Radiofrequency ablation of thyroid nodules: a clinical review of treatment complications.

Radiofrequency ablation (RFA) is a minimally invasive ablative modality for the treatment of thyroid nodules. Reports of RFA use have demonstrated an impressive safety profile and excellent volume reduction rates between 60-90%. Given its increased popularity in the United States as well as globally, numerous recent works have been published and a discussant of relevant complications incorporating recent insight may assist practitioners in minimizing complications and optimizing patient outcomes. Herein, we provide a comprehensive and updated review of the reported complications and side effects following RFA, summarizing their frequency and clinical presentation. We also describe a means of minimizing such complications and/or side effects. Overall, the safety profile of RFA is impressive and superior to that of thyroid surgery. The overall risk of complication is reportedly 2-3%. The risk of permanent complication or severe injury is very unlikely, below 1%. Complications are infrequent, but may be nerve-related, endocrine-related, or iatrogenic-related, and consequences of localized heat delivery. The vast majority of complications related to RFA can be managed conservatively, without need for invasive measures. This review will assist surgeons and clinicians in recognizing and treating the various complications and side effects in clinical practice.

Risk Factors for Postoperative Infections Following Appendectomy of Complicated Appendicitis: A Meta-analysis and Retrospective Single-institutional Study.

Patients with complicated appendicitis have an increased risk for postoperative infections. Potential risk factors for postoperative infections through a meta-analysis and retrospective chart review are discussed. A meta-analysis consisting of 35 studies analyzing complicated appendicitis treated with an appendectomy noting at least 1 postoperative infection was performed. A retrospective review was then conducted in patients diagnosed with complicated appendicitis after appendectomy. Of 5326 patients in total, 15.4% developed postoperative infections. Laparoscopic surgery and perioperative hyperoxygenation were found to be protective factors for the development of infection. Retrospectively, 53.2% of patients presented with complicated appendicitis. Patients with complicated appendicitis were more likely to be older in age and have an increased length of stay. Patient demographics, operative time, and comorbid status had no effect on postoperative infection or readmission rate. Physicians should strongly consider minimally invasive techniques to treat all cases of complicated appendicitis irrespective of comorbidities, age, sex, or body mass index.

From ablation to operation: Unraveling the surgical outcomes and complications of thyroidectomy after radiofrequency ablation.

BACKGROUND: Radiofrequency ablation is a minimally invasive treatment for thyroid nodules; however, concerns exist regarding its impact on subsequent thyroid surgery. We compared surgical outcomes and complications between patients undergoing thyroidectomy after radiofrequency ablation (post-radiofrequency ablation thyroidectomy group) and those without prior radiofrequency ablation (non-radiofrequency ablation thyroidectomy group). METHODS: We retrospectively analyzed thyroidectomy patients, comparing post-radiofrequency ablation thyroidectomy and non-radiofrequency ablation thyroidectomy groups, examining demographics, nodule characteristics, surgical techniques, and complications. RESULTS: The study included 96 patients (73 in the non-radiofrequency ablation thyroidectomy group and 23 in the post-radiofrequency ablation thyroidectomy group). The mean age was 53.3 ± 14.4 years, with 78.1% female patients and 36.5% African American patients. Median operative time was similar between the post-radiofrequency ablation thyroidectomy (110 minutes) and the non-radiofrequency ablation thyroidectomy (92 minutes) cohorts (P = .40). Complications were reported in 13 patients, without significant differences between groups (P = .54). No permanent complications, including nerve injury or hypoparathyroidism, were reported in either cohort. Prior radiofrequency ablation treatment did not increase the risk of complications (odds ratio = 3.48, 95% confidence interval = 0.70-17.43, P = .16). CONCLUSION: Our work found no differences in outcomes or safety in patients undergoing thyroidectomy with or without previous radiofrequency ablation treatment, potentiating the post-radiofrequency ablation thyroidectomy group as a safe management option. Accordingly, this may reassure both clinicians and patients of the safety of radiofrequency ablation in treating patients with thyroid nodules.

Comparison of Medical Management versus Parathyroidectomy in Patients with Mild Primary Hyperparathyroidism: A Meta-Analysis.

