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.

A combination of computed tomography scan and ultrasound provides optimal detection of cervical lymph node metastasis in papillary thyroid carcinomas: A systematic review and meta-analysis

BACKGROUND

Lymph node metastasis (LNM) in patients with papillary thyroid carcinoma (PTC) is common. This meta-analysis assesses the diagnostic accuracy of computed tomography (CT), ultrasound (US), and CT + US in detecting central and lateral LNM.

METHODS

A systematic review and meta-analysis was performed by searching PubMed, Embase, and Cochrane for studies published up to April 2022. The pooled sensitivity, specificity, and diagnostic odds ratio (DOR) were calculated. The area under the curve (AUC) for summary receiver operating curves (sROC) were compared.

RESULTS

The study population included 7902 patients with a total of 15 014 lymph nodes. Twenty-four studies analyzed the sensitivity of the overall neck region in which dual CT + US imaging (55.9%) had greater sensitivities (p < 0.001) than either US (48.4%) or CT (50.4%) alone. The specificity of US alone (89.0%) was greater (p < 0.001) than CT alone (88.5%) or dual imaging (86.8%). The DOR for dual CT + US imaging was greatest (p < 0.001) at 11.134, while the AUCs of the three imaging modalities were similar (p > 0.05). Twenty-one studies analyzed the sensitivity of the central neck region in which both CT (45.8%) and CT + US imaging (43.4%) had greater sensitivities (p < 0.001) than US alone (35.3%). The specificity of all three modalities was higher than 85%. The DOR for CT (7.985) was greater than US alone (4.723, p < 0.001) or dual CT + US imaging (4.907, p = 0.015). The AUC of both CT + US (0.785) and CT alone (0.785) were significantly greater (p < 0.001) than US alone (0.685). Of the 19 studies that reported lateral LNM, CT + US imaging sensitivity (84.5%) was higher than CT alone (69.2%, p < 0.001) and US alone (79.7%, p = 0.038). The specificity of all imaging techniques was all greater than 80.0%. CT + US imaging DOR (35.573) was greater than CT (20.959, p = 0.024) and US (15.181, p < 0.001) individually. The AUC of independent imaging was high (CT: 0.863, US: 0.858) and improved significantly when combined (CT + US: 0.919, p = 0.024 and p < 0.001, respectively).

CONCLUSIONS

We report an up-to-date analysis elucidating the diagnostic accuracy of LNM detection by either CT, US, or in combination. Our work suggests dual CT + US to be the best for overall detection of LNM and CT to be preferable in detecting central LNM. The use of either CT or US alone may detect lateral LNM with acceptable accuracy, yet dual imaging (CT + US) significantly improved detection rates.

Diagnostic Performance of Afirma and Interpace Diagnostics Genetic Testing in Indeterminate Thyroid Nodules: A Single Center Study

Indeterminate thyroid nodules (ITN) represent 20–30% of biopsied nodules, with a 10–60% risk of malignancy. Molecular testing can stratify the risk of malignancy among ITNs, and subsequently reduce the need for unnecessary diagnostic surgery. We aimed to assess the performance of these molecular tests at a single institution. Patients with Bethesda III, IV, and V nodules with Afirma and Interpace Diagnostics genetic testing data from November 2013 to November 2021 were included. Three cohorts were formed, including GSC + XA, ThyGeNEXT + ThyraMIR, and GSC + GEC. Statistical analysis determined the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), diagnostic odds ratio (DOR), and accuracy of each type of testing. The PPV of nodules undergoing genetic testing by ThyGeNEXT + ThyraMIR (45.00%, 95%CI: 28.28–62.93%, p = 0.032) and GSC + XA (57.14%, 95%CI: 29.32–81.08%, p < 0.001) were superior to that of GEC + GSC (30.72%, 95%CI: 26.83–34.90%). The NPV was above 85% in all cohorts, suggesting overall suitable rule-out tests. The Afirma platform (GSC + XA) had the highest NPV at 96.97%. The overall accuracy for nodules undergoing ThyGeNEXT + ThyraMIR was 81.42% (95%CI: 73.01–88.11%, p < 0.001). A total of 230 patients underwent thyroidectomy, including less than 60% of each of the ThyGeNEXT + ThyraMIR and GSC + XA cohorts. Specifically, only 25% of patients in the GSC + XA cohort underwent surgery, considerably decreasing the rate of unnecessary surgical intervention. Sub-group analysis, including only patients with surgical pathology, found that PPV tended to be higher in the GSC + XA cohort, at 66.67% (95%CI: 37.28–87.06%), as compared to the ThyGeNEXT + ThyraMIR cohort, at 52.94% (95%CI: 35.25–69.92%). The Afirma genetic testing platform GSC + XA outperformed the other platforms with regards to both PPV and NPV and decreased the rate of surgery in patients with ITNs by 75%, significantly preventing unnecessary surgical intervention.

