Pediatric Thyroidectomy: NSQIP-P Analysis of Adverse Perioperative Outcomes.

BACKGROUND: This study identifies risk factors and 30-day adverse outcomes of pediatric patients undergoing thyroidectomy. METHODS: Retrospective analysis utilizing the American College of Surgeons National Surgical Quality Improvement-Pediatric Database (2015-2016). Study population includes pediatric patients (≤18 years) who underwent hemithyroidectomy (HT), total thyroidectomy (TT), and total thyroidectomy with central neck dissection (TT+ND). RESULTS: A total of 720 cases were identified; mean age at time of surgery was 14.1 years, with a female-to-male ratio of 3.4:1. Following hospital discharge, there were 10 related readmissions, with 1 patient requiring reoperation for neck hematoma evacuation. Regression analysis revealed anesthesia time had a significant impact on total length of stay (P = .0020). CONCLUSION: Contemporary pediatric thyroidectomy has a low incidence of 30-day general surgical postoperative complications. Future research efforts are necessary once thyroidectomy specific variables are incorporated into ACS-NSQIP-P, which will provide further insights into managing this unique patient population.

Guidelines for radiographic imaging of cranial neuropathies.

Disruption of the complex pathways of the 12 cranial nerves can occur at any site along their course, and many, varied pathologic processes may initially manifest as dysfunction and neuropathy. Radiographic imaging (computed topography or magnetic resonance imaging) is frequently used to evaluate cranial neuropathies; however, indications for imaging and imaging method of choice vary considerably between the cranial nerves. The purpose of this review is to provide an analysis of the diagnostic yield and the most clinically appropriate means to evaluate cranial neuropathies using radiographic imaging. Using the PubMed MEDLINE NCBI database, a total of 49,079 articles' results were retrieved on September 20, 2014. Scholarly articles that discuss the etiology, incidence, and use of imaging in the context of evaluation and diagnostic yield of the 12 cranial nerves were evaluated for the purposes of this review. We combined primary research, guidelines, and best practice recommendations to create a practical framework for the radiographic evaluation of cranial neuropathies.

Cost-conscious decisions in the timing of operation for minimally symptomatic inguinal hernias in male patients.

BACKGROUND: Expectant management (EM) and early open repair (OR) are safe and effective as initial management strategies for minimally symptomatic inguinal hernia in male patients. Extended follow-up of patients in EM protocols have shown that most patients will eventually require repair, but it is not clear which strategy is less costly over the long term. METHODS: We constructed a mathematical model to compare 3rd-party payer expenditures for EM vs OR or laparoscopic repair in a simulated cohort of patients with inguinal hernia. Cohort characteristics and expenditures were calibrated to recent randomized trials that reported initial follow-up and expenditures at 2 years and long-term crossover rates from EM to OR. RESULTS: Cost comparisons between OR and EM are sensitive to direct long-term costs of inpatient and outpatient care, the likelihood of crossover from EM to operation, cost differences between OR and laparoscopic repair, and the net present value of longer-term costs. CONCLUSIONS: Our findings suggest that short-term costs of EM are less than those of OR and Lap-R, but early OR provides the highest long-term savings.

Optimal Frequency of Psychosocial Distress Screening in Radiation Oncology.

PURPOSE: To accurately hypothesize the optimal frequency of psychosocial distress screening in patients undergoing radiation therapy using exploratory modeling of prospective data. MATERIALS AND METHODS: Between October 2010 and May 2011, 71 RT patients underwent daily screening with the Distress Thermometer. Prevalences of Distress Thermometer scores ≥ 4 were recorded. Optimal screening frequency was evaluated by planned post hoc comparison of prevalence rates and required screening events estimated by numerical modeling, consisting of data point omission to mimic weekly, every-other-week, monthly, and one-time screening intervals. Dependence on clinical variables and chronologic trends were assessed as secondary end points. RESULTS: A total of 2,028 daily screening events identified that 37% of patients reported distress at least once during the course of treatment. Weekly, every-other-week, monthly, and one-time screening models estimated distress prevalences of 32%, 31%, 23%, and 17%, respectively, but required only 21%, 12%, 7%, and 4% of the assessments required for daily screening. No clinical parameter significantly predicted distress in univariable analysis, but "alone" living situation trended toward significance (P = .06). Physician-reported grade 3 toxicity predicted distress with 98% specificity, but only 19% sensitivity. CONCLUSION: Thirty-seven percent of radiation oncology patients reported distress at least once during treatment. Screening at every-other-week intervals optimized efficiency and frequency, identifying nearly 90% of distressed patients with 12% of the screening events compared with daily screening.

