Bioenergy production from chicken feather waste by anaerobic digestion and bioelectrochemical systems.

BACKGROUND: Poultry feather waste has a potential for bioenergy production because of its high protein content. This research explored the use of chicken feather hydrolysate for methane and hydrogen production via anaerobic digestion and bioelectrochemical systems, respectively. Solid state fermentation of chicken waste was conducted using a recombinant strain of Bacillus subtilis DB100 (p5.2). RESULTS: In the anaerobic digestion, feather hydrolysate produced maximally 0.67 Nm3 CH4/kg feathers and 0.85 mmol H2/day.L concomitant to COD removal of 86% and 93%, respectively. The bioelectrochemical systems used were microbial fuel and electrolysis cells. In the first using a microbial fuel cell, feather hydrolysate produced electricity with a maximum cell potential of 375 mV and a current of 0.52 mA. In the microbial electrolysis cell, the hydrolysate enhanced the hydrogen production rate to 7.5 mmol/day.L, with a current density of 11.5 A/m2 and a power density of 9.26 W/m2. CONCLUSIONS: The data indicated that the sustainable utilization of keratin hydrolysate to produce electricity and biohydrogen via bioelectrical chemical systems is feasible. Keratin hydrolysate can produce electricity and biofuels through an integrated aerobic-anaerobic fermentation system.

Nanocurcumin: A Promising Therapeutic Candidate for Experimental Trichinellosis.

In our pursuit of an alternative drug against Trichinella spiralis, we assessed the effectiveness of nanocurcumin in alleviating pathogenesis, parasitological factors, MMP-9 levels, and its expression in the enteral and parenteral phases of infection. The nanocurcumin particles, with a spherical shape and a size of 100 ± 20 nm, were used in the study. Eighty mice were divided into four groups: the control group, the untreated infected group, the nanocurcumin-treated group, and the albendazole-treated group. The nanocurcumin-treated group exhibited a statistically significant increase in the percentage of lymphocytes, along with a reduction in neutrophils, monocytes, and eosinophils compared to the untreated, infected group. Both the nanocurcumin (87.2 and 97.3%) and the albendazole-treated groups (99.8 and 98.2%) showed a significant reduction in the mean number of intestinal worms and encysted larvae, respectively. The treated groups exhibited normal intestinal villi, suppression of the inflammatory process, and fewer instances of degenerated larvae in the diaphragm and muscle compared to the untreated, infected group. Immunohistochemistry and ELISA analyses revealed a significant downregulation of MMP-9 levels in the intestines and muscles of the treated groups. Our data demonstrate that nanocurcumin contains highly versatile molecules capable of modulating biological activity against inflammation and its pathway markers.

Evaluation of the corneal thickness and endothelial changes following uncomplicated phacoemulsification in diabetic and non-diabetic patients with pseudo-exfoliation syndrome by specular microscopy.

PURPOSE: To evaluate corneal endothelial cell changes following uncomplicated phacoemulsification in diabetic patients with PEX, compared with diabetic patients and non-diabetic patients with PEX. METHODS: This prospective, comparative, non-randomized cohort study included 61 eyes of 61 patients who were diagnosed as having senile cataract. Patients were divided into three groups: Group (1) included 19 eyes of patients with DM and PEX, group (2) included 22 eyes of diabetic patients, and group (3) included 20 eyes of patients with PEX. All included patients had uncomplicated phacoemulsification with IOL implantation. Patients were examined by non-contact specular microscopy (NIDEK, CEM-530, Japan), preoperatively and postoperatively at regular follow-up periods (one, three, and six months postoperatively) with analysis of the endothelial cell density, percentage of hexagonal cells, CV, and CCT. RESULTS: By the end of follow-up period, there was a statistically significant reduction in ECD and HEX with a significant increase in CV and CCT in group one (DM-PEX). In group two (DM), a statistically significant decrease in ECD and HEX with a significant increase in CCT was reported, while in group three (PEX), the only significant difference was found in the form of ECD reduction. CONCLUSION: Patients with DM and PEX had significant changes regarding ECD, CV, HEX, and CCT which were more pronounced than in patients with DM only or PEX only. More attention should be paid while operating on diabetic patients with PEX to save corneal endothelium and decrease postoperative complications. STUDY REGISTRATION NUMBER: The study was retrospectively registered (16 July 2021) on ClinicalTrials.gov (NCT04965168).

