Outcomes of Immediate Total Thyroidectomy in First-Side Loss of Neuromonitoring Signal.

Importance: Use of intraoperative neuromonitoring (IONM) during thyroidectomy can nearly eliminate the risk of postoperative bilateral vocal cord palsy (VCP) by indicating staged surgery in cases of loss of signal (LOS) on the first side of planned total thyroidectomy. However, aborting planned total thyroidectomy may lead to persistence of symptoms, delay in adjuvant treatment, and patient inconvenience and distress. There are few data to guide a selective approach to total thyroidectomy in patients with first-side LOS. Objective: To investigate outcomes of immediate bilateral surgery in patients undergoing total thyroidectomy with first-side LOS. Design, Setting, and Participants: This cohort study was a retrospective review of outcomes for patients undergoing thyroidectomy between January 2016 and July 2023 at an academic tertiary referral center for thyroid surgery. Consecutive patients scheduled for total thyroidectomy using IONM were included. Exclusion criteria were preoperative VCP, deliberate sacrifice of recurrent laryngeal nerve (RLN), inadvertent RLN resection, and surgery performed without IONM. Exposures: Total thyroidectomy performed using IONM. Main Outcome Measures: Vocal mobility on first postoperative day as assessed by flexible laryngoscopy; secondary outcome measures included subjective voice assessment, other postoperative complications, and long-term vocal mobility. Results: Among 400 patients undergoing planned total thyroidectomy (mean age, 50.5 years [range, 4-88 years]; 318 female [79.5%]), 51 (12.8%) had first-side LOS, of whom 37 (9.3%) had persistent LOS. Twenty-nine patients (56% of procedures with first-side LOS, including 18 with persistent LOS) proceeded to immediate total thyroidectomy. Postoperatively, 16 patients (55% of patients undergoing total thyroidectomy following first-side LOS, including 14 of 18 with persistent LOS) had impaired vocal mobility. One patient had bilateral VCP that did not require tracheostomy, and 2 had postoperative hypoparathyroidism. Of those whose surgery was aborted after first-side LOS, 8 of 22 (36%) underwent completion thyroidectomy at a later stage. In those undergoing completion thyroidectomy, 2 of 8 (25%) had temporary VCP after the second surgery, 2 (25%) had permanent hypoparathyroidism, and 1 (12.5%) developed inoperable cancer. Postoperative VCP was fully reversible in all but 1 patient. Conclusion and Relevance: Among patients planned for total thyroidectomy who develop first-side LOS, immediate total thyroidectomy may be considered among those who have pressing reasons for same, and where surgical difficulties might be anticipated in a secondary surgery.

Low Cancer Occurrence Rate following Prophylactic Nipple-Sparing Mastectomy.

BACKGROUND: Nipple-sparing mastectomy (NSM) has become widely available for breast cancer prophylaxis. There are limited data on its long-term oncologic safety. The objective of this study was to determine the incidence of breast cancer in patients who underwent prophylactic NSM. METHODS: All patients undergoing prophylactic NSM at a single institution from 2006 through 2019 were retrospectively reviewed. Patient demographic factors, genetic predispositions, mastectomy specimen pathology, and oncologic occurrences at follow-up were recorded. Descriptive statistics were performed where necessary to classify demographic factors and oncologic characteristics. RESULTS: A total of 871 prophylactic NSMs were performed on 641 patients, with median follow-up of 82.0 months (standard error 1.24). A total of 94.4% of patients ( n = 605) underwent bilateral NSMs, although only the prophylactic mastectomy was considered. The majority of mastectomy specimens (69.6%) had no identifiable pathology. A total of 38 specimens (4.4%) had cancer identified in mastectomy specimens, with ductal carcinoma in situ being the most common (92.1%; n = 35). Multifocal or multicentric disease was observed in seven cases (18.4%) and lymphovascular invasion was identified in two (5.3%). One patient (0.16%), who was a BRCA2 variant carrier, was found to have breast cancer 6.5 years after prophylactic mastectomy. CONCLUSIONS: Overall primary oncologic occurrence rates are very low in high-risk patients undergoing prophylactic NSM. In addition to reducing the risk of oncologic occurrence, prophylactic surgery itself may be therapeutic in a small proportion of patients. Continued surveillance for these patients remains important to assess at longer follow-up intervals. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, IV.

A Novel Risk Score to Predict Hungry Bone Syndrome After Parathyroidectomy for Renal Hyperparathyroidism.

