Evaluating the projected surgical impact of reclassifying noninvasive encapsulated follicular variant of papillary thyroid cancer as noninvasive follicular thyroid neoplasm with papillary-like nuclear features.

BACKGROUND: The reclassification of noninvasive encapsulated follicular variant of papillary thyroid cancer to noninvasive follicular thyroid neoplasm with papillary-like nuclear features will reduce nonefficacious and potentially harmful care. Reclassification is estimated in 18.6% of patients with papillary thyroid carcinoma; we aimed to quantify the implications of this change. METHODS: Pathology reports from April 2006 to April 2016 were reviewed to isolate cases that would have been designated as neoplasm with papillary-like nuclear features. Of the 1,335 cases of papillary thyroid carcinomas, 194 cases (14.5%) met criteria. Cases in which neoplasm with papillary-like nuclear features was found in combination with other thyroid malignancies (n = 25) and cases of prior thyroid lobectomy (n = 5) were excluded. Demographic, pathologic, treatment, and follow-up data were assessed for the remaining 164 potential neoplasm with papillary-like nuclear features cases. Logistic regression analysis was performed to evaluate association between fine-needle aspiration result and index procedure. RESULTS: Of the 164 patients with tumors who met neoplasm with papillary-like nuclear features criteria, fine-needle aspiration results were nondiagnostic (2%), benign (18%), atypia/follicular lesion of undetermined significance (26%), follicular neoplasm or suspicious for follicular neoplasm (20%), suspicious for malignancy (19%), malignant (6%), and not obtained (9%). Eighty-five (52%) patients underwent total thyroidectomy. A "suspicious for malignancy" fine-needle aspiration result was associated with undergoing total thyroidectomy versus thyroid lobectomy (P = .006). Thyroid lobectomy was the index procedure for 79 patients (48%); of these patients, 54% (n = 43, 3.2% of all patients with papillary thyroid carcinomas) underwent subsequent total thyroidectomy, and 24% received postoperative radioactive iodine treatment. There were no recurrences among the 125 patients with >3 months of follow-up. CONCLUSION: The reclassification of noninvasive encapsulated follicular variant of papillary thyroid cancer as neoplasm with papillary-like nuclear features will decrease nonefficacious treatment and reduce costs. However, the impact of this change with regard to extent of surgery was limited to 3.2% of patients with papillary thyroid carcinomas compared with the projected potential impact on 18.6%.

Quality of colorectal cancer care among veterans: a 10-year retrospective cohort.

BACKGROUND: Nearly 5,000 patients within Veterans Health Administration (VHA) are diagnosed with colorectal cancer (CRC) annually. However, the link between performance on CRC practice guidelines and outcomes is unclear. The purpose of this study was to evaluate quality of CRC care by assessing adherence to National Comprehensive Cancer Network (NCCN) guidelines and to determine if receipt of these metrics was associated with improvement in mortality. METHODS: We performed a retrospective cohort study of all patients who underwent resection for nonmetastatic CRC at VHA Tennessee Valley Healthcare System from 2001 to 2010. We defined "excellent" care as receipt of at least 75 % of eligible NCCN metrics. We also examined time to treatment and the relationship between excellent care and mortality. RESULTS: A total of 331 patients underwent resection for CRC within the study period. Only 47 % of patients received excellent care, and 9 % received 100 % of eligible metrics. The median time from diagnosis to definitive treatment was 22 days [interquartile range (IQR) 12, 41] and 37 days (IQR 24, 56) among colon and rectal cancer patients, respectively. The likelihood of receiving excellent care increased significantly over time. However, there was no association between receipt of excellent care and 5-year all-cause mortality [hazard ratio (HR) 0.85; 95 % CI 0.53-1.36]. CONCLUSIONS: Although patients received timely care overall, fewer than half of CRC patients received at least 75 % of eligible NCCN metrics. Although receipt of excellent care was not associated with reduction in all-cause mortality, further research is necessary to identify quality metrics likely to influence patient outcomes.

Achievement in surgical residency: are objective measures of performance associated with awards received in final years of training?