Effect of Light Conditions and Accommodation on Implantable Phakic Contact Lens Vault by Anterior Segment Optical Coherence Tomography.

Purpose: To investigate the dynamic pupil and vault changes in eyes with implantable phakic contact lens (IPCL) under photopic and scotopic settings, as well as during accommodation using the anterior segment optical coherence tomography (AS-OCT). Methods: A prospective observational study included consecutive 36 eyes of myopic patients who underwent IPCL V2.0 implantation. Under photopic and scotopic light settings, as well as during accommodation, all patients were scanned using CASIA OCT (CASIA2; TOMEY, Nagoya, Japan). The pupil size, the vault (distance between the back surface of the IPCL and the anterior lens capsule), ACD-lens (distance between the posterior corneal surface and the anterior lens surface), IPCL-lens (distance between the posterior corneal surface and the anterior IPCL surface), and lens thickness (LT) were the study parameters. Results: The vault was significantly lower under photopic conditions (p-value<0.001). The pupil size was significantly smaller in photopic conditions (p-value<0.001). LT (p-value=0.975) and ACD-lens (p-value=0.917) were not significantly different between scotopic and photopic conditions, while the ACD-IPCL was significantly larger during photopic conditions (p-value=0.013). There were significant changes in all parameters between accommodative and non-accommodative conditions. Conclusion: The IPCL vault decreased significantly under photopic light conditions and accommodation.

Evaluation of the anterior chamber angle by anterior segment optical coherence tomography after implantable phakic contact lens implantation in myopic eyes.

PURPOSE: To evaluate the changes in the angle of the AC and lens vault after IPCL implantation by AS-OCT in myopic patients. METHODS: This was a prospective observational study involving 30 myopic eyes implanted with IPCL. AS-OCT was used to evaluate lens vault and AC angle parameters including anterior chamber angle, angle opening distance and trabecular-iris space area (TISA) at 1, 3 and 6 months postoperatively. RESULTS: All 3 AC angle parameters were significantly reduced at the 1st postoperative month compared to preoperative values, but remained stable thereafter with no significant change at the 3rd or 6th postoperative months. The lens vault showed no significant change over the entire follow-up period. CONCLUSION: IPCL implantation is a safe method for correction of myopia with stable AC angle narrowing over the course of 6 months postoperatively as monitored using AS-OCT.

Macular vessel density before and after panretinal photocoagulation in patients with proliferative diabetic retinopathy.

INTRODUCTION: Diabetic retinopathy (DR) is microangiopathy causing ischemia leading to proliferative diabetic retinopathy and macular edema. Panretinal photocoagulation (PRP) reverses the ischemia leading to regression of neovessels. Most previous studies showed the large vessel effects of PRP, while optical coherence tomography angiography (OCTA) allowed noninvasive quantification of microvascular retinal changes. AIM: To study the effect of PRP on microvascular retinal vessels in a detailed manner at different retinal and choroidal levels using OCTA. PATIENTS AND METHODS: This study was a prospective interventional study. 30 eyes of 18 diabetic patients with PDR were included. All patients were evaluated clinically and with OCTA (Avanti RTVue-XR system, Optovue) to evaluate superficial and deep vessels density (VDs), choroidal flow, and FAZ area before PRP (base line) and 1 month and 6 months after PRP. RESULTS: PRP improved vessels density at superficial (SCP), deep (DCP), and choriocapillaris levels. Foveal vessel density at SCP and DCP were statistically significantly increased. SCP was 28.76 ± 2.56 at base line and was increased to 29.84 ± 2.47 and 30.89 ± 2.20 after 1 month and after 6 months, respectively. DCP was 34.08 ± 5.59 at base line and was increased to 34.93 ± 5.66 and 36.09 ± 5.62 after 1 month and after 6 months, respectively. Foveal choriocapillaris was statistically significantly increased from 63.04 ± 2.66 at base line to 63.48 ± 2.65 and 63.98 ± 2.78 after 1 month and 6 months, respectively. Choroidal flow was increased from 1.74 ± 0.07 at base line to 1.75 ± 0.09 at 1 month which was nonsignificant (P = 0.72), but it was significantly increased to 1.87 ± 0.27 6 months after PRP (P = 0.009). FAZ area was significantly improved after PRP. FAZ area was decreased from 0.56 ± 0.27 at base line to 0.50 ± 0.21 after 1 month and to 0.46 ± 0.21 after 6 months. CONCLUSION: OCTA parameters were significantly improved by PRP in PDR patients, possibly due to redistribution of blood in occluded capillary plexuses. TRIALS REGISTRY: NCT04976361.