OBJECTIVE: Hungry bone syndrome (HBS) is a known complication of parathyroidectomy. Patients with renal hyperparathyroidism are particularly vulnerable to HBS because of their prolonged exposure to electrolyte abnormalities and elevated parathyroid hormone (PTH). However, in-depth characterization of predictive factors for HBS in these patients is lacking. METHODS: A retrospective analysis was performed of patients with renal hyperparathyroidism who underwent parathyroidectomy at a single institution from 2011-2021. Patient demographics, clinical characteristics, and biochemical data were collected and analyzed. Boruta and binary logistic regression analyses were used to develop a scoring system. RESULTS: Thirty-three patients were identified; 16 (48%) developed HBS. Patients with HBS had significantly higher preoperative levels of serum PTH (mean difference [MS] = 2167.2 pg/mL, P <.001), phosphorus (MD = 3.5 mg/dl, P <.001), and alkaline phosphatase (ALP) (MD = 344.2 U/L, P =.002) and significantly lower levels of preoperative serum calcium (MD = -0.96 mg/dL, P =.004). Stepwise regression analysis identified elevated ALP (>150 U/L) and markedly elevated PTH (>1000 pg/mL) as positive predictors of HBS. A two-point scoring system with these 2 variables had overall diagnostic accuracy of 96.8% (sensitivity 100% and specificity 94.1%) with 1 point conferring 93.8% positive predictive value and 2 points conferring 100% positive predictive value. CONCLUSION: Preoperative serum PTH and ALP are significantly associated with HBS in patients with renal hyperparathyroidism undergoing parathyroidectomy for renal hyperparathyroidism. A scoring system with these 2 variables may be of clinical utility in predicting patients at high risk of HBS.

No Cancer Occurrences in 10-year Follow-up after Prophylactic Nipple-sparing Mastectomy.

Prophylactic nipple-sparing mastectomies (NSM) have become increasingly common, although there is little long-term data on its efficacy in prevention of breast cancer. The objective of this study was to assess the incidence of breast cancer in a cohort of patients undergoing prophylactic NSM with a median follow-up of 10 years. Methods: Patients receiving prophylactic NSM at a single institution from 2006 to 2019 were included in a retrospective nature. Patient demographics, genetic mutations, operative details, and specimen pathology were recorded, and all postoperative patient visits and documentation were screened for cancer occurrence. Descriptive statics were performed where appropriate. Results: Two hundred eighty-four prophylactic NSMs were performed on 228 patients with a median follow-up of 120.5 ± 15.7 months. Roughly, a third of patients had a known genetic mutation, with 21% BRCA1 and 12% BRCA2. The majority (73%) of prophylactic specimens had no abnormal pathology. The most commonly observed pathologies were atypical lobular hyperplasia (10%) and ductal carcinoma in situ (7%). Cancer was identified in 10% of specimens, with only one case of lymphovascular invasion. Thus far, there have been no incidences of locoregional breast cancer occurrence in this cohort. Conclusions: The long-term breast cancer occurrence rate in this cohort of prophylactic NSM patients at the time of this study is negligible. Despite this, continued surveillance of these patients is necessary until lifetime risk of occurrence following NSM has been established.

Household socioeconomic status relates to specific hippocampal subfield volumes across development.

The hippocampus is composed of cytoarchitecturally distinct subfields that support specific memory functions. Variations in total hippocampal volume across development have been linked to socioeconomic status (SES), a proxy for access to material resources, medical care, and quality education. High childhood household SES is associated with greater cognitive abilities in adulthood. Currently, it is not known whether household SES differentially impacts specific hippocampal subfield volumes. We assessed susceptibility of subfields to variations in household SES across development in a sample of 167 typically developing 5- to 25-year-old. Bilateral cornu ammonis (CA) 1-2, combined CA3-dentate gyrus (DG), and subiculum (Sub) volumes were measured by highly reliable manual segmentation of high-resolution T2-weighted images and adjusted for intracranial volume. A summary component score of SES measures (paternal education, maternal education, and income-to-needs ratio) was used to examine variability in volumes across ages. We did not identify age-related differences in any of the regional volumes, nor did age modify SES-related effects. Controlling for age, larger volumes of CA3-DG and CA1-2 were associated with lower SES, while Sub volume was not. Overall, these findings support the specific impact of SES on CA3-DG and CA1-2 and highlight the importance of considering environmental influences on hippocampal subfield development.

Mal de Débarquement Syndrome in Children: A Case Series.

Currently, mal de débarquement syndrome (MdDS) has been reported only among adults. This case series describes 3 pediatric patients with MdDS. MdDS presentation in children is similar to that of adults, although the frequency of comorbid conditions is greater. Diagnostic delays are common and likely due to under-recognition of MdDS among children.

Transition Metal Coordination Complexes of Flavonoids: A Class of Better Pharmacological Active Molecules to Develop New Drugs.