BACKGROUND: Parathyroidectomy is the definitive cure for patients with primary hyperparathyroidism (pHPT) and has an annual prevalence of 0.2-1% in the United States. Some patients with mild disease are medically managed effectively using calcium-lowering medications and drugs against complications such as osteoporosis; however, many maintain a persistently high calcium level that negatively impacts their skeletal, renal, and psychogenic systems over the long term. This meta-analysis aims to compare the outcomes of medical management versus parathyroidectomy in patients with mild pHPT. STUDY DESIGN: This meta-analysis was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using PubMed, Embase, and Web of Science by two teams of investigators. Analysis was run using R packages. RESULTS: A total of 12 publications including seven randomized control, two prospective, and three retrospective trials with a total of 1346 patients were included for analysis. The average follow-up for all patients was 41 ± 23.8 months. Demographics, pre-treatment calcium, PTH, and bone mineral density (BMD) were similar between the medical (N = 632) and surgical (N = 714) cohorts. Post-treatment calcium and PTH levels were significantly higher in the medical cohort (10.46 vs. 9.39, p < 0.01), (106.14 vs. 43.25, p = 0.001), respectively. Interestingly, the post-treatment PTH in the medical cohort increased when compared to pre-treatment (83.84 to 106.14). Patients in the medical cohort had lower BMD in lumbar (0.48 g/cm2; OR = 0.42, 95% CI = 0.21, 0.83), femoral (0.48; OR = 0.42, 95% CI = 0.29, 0.61), and hip (0.61; OR = 0.33, 95% CI = 0.13, 0.85). Incidences of fracture, nephrolithiasis, cardiovascular death, or overall mortality were not significantly different between the cohorts. CONCLUSIONS: The present study is the most comprehensive meta-analysis on mild pHPT to date. Our findings reflect that parathyroidectomy is the superior option in the treatment of mild pHPT patients as opposed to medical management.

Elevated Calcitonin Levels in a Patient With a Pheochromocytoma: A Case Report.

Elevated calcitonin and catecholamine levels in patients with adrenal masses and thyroid nodules are suspicious for multiple endocrine neoplasia type 2A. Here, we present an interesting case with elevated catecholamines, thyroid nodules, and hypercalcitoninemia. A 46-year-old woman with complaint of abdominal pain was recently hospitalized. Abdominal computed tomography elicited a 7 cm left adrenal mass. Upon presentation to our clinic, the patient complained of abdominal pain, nausea, and diaphoresis. Laboratory studies showed elevated catecholamines, and a pheochromocytoma was subsequently diagnosed. Further evaluation elicited elevated calcitonin levels and a suspicious 3 cm left thyroid nodule, inciting concern for medullary thyroid carcinoma. The patient underwent an uneventful robot-assisted laparoscopic left adrenalectomy. Surgical pathology confirmed a pheochromocytoma. Post-operative calcitonin levels resolved to within normal range. The patient elected to undergo a left hemithyroidectomy. Surgical pathology confirmed calcitonin-negative nodular hyperplasia, negative for malignancy. The patient's diagnosis was confined to a pheochromocytoma. Clinicians should investigate high calcitonin levels associated with a pheochromocytoma as it may not always be ascribed to the thyroid.

Anatomical study of the internal carotid venous plexus: new findings with application to skull base surgery.

OBJECTIVE: The venous plexus (internal carotid venous plexus) surrounding the petrous part of the internal carotid artery (ICAp) is said to be one drainage pathway of the cavernous sinus. These veins have many potential clinical implications including iatrogenic hemorrhage during surgical approaches to the skull base and carotid-cavernous fistulas. Because there are few morphological data about this venous plexus at the skull base, this descriptive/quantitative study was performed to elucidate its anatomy. METHODS: Six latex-injected cadaveric heads (twelve sides) were dissected via a superior craniotomy approach in which the ICAp was exposed by drilling away the overlying bone. A venous plexus surrounding parts of the ICAp in all sides was documented along with the positions of its major tributaries and their connections. RESULTS: The veins were most concentrated near the junction of the ICAp and the cavernous part of the internal carotid artery, and usually along the medial and lateral sides of the ICAp. Tributaries included branches joining the basilar venous plexus posteriorly and branches joining the veins surrounding the foramen ovale anteriorly. CONCLUSION: Detailed knowledge of the anatomy of this venous plexus surrounding the ICAp is useful for interpreting imaging of the skull base and valuable for surgeons operating in this part of the cranium.