Circulating microRNA 9-3p and serum endocan as potential biomarkers for hepatitis C virus-related hepatocellular carcinoma.

BACKGROUND: The high mortality rate of hepatocellular carcinoma (HCC) in Egypt is due mainly to the increasing prevalence of hepatitis C virus infection (HCV) and late diagnosis of the carcinoma. MicroRNAs (miRNA), which regulate tumor proliferation and metastasis in HCC, may serve as a useful diagnostic approach for the early detection of HCC, thus decreasing its mortality. Meanwhile, endocan is a protein with angiogenic and inflammatory properties that are associated with tumor progression and poor outcomes. AIM: To analyze the levels of miRNA 9-3p and endocan in HCV-infected HCC patients and correlate them with clinicopathological parameters. METHODS: We compared levels of endocan and circulating miRNA 9-3p from 35 HCV-related HCC patients to 33 patients with HCV-induced chronic liver disease and 32 age and gender matched healthy controls recruited from inpatient and outpatient clinics of the National Liver Institute, Menoufia University, Egypt in the period from January to March 2021 in a case-control study. Serum samples from all groups were analyzed for HCV. Endocan was measured by enzyme-linked immunosorbent assays, and the expression levels of circulating miRNA 9-3p were measured by real-time quantitative reverse transcriptase PCR. RESULTS: The levels of circulating miRNA 9-3p were significantly lower in the HCC group compared to the chronic liver disease (P < 0.001) and control (P < 0.001) groups, while levels in the chronic liver disease were significantly lower than those in the control group (P < 0.001). The levels of serum endocan were significantly higher in the HCC group compared to the chronic liver disease (P < 0.001) and control (P < 0.001) groups. Moreover miRNA 9-3p and endocan performed better than α-fetoprotein in discriminating HCC patients from cirrhosis and healthy patients. The levels of miRNA 9-3p were significantly inversely correlated to vascular invasion (P = 0.002), stage of advancement of Barcelona Clinical Liver Cancer (P < 0.001) and the metastatic site (P < 0.001) of the HCC group. CONCLUSION: Circulating miRNA 9-3p and endocan can be used as novel biomarkers for the early diagnosis of HCV-related HCC.

Anterior Segment Optical Coherence Tomography of Tear Film and Cornea in Systemic Lupus Erythematosus Patients.

PURPOSE: To study tear film and corneal thickness measurements in systemic lupus erythematosus (SLE) patients compared to age-matched controls using anterior segment optical coherence tomography (AS-OCT). METHODS: This was a cross-sectional study. Study participants were divided into 3 groups: Group A: SLE patients with clinical dry eye, Group B: SLE patients without clinical dry eye and Group C: healthy controls. The lower tear meniscus parameters measured using AS-OCT were tear meniscus height (TMH), tear meniscus depth (TMD) and tear meniscus area (TMA). The central corneal and corneal epithelial thickness were automatically calculated. RESULTS: The study included 40 eyes in Group A, 60 in Group B, and 100 in Group C. Mean age was 26.9±6.6 years for Group A, 27.6±7.3 years for Group B and 35.7±9.2 years for Group C (p= 0.06). All subjects were females except for 1 male patient in Group A. Mean TMH, TMA and TMD in Group C were 487.7±185.6 µm, 0.068±0.040 mm2, and 341.2±99.1 µm, respectively, which was significantly higher compared to Group A (225.5±27.9 µm, 0.018±0.004 mm2 and 171.9±26.0 µm, respectively, all p < 0.001) and Group B (395.4±118.8 µm, p < 0.001; 0.05±0.04 mm2, p=0.016 and 280.6±93.4 µm, p < 0.001, respectively). Group B eyes also had significantly higher parameters compared to Group A (all p < 0.001). Mean corneal and epithelial thickness in Group C were 501.6±37.5 µm and 53.3±4.5 µm, respectively, which was significantly higher compared to Group A (496.1±24.1 µm, p=0.044 and 49.5±3.5 µm, p < 0.001, respectively) and Group B (504.2±22.03 µm, p=0.046 and 47.5±5.6 µm, p < 0.001, respectively). Group B eyes also had a significantly higher corneal thickness (p=0.031) and epithelial thickness (p=0.011) compared to Group A. CONCLUSION: We demonstrated significant reduction of tear meniscus dimensions, central corneal thickness and epithelial thickness in SLE patients compared to age-matched controls using AS-OCT.