OBJECTIVE: For the past 15 years at our institution's general surgery residency program, 3 of the senior residents have been chosen to be awarded either (1) Best Resident in Research, (2) Best Resident in Teaching, or (3) Best Resident Overall. Considering that these awards serve as data representing outstanding performance as surgical residents, the objective of this study was to determine the association between receiving one of these awards and objective measures of performance. METHODS: Individual files were reviewed for the 103 residents who graduated from our institution's general surgery program from 1994 to 2010. These data were studied as a whole, and then divided into an award-winning group and a non-award winning group and subsequently compared across several objective parameters, including The United States Medical Licensing Examination (USMLE) scores, American Board of Surgery In-Training Examination (ABSITE) scores, first-time American Board of Surgery Certifying and Qualifying Examination pass rates, Alpha Omega Alpha membership status, and number of research years, using a logistic regression model. RESULTS: Overall, 103 residents completed their general surgery residency training at our institution from 1994 to 2010, and of these residents, 16 (16%) received the Best Resident in Research award, 15 (16%) received the Best Resident in Teaching award, and 17 (17%) received the Best Resident Overall award in their final years of training. Compared with those who did not receive an award, a hypothesis-based one-tailed test revealed that award winners had a significantly lower median USMLE Step 1 scores (p = 0.04) and marginally lower median USMLE Step 2 scores (p = 0.05). Alpha Omega Alpha membership status, median ABSITE percent correct overall, first-time American Board of Surgery examination pass rates, and number of research years during residency were not significantly different between the 2 groups. CONCLUSION: Many factors contribute to success during general surgery residency. Our study showed that higher USMLE and ABSITE scores were not associated with receiving top awards in final years of training at one institution over 15 years.

Stimulation of denervated muscle promotes selective reinnervation, prevents synkinesis, and restores function.

OBJECTIVES/HYPOTHESIS: Previously, electrical stimulation of denervated canine laryngeal muscle was shown to promote reinnervation by native over foreign motoneurons. The goal of this study was to assess the effect of different stimulus paradigms on reinnervation quality and functional recovery. STUDY DESIGN: A prospective study of six canines over 8 to 20 months. METHODS: A clinical model of laryngeal paralysis was used, where recurrent laryngeal nerves of the animals were sectioned and ventilation compromised. The abductor, posterior cricoarytenoid (PCA) muscles were implanted bilaterally with electrodes from an implantable pulse generator. Animals were randomly assigned to three groups to assess the effect of different stimulus paradigms: 1) 40 pulses per second (pps) train, 2) 10 pps train, 3) no stimulation. Spontaneous vocal fold movement was measured endoscopically during hypercapnia. Exercise tolerance was measured on a treadmill using pulse oximetry. In the terminal session, electromyography (EMG) potentials were recorded during superior laryngeal nerve stimulation to index foreign reinnervation of the PCA by reflex glottic closure (RGC) motoneurons. RESULTS: After reinnervation started, nonstimulated and stimulated 40 pps animals displayed paradoxical closure of the glottis during hypercapnia and severely decreased exercise tolerance due to faulty reinnervation. In contrast, stimulated 10 pps animals displayed minimal paradoxical closure and normal exercise tolerance (12 minutes up to 8 mph). EMG findings in this group demonstrated significantly less PCA reinnervation by foreign RGC motoneurons. CONCLUSION: PCA stimulation with low frequency reduced synkinetic reinnervation by foreign RGC motoneurons. Paradoxical closure of the glottis with inspiration was reduced and exercise tolerance restored to normal.

The usefulness of a yearly head and neck surgery trip to rural Kenya.

OBJECTIVE: Surgical specialty trips to third world countries have been praised and criticized. Our objective was to learn the usefulness of a yearly head and neck surgery trip through initial analysis of 2 years of patient data. METHODS: We reviewed data from a prospectively maintained repository of surgical patients treated during head and neck surgical trips to Malindi, Kenya, in 2010 and 2011. Basic demographics, distance traveled for care, access to physicians, preoperative diagnosis, surgical procedure(s), and pathology were recorded when available. RESULTS: In 2 years, 226 surgeries were performed. Patient age ranged between 3 months and 85 years, and gender was evenly split. Half of patients came from outside the town of Malindi, and a third traveled over 100 kilometers for care. The majority reported access to a local physician, yet very few patients were offered prior surgical treatment. The most common operations performed were adenotonsillectomy and hemithyroidectomy. A wide variety of cases were performed, including parotidectomies, maxillectomies, mandibulectomies, cleft lip and palate repair, and free flap reconstructions. Local and national visiting otolaryngologist-head and neck surgeons participated or observed throughout our visits with teaching emphasis based on their skills and specific learning goals. CONCLUSIONS: Annual surgical specialty trips to rural, resource-limited regions are useful and worthwhile and offer procedures not otherwise available. On such trips, it is important to collect patient, surgical, and pathology data to help visiting surgeons determine the best procedures to teach local physicians and provide needed resources.