Cardiovascular Health by Graves' Disease Management Modality - Surgery Versus Radioactive Iodine Versus Antithyroid Medications: A Network Meta-Analysis

INTRODUCTION

Graves' disease is an autoimmune disorder of the thyroid gland associated with the overproduction of thyroid hormones. Excess secretion of thyroid hormones leads to cardiovascular consequences. Treatment options include antithyroid medications (ATM), radioactive iodine (RAI) ablation, and total thyroidectomy. We examined the cardiovascular outcomes following Graves' disease management modality.

METHODS

A systematic search was performed up to September 22nd, 2021, using PubMed, EMBASE, and Web of Science databases. We conducted a network meta-analysis analyzing cardiovascular outcomes of interest, including congestive heart failure (CHF), arrhythmia, atrial fibrillation (AF), and hypertension.

RESULTS

Three studies were included in this analysis totaling 6700 patients with Graves' disease, of which 74% were female. The mean age was 44.34 y. When compared to pretreatment, management options lowered the risk of maintaining arrhythmia 81% with surgery (relative risk [RR] = 0.19; 95% confidence interval [CI] = 0.12 to 0.31), 67% with ATM (RR = 0.33; 95% CI = 0.23 to 0.49), and 50% with RAI (RR = 0.50; 95% CI = 0.13 to 1.95). Risk of maintaining CHF was reduced 80% with surgery (RR = 0.20; 95% CI = 0.08 to 0.49), 41% with ATM (RR = 0.59; 95%CI = 0.52 to 0.67), and only 7% with RAI (RR = 0.93; 95%CI = 0.68 to 1.26). Treatment-ranking analysis found all parameters, including CHF, arrhythmia, AF, and hypertension, to be in favor of surgical treatment over medical treatment and RAI ablation.

CONCLUSIONS

This is the first network meta-analysis analyzing the cardiovascular outcomes in Graves' disease patients by treatment option. Our study demonstrated that surgery is superior to RAI and medical treatment.

The Diagnostic Performance of Ultrasonography in the Evaluation of Extrathyroidal Extension in Papillary Thyroid Carcinoma: A Systematic Review and Meta-Analysis

Extrathyroidal extension (ETE) in patients with papillary thyroid carcinoma (PTC) is an indication of disease progression and can influence treatment aggressiveness. This meta-analysis assesses the diagnostic accuracy of ultrasonography (US) in detecting ETE. A systematic review and meta-analysis were performed by searching PubMed, Embase, and Cochrane for studies published up to April 2022. The pooled sensitivity, specificity, and diagnostic odds ratio (DOR) were calculated. The areas under the curve (AUC) for summary receiver operating curves were compared. A total of 11 studies analyzed ETE in 3795 patients with PTC. The sensitivity of ETE detection was 76% (95%CI = 74-78%). The specificity of ETE detection was 51% (95%CI = 49-54%). The DOR of detecting ETE by US was 5.32 (95%CI = 2.54-11.14). The AUC of ETE detection was determined to be 0.6874 ± 0.0841. We report an up-to-date analysis elucidating the diagnostic accuracy of ETE detection by US. Our work suggests the diagnostic accuracy of US in detecting ETE is adequate. Considering the importance of ETE detection on preoperative assessment, ancillary studies such as adjunct imaging studies and genetic testing should be considered.

Radiofrequency ablation as a novel modality in the USA for treating toxic thyroid nodules: case series and literature review

Background

Radiofrequency ablation (RFA) is widely accepted as a treatment for non-functioning benign thyroid nodules, mainly to reduce compressive symptoms. In addition to potential compressive symptoms, autonomously functioning thyroid nodules (AFTNs) can cause palpitations, weight loss, diarrhea, increased appetite, flushing, irritability, tiredness, poor sleep, and long-term cardiovascular and musculoskeletal consequences. Currently, there are no United States based RFA practice guidelines for the treatment of AFTNs. However, several reports from Asia and Europe have described the resolution of hyperthyroidism secondary to AFTNs with RFA.