Comparison between a Conventional Anti-Biofouling Compound and a Novel Modified Low-Fouling Polyethersulfone Ultrafiltration Membrane: Bacterial Anti-Attachment, Water Quality and Productivity.

In this work, the efficiency of a conventional chlorination pretreatment is compared with a novel modified low-fouling polyethersulfone (PES) ultrafiltration (UF) membrane, in terms of bacteria attachment and membrane biofouling reduction. This study highlights the use of membrane modification as an effective strategy to reduce bacterial attachment, which is the initial step of biofilm formation, rather than using antimicrobial agents that can enhance bacterial regrowth. The obtained results revealed that the filtration of pretreated, inoculated seawater using the modified PES UF membrane without the pre-chlorination step maintained the highest initial flux (3.27 ± 0.13 m3·m-2·h-1) in the membrane, as well as having one and a half times higher water productivity than the unmodified membrane. The highest removal of bacterial cells was achieved by the modified membrane without chlorination, in which about 12.07 × 104 and 8.9 × 104 colony-forming unit (CFU) m-2 bacterial cells were retained on the unmodified and modified membrane surfaces, respectively, while 29.4 × 106 and 0.42 × 106 CFU mL-1 reached the filtrate for the unmodified and modified membranes, respectively. The use of chlorine disinfectant resulted in significant bacterial regrowth.

Aggregation properties of triamcinolone acetonide injection in human serum: considerations when performing epidural steroid injections.

BACKGROUND: Morbidity has been reported as a sequelae of crystalline steroid epidural steroid injections (ESIs), and particulate steroid size, aggregation, and embolization in brain and spinal cord may be the mechanism related to these neurologic effects. OBJECTIVE: The objective of the study was to examine the aggregation properties of triamcinolone acetonide in commonly used local anesthetics with and without human serum. SETTING: This study was conducted in an academic tertiary care center. HYPOTHESIS: Triamcinolone acetonide shows different aggregation characteristics in serum compared to a non-physiologic solution. DESIGN: Triamcinolone acetonide was mixed with lidocaine 1% (first group) and bupivacaine 0.5% (second group) in a 1:1 ratio and then mixed with either distilled water (control group) or serum ex vivo. A pathologist blinded to our hypothesis inspected all solutions under light microscopy with 100× and 400× magnifications. Total number of particulate steroid aggregates and the number of particles forming each aggregate (recorded as single,1 double,2 triple,3 quadruple,4 or large [>4} crystals) were counted. Particle size and aggregate size were measured (in µm). The ratios of quadruple to total aggregates, large to total, and quadruple with large to total aggregates were calculated. Steroid-serum solutions and steroid-sterile water were then compared. RESULTS: Triamcinolone aggregates showed an increased crystal and aggregate size when compared with other steroids. Within the triamcinolone subgroup, the mixture of lidocaine 1% and serum resulted in the largest crystal aggregates. LIMITATIONS: Whole blood analysis may have provided a more physiologically accurate model but was not chosen due to poor microscopic analysis. Serum donor variability may also have affected particle characteristics. CONCLUSION: Fewer large triamcinolone aggregates were noted in the presence of serum when compared to the non-serum control groups. However, when compared to previously studied particulate steroids, it had the largest aggregates when added to serum.

Predictors of future microalbuminuria in children and adolescents with type 1 diabetes mellitus in Egypt.