Comparison of ventilation and voice outcomes between unilateral laryngeal pacing and unilateral cordotomy for the treatment of bilateral vocal fold paralysis.

BACKGROUND/AIMS: Rehabilitation of the bilaterally paralyzed human larynx remains a complex clinical problem. Conventional treatment generally involves surgical enlargement of the compromised airway, but often with resultant dysphonia and risk of aspiration. In this retrospective study, we compared one such treatment, posterior cordotomy, with unilateral laryngeal pacing: reanimation of vocal fold opening by functional electrical stimulation of the posterior cricoarytenoid muscle. METHODS: Postoperative peak inspiratory flow (PIF) values and overall voice grade ratings were compared between the two surgical groups, and pre- and postoperative PIF were compared within the pacing group. RESULTS: There were 5 patients in the unilateral pacing group and 12 patients in the unilateral cordotomy group. Within the pacing group, postoperative PIF values were significantly improved from preoperative PIF values (p = 0.04) without a significant effect on voice (grade; p = 0.62). Within the pacing group, the mean postoperative PIF value was significantly higher than that in the cordotomy group (p = 0.05). Also, the mean postoperative overall voice grade values in the pacing group were significantly lower (better) than those of the cordotomy group (p = 0.03). CONCLUSION: Unilateral pacing appears to be an effective treatment superior to posterior cordotomy with respect to postoperative ventilation and voice outcome measures.

Methodology and bias in assessing compliance with a surgical safety checklist.

BACKGROUND: Surgical safety checklists, such as the perioperative time-out, have been shown to improve performance on a variety of patient safety measures. A variety of methods have been used to assess compliance with the perioperative time-out, but no standardized methodology with a reliable observer group currently exists. An observation-based methodology was used to assess time-out compliance at an academic medical center. METHODS: A single observer group made up of medical students and nurses recorded compliance with each of the 11 standardized items of the time-out. A total of 193 time-out procedures were observed, 48 by medical students and 145 by nurses. RESULTS: One item (procedure to be performed) achieved > 95% compliance. Three items (surgical site; availability of necessary blood products, implants, devices; and start of antibiotics) achieved 80%-95% compliance. Seven items achieved < 80% compliance (presence of required members of procedure team, presence of person who marked patient, patient identity, side marking, relevant images, allergies, and discussion of relevant special considerations). Compliance with the four core time-out items was 78.2%. Of the 11 items on the time-out being evaluated, there was a statistically significant difference between medical student and nursing observations for 10 items (p < .05). CONCLUSIONS: In our cohort of observed time-outs, the compliance rate was low, calling into question time-out quality, and, more importantly, patient safety. Measures must be taken by large hospitals to regularly audit time-out compliance and create effective programming to improve performance. Although observational assessment is an effective method to assess compliance with surgical safety checklists, observer group bias has the potential to skew results.

A model for improving the health and quality of life of single mothers in the developing world.

Among the impoverished population of coastal Kenya, there is a rapidly growing group of young single mothers who suffer from adverse health outcomes, incomplete schooling, social ostracism by their communities, and economic hardship. To address this problem, in 2008 the Single Mothers Program (SMP) selected a group of vulnerable single mothers, provided them with basic relief and education, equipped them with training and start-up capital to run their own businesses, and assessed the impact of the program via a pre- and post-implementation survey. After two years in the program, a majority of the single mothers increased their contraceptive use, increased their degree of literacy, increased their individual incomes, and were more positively perceived by their communities. This study demonstrates a program model that can be used to improve the health and quality of life of single mothers and their children in similar communities throughout the world.

Novel use of electronic whiteboard in the operating room increases surgical team compliance with pre-incision safety practices.