Relationship between obesity, diabetes and the risk of thyroid cancer.

PURPOSE: Analyze the relationship between obesity and type-2 diabetes mellitus (DM) and the development of differentiated thyroid cancer (DTC). MATERIALS AND METHODS: A randomized case-controlled retrospective chart review of outpatient clinic patients at an academic medical center between January 2005 and December 2012. DTC patients were compared to two control groups: primary hyperparathyroidism (PHPTH) patients with euthyroid state and Internal Medicine (IM) patients. Exposure variables included historical body-mass-index (BMI), most recent BMI within 6 months and DM. Multivariate logistic regressions adjusting for gender, age, and year of BMI assessed the adjusted Odds Ratio (OR) of DTC with both BMI and DM. RESULTS: Comparison of means showed a statistically significant higher BMI in DTC (BMI=37.83) than PHPTH, IM, and pooled controls, BMI=30.36 p=<0.0001, BMI=28.96 p=<0.0001, BMI=29.53 p=<0.0001, respectively. When compared to PHPTH, DM was more frequent in DTC (29% vs. 16%) and prevalence trended towards significance (p=0.0829, 95% CI =0.902-5.407). BMI adjusted OR was significant when compared to PHPTH, IM and pooled controls: 1.125 (p=0.0001), 1.154 (p=<0.0001), and 1.113 (p=<0.0001), respectively. DM adjusted OR was significant when compared to PHPTH and pooled controls at 3.178 (95% 1.202,8.404, p=0.0198) and 2.237 (95% 1.033,4.844, p=0.0410), respectively. CONCLUSION: Our results show that obesity and, to a lesser degree, DM are significantly associated with DTC. BMI in particular was a strong predictive variable for DTC (C=0.82 bivariate, C=0.84 multivariate).

An implemented MRI program to eliminate radiation from the evaluation of pediatric appendicitis.

BACKGROUND: Recent efforts have been directed at reducing ionizing radiation delivered by CT scans to children in the evaluation of appendicitis. MRI has emerged as an alternative diagnostic modality. The clinical outcomes associated with MRI in this setting are not well-described. METHODS: Review of a 30-month institutional experience with MRI as the primary diagnostic evaluation for suspected appendicitis (n=510). No intravenous contrast, oral contrast, or sedation was administered. Radiologic and clinical outcomes were abstracted. RESULTS: MRI diagnostic characteristics were: sensitivity 96.8% (95% CI: 92.1%-99.1%), specificity 97.4% (95% CI: 95.3-98.7), positive predictive value 92.4% (95% CI: 86.5-96.3), and negative predictive value 98.9% (95% CI: 97.3%-99.7%). Radiologic time parameters included: median time from request to scan, 71 minutes (IQR: 51-102), imaging duration, 11 minutes (IQR: 8-17), and request to interpretation, 2.0 hours (IQR: 1.6-2.6). Clinical time parameters included: median time from initial assessment to admit order, 4.1 hours (IQR: 3.1-5.1), assessment to antibiotic administration 4.7 hours (IQR: 3.9-6.7), and assessment to operating room 9.1 hours (IQR: 5.8-12.7). Median length of stay was 1.2 days (range: 0.2-19.5). CONCLUSION: Given the diagnostic accuracy and favorable clinical outcomes, without the potential risks of ionizing radiation, MRI may supplant the role of CT scans in pediatric appendicitis imaging.