INTRODUCTION: The present study was designed to assess the validity and efficacy of urinary markers (NAG, RBP, transferrin, α1-microglobulin, and plasma homocysteine) as early predictors of microalbuminuria in diabetic nephropathy in children and adolescents with type-1 diabetes, and its relation with haemoglobin glycated (HbA1c), serum lipid profile, and blood pressure. MATERIAL AND METHODS: This study is a follow-up study to the 2002 study by Salem et al. The present study included 35 type 1 diabetes mellitus (T1DM) children and adolescents recruited from regular attendees of the specialised Diabetology Clinic, Children's hospital, Ain Shams University, with previously measured urinary N-acetyl-ß-glucosaminidase (13) or homocysteine (11) or transferrin (28) or α1-microglobulin (27) or retinol binding protein (13) as an early predictor of diabetic nephropathy in T1DM. Thirty-five patients with type 1 diabetes mellitus were enrolled, and 24 patients were normoalbuminuric at baseline. The patients were tested for markers other than urinary microalbumin, to predict diabetic nephropathy and early renal impairment in children and adolescents with type 1 diabetes mellitus. RESULTS: Regarding the metabolic control between the studied groups, we found that there is significant difference in HbA1c between the microalbuminuric patients and the normoalbuminuric patients. According to the number of positive markers of diabetic nephropathy, the only parameter that was higher in patients with more than one elevated marker was mean systolic blood pressure. Although mean diabetic blood pressure was higher, it was not statistically significant. Regarding to the predictability of urinary markers, urinary N-acetyl-ß-glucosaminidase is the most predictable marker with high sensitivity and specificity. The least sensitivity noticed was urinary RBP and the least specificity noticed was urinary α1-microglobulin. CONCLUSIONS: Regarding the predictability of urinary markers, urinary NAG is the most predictable marker with both high sensitivity and specificity, with a sensitivity of 60%, specificity 75%, positive predictive value 60%, negative predictive value 75%, and a diagnostic accuracy of 0.58%. Urinary RBP is another marker with low sensitivity but high specificity. Urinary α1-microglobulin is a valid marker with high sensitivity but low specificity. Contrary to previous markers, plasma homocysteine has high specificity but low sensitivity.

The effect of Hepatitis C Virus infection on cardiovascular complications in end stage kidney disease patients on regular hemodialysis.

INTRODUCTION: Cardiovascular complications are the most important cause of mortality in patients with ESKD, such as coronary artery disease, left ventricular hypertrophy, heart failure and arrhythmia. Other well-known risk factors, such as diabetes mellitus, hypertension and dyslipidemia are prevalent in ESKD, yet they are not sufficient enough to explain the high prevalence of cardiovascular mortality, hence searching for other hidden risk factors to explain this high prevalence is of an utmost importance. The aim of this study was to identify the exact mechanisms connecting HCV infection, chronic liver disease, and atherogenesis. METHODS: This case control study was done on 80 patients with chronic renal failure undergoing haemodialysis at Sheikh Zayed Specialized Hospital in Giza, Egypt in 2016. The participants were divided into four groups: a control group with HCV negative by PCR (20 patients), and three HCV Positive groups according to viral load by PCR: low, moderate and high viremia. Inclusion criteria were normal serum calcium (8.5-10.5 mg/dL), phosphorus ≤5mg/dL, PTH≤250 pg/ml, Hb 10-12 g/dL, and duration of dialysis less than two years. Data were analyzed using Chi square, t-test, Mann-Whitney U test, ANOVA, and Spearman rank correlation coefficient. RESULTS: The study showed significant increase in LVM index in hemodialysis patients with high and moderate viremia compared to low viremia (p<0.001) and to control group (p<0.001). Also, significant increase in end diastolic diameter in high and moderate viremia (p<0.001), significant difference in end systolic diameter in the high viremia group (p<0.001), significant increase in the interventricular septal thickness (p<0.002) and posterior wall thickness (p<0.002) among moderate viremia were determined. CONCLUSION: HCV has a significant effect on the development of cardiovascular diseases in the general population, and in renal disease patients on the structural level.

The significance of enlarged cervical lymph nodes in diagnosing thyroid cancer.