Human Immunodeficiency Virus and Hepatitis C Linkage-to-Care Initiative for New Orleans Residents Experiencing Homelessness During the COVID-19 Pandemic.

BACKGROUND: People experiencing homelessness are disproportionately infected with human immunodeficiency virus (HIV) and hepatitis C virus (HCV). In response to COVID-19, cities nationwide temporarily housed people experiencing homelessness in unused hotels. One such initiative in New Orleans also enacted a screening, counseling, and linkage-to-care model for HIV and HCV treatment for this temporarily housed population between May and July 2020. METHODS: A nonconcurrent cohort study was performed assessing follow up in the treatment of HIV and HCV for this population. Outcome data were collected on seropositive patients' electronic medical record to assess patient progression through the treatment cascade. RESULTS: Of 102 unhoused residents, 25 (24.5%) tested HCV seropositive. Of the HCV positive 21/25 (84%) were connected to the associated clinic for follow up care and 10 (40%) obtained HCV treatment medication. Furthermore, all 3 patients who tested seropositive for HIV either started or re-initiated antiviral treatment. The greatest barrier to providing medication for the HCV seropositive patients, once care was initiated, was loss-to-follow-up. CONCLUSIONS: Targeting homeless persons living in temporary residences for HCV and HIV screening can be effective at promoting access to care for those infected due to this population's high HCV seropositivity especially significant if the patient has a history of intravenous drug use or is older than 40 years. However, continued outreach strategies are needed to assist patients in retention of care.

Anatomical Study of the Posterior Spinal Artery Branches to the Medulla Oblongata.

BACKGROUND: The posterior spinal arteries (PSAs), branches of the intracranial segment of the vertebral artery or posterior inferior cerebellar artery, run bilaterally along the spinal cord and are integral to the blood supply primarily to the posterior one third of this structure. However, a less well-described distribution of the PSAs is their supply to the posterior medulla. The purpose of this study is to examine the medullary branches of the PSA anatomically. METHODS: We conducted a cadaveric study to evaluate for branches of the PSA supplying the medulla oblongata. RESULTS: All 14 sides had medullary branches arising from the PSAs. The average number of branches supplying the medulla oblongata on each side was 6. Most of these branches traveled laterally to anastomose with medullary branches arising from the anterior spinal artery. Additionally, lateral and ascending branches were noted. CONCLUSIONS: Physicians who interpret imaging of the craniocervical junction, in particular arteriograms, should be aware of ascending medullary branches arising from the anterior spinal artery. Additionally, neurosurgeons operating this region must be careful in dissecting over the posterior medulla and manipulating the cerebellar tonsils, as in telovelar approaches to the fourth ventricle, in order to avoid iatrogenic injury to these vessels. Additionally, variable stroke patterns involving the vertebral artery or posterior inferior cerebellar artery might include ischemia to the medulla oblongata via PSA branches, and this anatomy should be kept in mind by interventionalists, radiologists, and neurologists alike.

Triangular-Shaped Odontoid Process With Chiari 1 Malformation Patient.

Several anatomical variations of osseous structures around the craniovertebral junction (CVJ) have been observed in those presenting with Chiari 1 malformation (CM-1) due to the junction's unique embryology and its pivotal role in neck stability. During a clinic visit, a 14-year-old female presented with the classic symptoms of CM-1. Upon follow-up imaging and confirmation of the inferiorly displaced cerebellar tonsils, a unique triangular-shaped odontoid process was identified. To our knowledge, this osseous malformation of the dens has not been reported in the current literature. This unique deviation may cause ligamentous instability and decreased motion capacity and predispose a patient to axial fractures. Thus, we aim to further discuss this case, cervical vertebrae axis (C2) embryology, and the resulting clinical significance of this observed odontoid process variant.

Arterial Supply to the Pituitary Gland: A Comprehensive Review.

Knowledge of the blood supply to the pituitary gland is important for clinicians and surgeons. Therefore, a good working knowledge of this anatomy is important. The goal of this article was to review current anatomic knowledge of the blood supply to the pituitary gland and its clinical relevance.