (95% CI: -14.329, 4.257), or peripheral vascular flow rate between malignant and benign thyroid nodules (95% CI: -29.254, 4.313). Also, there was no significant difference in internal vascularity between malignant and benign thyroid nodules (95% CI: -72.067, 2.824). CONCLUSIONS: It appears that utilization of vascular flow on color Doppler sonography may not accurately predict malignancy in thyroid nodules. Further studies are warranted to investigate the predictive role of increased vascularity in diagnosing suspicious thyroid nodules.

Different surgical approaches in parathyroid adenoma resections.

Three patients were referred to our clinic for the management of a persistent symptomatic primary hyperparathyroidism. Pre-operative imageological localization revealed evidence of an adenoma. Here we are presenting three videos demonstrating the different surgical approaches of parathyroid adenoma resection, with the use of an intraoperative gamma probe and nerve monitoring.

Delayed failure after endoscopic staple repair of an anterior spine surgery related pharyngeal diverticulum.

We present a rare complication of endoscopic staple repair of a pharyngeal diverticulum related to prior anterior cervical spine surgery. A 70-year-old male developed a symptomatic pharyngeal diverticulum 2 years after an anterior cervical fusion that was repaired via endoscopic stapler-assisted diverticulectomy. He initially had improvement of his symptoms after the stapler-assisted approach. Three years later, the patient presented with dysphagia and was found to have erosion of the cervical hardware into the pharyngeal lumen at the site of the prior repair. We present the first reported case of late hardware erosion into a pharyngeal diverticulum after endoscopic stapler repair.

Electrocardiogram in pneumonia.

Findings on electrocardiogram may hint that pulmonary embolism (PE) is present when interpreted in the proper context and lead to definitive imaging tests. However, it would be useful to know if electrocardiographic (ECG) abnormalities also occur in patients with pneumonia and whether these are similar to ECG changes with PE. The purpose of this investigation was to determine ECG findings in patients with pneumonia. We retrospectively evaluated 62 adults discharged with a diagnosis of pneumonia who had no previous cardiopulmonary disease and had electrocardiogram obtained during hospitalization. The most prevalent ECG abnormality, other than sinus tachycardia, was minor nonspecific ST-segment or T-wave changes occurring in 13 of 62 (21%). Right atrial enlargement occurred in 4 of 62 (6.5%). QRS abnormalities were observed in 24 of 62 (39%). Right-axis deviation and S(1)S(2)S(3) were the most prevalent QRS abnormalities, which occurred in 6 of 62 (9.7%). Complete right bundle branch block and S(1)Q(3)T(3) pattern occurred in 3 of 62 (4.8%). ECG abnormalities that were not present within 1 month previously or abnormalities that disappeared within 1 month included left-axis deviation, right-axis deviation, right atrial enlargement, right ventricular hypertrophy, S(1)S(2)S(3), S(1)Q(3)T(3), low-voltage QRS complexes, and nonspecific ST-segment or T-wave abnormalities. In conclusion, electrocardiogram in patients with pneumonia often shows QRS abnormalities or nonspecific ST-segment or T-wave changes. ECG findings are similar to ECG abnormalities in PE and electrocardiogram cannot assist in the differential diagnosis.