INTRODUCTION: We aim to investigate the significance of enlarged cervical lymph nodes (ECLN) identified by initial surgeon-performed ultrasound (US) as a tool for determining the risk of malignancy in the patients presenting with suspicious thyroid nodules. METHODS: Radiological and surgical reports were retrospectively reviewed for the patients with suspicious thyroid nodules who underwent thyroidectomy and preoperative comprehensive neck US. Ultrasonographic features of the identified cervical lymph nodes were correlated with the final pathology report. Patients with malignancy other than papillary thyroid cancer (PTC) were excluded. RESULTS: The study consisted of 440 patients. On final pathology, PTC was found in 142 patients (32.3%), the remaining 298 (67.7%) exhibited benign findings. ECLN (>1 cm) were found in 66 (46.5%) patient with PTC compared to only 53 (17.8%) patients with benign nodules (P < 0.001). Of the 119 patients with ECLN, 54.6% had benign appearing ECLN with no suspicious features, 26.1% had one suspicious feature, and 19.3% had more than one suspicious features. Benign appearing ECLN had a positive predictive value (PPV) of 41.54%, negative predictive value (NPV) of 59.02%, sensitivity of 51.92%, and specificity of 48.65% in predicting malignancy as opposed to the absence of ECLN. While as opposed to benign looking ECLN, ECLN with only one suspicious feature had a PPV of 70.97%, NPV of 50.00%, sensitivity of 33.33%, and specificity of 83.02%, and ECLN with two or more suspicious feature had a PPV of 73.91%, NPV of 48.96%, sensitivity of 25.76%, and specificity of 88.68%. CONCLUSION: ECLN are associated with an increased likelihood of thyroid malignancy in the patients undergoing evaluation of a suspicious nodule. The risk of malignancy in thyroid nodules increases with the presence of suspicious ultrasonographic features on cervical lymph nodes.

Robotic Thyroidectomy Versus Nonrobotic Approaches: A Meta-Analysis Examining Surgical Outcomes.

Background Robotic surgery has been recently used as a novel tool for remote access thyroid surgery. We performed a meta-analysis of the current literature to examine the safety and oncological efficacy of robotic surgery compared to endoscopic and conventional approaches for different thyroid procedures. Methods A systematic search of the online data bases was done using the following (MeSH) terms "robotic surgery," "robotic thyroidectomy," "robot-assisted thyroidectomy," and "robot-assisted thyroid surgery." Outcomes measured included total operative time, length of hospital stay, postoperative thyroglobulin levels, and postoperative complications. Statistical differences were analyzed between groups through the standard means and/or relative risk by using STATA analytical software. Results In this study, 144 articles were identified; of which 18 of them met our inclusion criteria, totaling 4878 patients. Robotic approach was associated with longer total operative time (mean difference of 43.5 minutes) when compared to the conventional cervical approach (95% CI = 20.9-66.2; P < .001). Robotic approach was also found to have a similar risk of total postoperative complications when compared to the conventional and endoscopic approaches. Conclusion Robotic thyroid surgery is as safe, feasible and provides similar periperative complications and oncological outcomes when compared to both, conventional cervical and endoscopic approaches. However, robotic thyroid surgery is associated with longer operative time when compared to the conventional open approach.

Electrophysiologic identification and monitoring of the external branch of superior laryngeal nerve during thyroidectomy.

OBJECTIVE: The aim of the study is to examine the correlation between weight, gender, and race with external branch of superior laryngeal nerve (EBSLN) visualization. Furthermore, we compared normative EBSLN neural-monitoring values to those of the recurrent laryngeal nerve (RLN). STUDY DESIGN: Retrospective study. SETTING: North American tertiary academic hospital. SUBJECTS AND METHODS: A retrospective, institutional review board-approved review was carried out on patients undergoing thyroid surgery by a single surgeon over 3.5 years. Preoperative and postoperative laryngoscopy was done on all patients in accordance with recently published American Academy of Otolaryngology voice optimization at thyroidectomy guidelines, and patients' clinical and operative relevant data were collected. RESULTS: A total of 447 nerves were at risk in 371 thyroidectomy patients. Of these nerves at risk, 237 (53.02%) were visualized and stimulated. The average amplitude and latency for the EBSLN were significantly lower when compared to the amplitude and the latency of RLN stimulation (P < 0.0001, P < 0.0001, respectively). There was no gender or racial disparity. Out of our study population, the EBSLN was identified in 64.56% in nonobese patients, whereas it was only 40.00% in obese patients (P < 0.001). Additionally, of the 56 patients in whom the EBSLN was visualized on one side and who further underwent bilateral neck exploration, 41 (73%) had visualization of the nerve on the contralateral side as well. CONCLUSION: EBSLN is less likely to be visualized in obese patients; however, there was no gender or racial disparity. Stimulation of EBSLN was felt to be a useful adjunct during superior pole dissection to assure the nerve integrity. LEVEL OF EVIDENCE: 4.