BACKGROUND: Despite evidence that use of a checklist during the pre-incision time out improves patient morbidity and mortality, compliance with performing the required elements of the checklist has been low. In an effort to improve compliance, a standardized time out interactive Electronic Checklist System [iECS] was implemented in all hospital operating room (OR) suites at 1 institution. The purpose of this 12-month prospective observational study was to assess whether an iECS in the OR improves and sustains improved surgical team compliance with the pre-incision time out. METHODS: Direct observational analyses of preprocedural time outs were performed on 80 cases 1 month before, and 1 and 9 months after implementation of the iECS, for a total of 240 observed cases. Three observers, who achieved high interrater reliability (kappa = 0.83), recorded a compliance score (yes, 1; no, 0) on each element of the time out. An element was scored as compliant if it was clearly verbalized by the surgical team. RESULTS: Pre-intervention observations indicated that surgical staff verbally communicated the core elements of the time out procedure 49.7 ± 12.9% of the time. After implementation of the iECS, direct observation of 80 surgical cases at 1 and 9 months indicated that surgical staff verbally communicated the core elements of the time out procedure 81.6 ± 11.4% and 85.8 ± 6.8% of the time, respectively, resulting in a statistically significant (P < .0001) increase in time out procedural compliance. CONCLUSION: Implementation of a standardized, iECS can dramatically increase compliance with preprocedural time outs in the OR, an important and necessary step in improving patient outcomes and reducing preventable complications and deaths.

Bilateral motion restored to the paralyzed canine larynx with implantable stimulator.

OBJECTIVES/HYPOTHESIS: Bilateral stimulation of posterior cricoarytenoid (PCA) muscles offers a physiologic approach to restore ventilation to a normal level in case of bilateral laryngeal paralysis. The objective of this study was to evaluate the long-term efficacy and safety of a new generation stimulator in restoring ventilation and exercise tolerance. STUDY DESIGN: A prospective study of four canines over 8-20 months. METHODS: A Genesis XP stimulator and electrodes were implanted and recurrent laryngeal nerves were sectioned and repaired bilaterally. In bimonthly sessions, vocal fold movement resulted from PCA stimulation or induced hypercapnea, was measured endoscopically in the anesthetized animal. Exercise tolerance was measured on a treadmill and swallowing function was examined endoscopically and radiographically. RESULTS: During the denervation phase, there was minimal ventilatory compromise and near-normal exercise tolerance. PCA stimulation produced only nominal abduction. During the reinnervation phase, synkinetic reinnervation became significant, resulting in a narrowed passive airway and paradoxical glottic closure during hypercapnea. Animals were stridorous and could walk for only 1-2 minutes. Bilateral PCA stimulation increased glottal area, equaling that of a normally innervated animal. Exercise tolerance was also normal. The optimal stimulus paradigm for the synkinetically reinnervated larynx was not different from that for the innervated larynx. Stimulation remained efficacious over the study period. Lead integrity could be maintained by prevention of device migration. There was no evidence of aspiration. CONCLUSIONS: This study demonstrates that ventilatory compromise only occurs following faulty reinnervation. Bilateral PCA stimulation can restore ventilation and exercise tolerance completely without aspiration over the long term.

A model for neurosurgical humanitarian aid based on 12 years of medical trips to South and Central America.

The pediatric neurosurgical mission trips led by physicians at Virginia Commonwealth University (VCU) Health Systems began in 1996 with the formation of Medical Outreach to Children, founded by 1 of the authors (J.D.W.) after a visit to Guatemala. Since then, 19 surgical trips to 4 different countries in Central and South America have been coordinated from 1996 to 2008. This humanitarian work serves a number of purposes. First and foremost, it provides children with access to surgical care that they would otherwise not receive, thereby significantly improving their quality of life. Second, the visiting surgical team participates in the education of local physicians, parents, and caregivers to help improve the healthcare provided to the children. Last, the team works to promote sustainable global health solutions in the countries it travels to by generating a forum for clinical and public health research discourse. Thus far, a total of 414 children have undergone 463 operations, including 154 initial shunt surgeries, 110 myelomeningocele repairs, 39 lipoma resections, 33 tethered cord releases, 18 shunt revisions, 16 encephalocele repairs, 9 lipomyelomeningocele repairs, and 7 diastematomyelia repairs. The complication rate has been 5-8%, and the team has obtained reliable follow-up in approximately 77% of patients. A correlation was found between an increase in the number of trained neurosurgeons in the host countries and a decrease in the average age of patients treated by the visiting surgical team over time. It is also hypothesized that a decrease in the percentage of myelomeningocele repairs performed by the surgical team (as a fraction of total cases between 1996 and 2006) correlates to an increase in the number of local neurosurgeons able to treat common neural tube defects in patients of younger ages. Such analysis can be used by visiting surgical teams to assess the changing healthcare needs in a particular host country.