Flavonoid metal ion complexes are one of the classes of biologically active molecules with immense pharmacological potential, including antioxidant, antidiabetic, antimicrobial, and anticancer activity, to name a few. The effectiveness of this complexion depends on the state and nature of the transition metal ions and on the position to which the metal ion coordinates with their corresponding parent flavonoid. The metal coordination of flavonoids also improves the biological activities to a maximum extent compared to the parent compound. This may be attributed to many factors such as metal ions, coordination sites, structural configuration, and stability of the complexes. On the other hand, some of the metal ion complexes reduce the biological efficiency of the corresponding parent flavonoids, which can be due to the shift from antioxidant to pro-oxidant nature as well as the stability of the complexes both in in vitro and in vivo conditions. However, the literature on the stability of flavonoid metal ion complexes in in vivo conditions is very scanty. Therefore, this review summarizes and critically addresses all these parameters a favor together in a single slot that favours for the researchers to put forward to understand the mode and detailed molecular mechanism of flavonoid metals complexes compared with their corresponding parent flavonoids.

Breast reconstruction during the COVID-19 pandemic: Single institution experience from the pandemic's epicenter in the United States.

INTRODUCTION: The coronavirus disease-19 (COVID-19) pandemic dramatically changed the delivery of breast cancer care. The objective of this study was to quantify the effect of the pandemic on breast cancer screening, treatment, and reconstruction at a single institution in New York City. METHODS: A retrospective chart review was conducted to determine the number of mammograms, lumpectomies, mastectomies, and breast reconstruction operations performed between January 1, 2019 and June 30, 2021. Outcomes analyzed included changes in mammography, oncologic surgery, and breast reconstruction surgery volume before, during and after the start of the pandemic. RESULTS: Mammography volume declined by 11% in March-May of 2020. Oncologic breast surgeries and reconstructive surgeries similarly declined by 6.8% and 11%, respectively, in 2020 compared with 2019, reaching their lowest levels in April 2020. The volume of all procedures increased during the summer of 2020. Mammography volumes in June and July 2020 were found to be at pre-COVID levels, and in October-December 2020 were 15% higher than in 2019. Oncologic breast surgeries saw a similar rebound in May 2020, with 24.6% more cases performed compared with May 2019. Breast reconstruction volumes increased, though changes in the types of reconstruction were noted. Oncoplastic closures were more common during the pandemic, while two-stage implant reconstruction and immediate autologous reconstruction decreased by 27% and 43%, respectively. All procedures are on track to increase in volume in 2021 compared to that in 2020. CONCLUSION: The COVID-19 pandemic reduced the volume of breast cancer surveillance, surgical treatment, and reconstruction procedures. While it is reassuring that volumes have rebounded in 2021, efforts must be made to emphasize screening and treatment procedures in the face of subsequent surges, such as that recently attributable to the Delta and Omicron variants.

Test-retest reliability of hippocampal subfield volumes in a developmental sample: Implications for longitudinal developmental studies.

The hippocampus (Hc) is composed of cytoarchitectonically distinct subfields: dentate gyrus (DG), cornu ammonis sectors 1-3 (CA1-3), and subiculum. Limited evidence suggests differential maturation rates across the Hc subfields. While longitudinal studies are essential in demonstrating differential development of Hc subfields, a prerequisite for interpreting meaningful longitudinal effects is establishing test-retest consistency of Hc subfield volumes measured in vivo over time. Here, we examined test-retest consistency of Hc subfield volumes measured from structural MR images in two independent developmental samples. Sample One (n = 28, ages 7-20 years, M = 12.64, SD = 3.35) and Sample Two (n = 28, ages 7-17 years, M = 11.72, SD = 2.88) underwent MRI twice with a 1-month and a 2-year delay, respectively. High-resolution PD-TSE-T2 -weighted MR images (0.4 × 0.4 × 2 mm3 ) were collected and manually traced using a longitudinal manual demarcation protocol. In both samples, we found excellent consistency of Hc subfield volumes between the two visits, assessed by two-way mixed intraclass correlation (ICC (3) single measures ≥ 0.87), and no difference between children and adolescents. The results further indicated that discrepancies between repeated measures were not related to Hc subfield volumes, or visit number. In addition to high consistency, with the applied longitudinal protocol, we detected significant variability in Hc subfield volume changes over the 2-year delay, implying high sensitivity of the method in detecting individual differences. Establishing unbiased, high longitudinal consistency of Hc subfield volume measurements optimizes statistical power of a hypothesis test and reduces standard error of the estimate, together improving external validity of the measures in constructing theoretical models of memory development.