The impact of thyroid nodule size on the risk of malignancy in follicular neoplasms.

BACKGROUND/AIM: Studies have shown that the risk of malignancy in follicular neoplasms is as high as 30%. Often, surgery is recommended for such lesions, not for therapeutic purposes but as a diagnostic method, leading to increased hospital costs and related morbidities. Recent studies have suggested that tumor size predicts malignant potential of these follicular neoplasms. Our aim was to identify the impact of nodule size on the risk of malignancy for such lesions. PATIENTS AND METHODS: A retrospective medical chart review was undertaken for patients who underwent thyroid surgery at a single academic North American Institution. A total of 120 follicular lesions, follicular neoplasms (Bethesda category IV) or follicular lesions of undetermined significance (Bethesda category III) in 110 patients undergoing thyroid surgery were evaluated. Nodule size as measured by ultrasound, fine-needle aspiration cytological results, and final histopathology reports were reviewed. Analysis was performed by classification according to nodule size: <3 cm, ≥3 cm, <4 cm and ≥4 cm. RESULTS: Out of the 120 nodules, 48 (40%) were reported to be malignant on final pathological examination. The malignancy rate in nodules<3 cm and ≥ 3cm was 41% and 37.8%, respectively (p=0.84). When 4 cm was used as the cut-off, the rate in nodules<4 cm and ≥4 cm was 40.6% and 37.5%, respectively (p=0.82). CONCLUSION: Increased thyroid nodule size does not increase the malignancy rate for follicular neoplasms. Hence, we recommend against routine total thyroidectomy for patients with follicular neoplasms based on the size criteria.

Retroauricular robotic thyroidectomy with concomitant neck-lift surgery.

BACKGROUND: Robotic-assisted thyroid surgery using a retroauricular approach was reported as a novel remote access technique for hemithyroidectomy. We report our experience with this remote access technique using a single incision in the retroauricular crease and occipital hairline incision. For the first time, we show additional neck-lift surgery performed concomitantly to achieve better cosmetic outcomes. METHODS: Robotic retroauricular left hemithyroidectomy with concomitant neck-lift surgery was performed in a 59-year-old female patient who was referred for management of a 1.7 cm thyroid nodule located in the mid-lower right thyroid lobe, with fine-needle aspiration biopsy suggestive for follicular neoplasm. The patient had redundant submental skin in her neck, and was planning for a future neck-lift surgery. A concomitant neck lift was performed by the plastic surgeon using the same retroauricular approach to perform the operation. The patient agreed to participate in Institutional Review Board approved protocol. RESULTS: Total operative time was 115 min-flap creation time was 50 min, robot docking time was 10 min, operative console time was 25 min, and concomitant neck-lift surgery extended for 30 min. Estimated blood loss was approximately 30 ml. The patient was discharged home on the same day of surgery and had no postoperative complications. Final pathology confirmed benign follicular adenoma. CONCLUSIONS: Our experience with robotic retroauricular thyroidectomy showed that it is a feasible and safe remote access approach. We suggest that concomitant neck lift can be done in a select group of patients with excess skin on the neck. This approach can be offered to patients with benign and indeterminate thyroid lesions, and future prospective studies are warranted to evaluate the oncological efficacy of this approach in patients with thyroid cancer.

Alternate incision-site thyroidectomy.

PURPOSE OF REVIEW: Thyroid surgery has evolved throughout the years, from being one of the riskiest surgeries into one of the safest surgical procedures performed today. Recent technologic innovations have allowed surgeons to remove the thyroid gland from a remote site while avoiding visible neck scars. This article aims to provide the reader with an overview of the current alternate-site approaches used and their capability to assist the surgeons in accomplishing remote-access thyroid surgery. RECENT FINDINGS: There are many described endoscopic approaches for thyroid surgery. The most common cervical approach is the minimally invasive gasless video-assisted cervical technique. The robotic transaxillary, retroauricular, and axillary breast approaches avoid a neck scar and are becoming popular. SUMMARY: A number of surgeons today have adapted new surgical techniques for thyroid surgery. Even though conventional thyroidectomy remains in the gold standard for thyroidectomy with low morbidity and excellent outcomes, minimally invasive and remote-access techniques have been used in an attempt to avoid visible neck scars without compromising patients' safety and the effectiveness of the procedure.

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.