Case Description

Three patients with toxic thyroid nodules presented with symptomatic hyperthyroidism, suppressed thyroid-stimulating hormone (TSH), and increased uptake on nuclear medicine thyroid scan. These patients were treated with RFA. At 3 months following ablation, TSH normalized to 2.09, 1.91, and 1.34 mIU/mL respectively. However, temporary hypothyroidism was encountered at 1 month following ablation. All patients discontinued their antithyroid medications following ablation. Nodules exhibited significant volume reductions of 38%, 32%, and 54% from the baseline at 1-month follow-up.

Conclusions

RFA potentiates as a safe and effective treatment of toxic thyroid nodules. Though it carries a risk of temporary hypothyroidism following ablation, long-term consequences appear to be minimal. Future study with larger sample size and longer follow-up are encouraged to identify factors predicting response.

Excess of cesarean births in pregnant women with COVID-19: A meta-analysis

BACKGROUND

Studies have suggested that cesarean birth in pregnant women with COVID-19 may decrease maternal adverse events and perinatal transmission. This systematic review aimed to evaluate variations in clinical presentation, laboratory findings, and maternal/neonatal outcomes in COVID-19 patients who delivered vaginally versus via cesarean.

METHODS

A comprehensive search following PRISMA guidelines was performed for studies published up to May 23, 2020, using PubMed, Web of Science, Scopus, Embase, Cochrane, Science Direct, and clinicaltrials.gov. Original retrospective and prospective studies, case reports, or case series with sufficient data for estimating the association of COVID-19 with different pregnancy outcomes with no language restriction and published in peer-reviewed journals were included. Pooled mean and arcsine transformation proportions were applied. Next, a two-arm meta-analysis was performed comparing the perinatal outcomes between the study groups.

RESULTS

Forty-two studies with a total of 602 pregnant women with COVID-19 were included. The mean age was 31.8 years. Subgroup analysis showed that Americans had the lowest gestational age (mean = 32.7, 95%CI = 27.0-38.4, P < 0.001) and the highest incidence of maternal ICU admission (95%CI = 0.45%-2.20, P < 0.001) of all nationalities in the study. There was no significant difference in perinatal complications, premature rupture of membrane, placenta previa/accreta, or gestational hypertension/pre-eclampsia between women who delivered vaginally versus by cesarean. Importantly, there were also no significant differences in maternal or neonatal outcomes.

CONCLUSION

Vaginal delivery was not associated with worse maternal or neonatal outcomes when compared with cesarean. The decision to pursue a cesarean birth should be based on standard indications, not COVID-19 status.

Accuracy of the 'CUT' Score for Assessing Malignancy in Bethesda 3 and 4 Thyroid Nodules in North American population: a retrospective study

BACKGROUND

The CUT score is a thyroid nodule malignancy risk assessment scoring system intended to guide surgeons in treating Bethesda 3 and 4 thyroid nodules. It is based on clinical (C) and ultrasonographic (U) features and a five-tiered (T) representing cytology.

PURPOSE

Our study aimed to assess the utility of the CUT score in predicting thyroid malignancy in the North American population. The main reason for creating this score is to reduce unnecessary surgeries on these challenging thyroid nodules.

MATERIALS AND METHODS

A retrospective record review study applied the CUT score to 219 Bethesda 3 and 4 thyroid nodules. A total of 203 Bethesda 3 and 16 Bethesda 4 nodules from patients treated between January 2015 and December 2019 at a single institution were assessed. A receiver operating characteristic (ROC) curve analysis was performed to evaluate the CUT diagnostic test. Binary logistic regression analysis was performed. Iteration of analysis was performed after stratification according to body mass index to assess CUT score accuracy in obese and non-obese patients.

RESULTS

Of 219 nodules analyzed, 148 were characterized as benign and 71 as malignant. Prevalence rates of malignancy were 29.6% (n = 60) and 68.8% (n = 11) in Bethesda 3 and 4 nodules, respectively. The mean CU (clinical, ultrasonography) score was 5.35 ± 1.38 in benign nodules versus 4.96 ± 1.5 in malignant nodules (p = 0.08). The area under the curve (AUC =0.433) for the association of CUT scores with nodule malignancy was not significant (p = 0.13). The CUT score was insignificant as a diagnostic test for nodule malignancy in obese (AUC =0.45; p = 0.72) and non-obese patients (AUC =0.39; p = 0.08).

CONCLUSION

The CUT score did not correlate with preoperative malignancy risk estimates in Bethesda 3 thyroid nodules and, therefore, may have limited utility as a predictor of malignancy in these thyroid nodules.

Efficacy and safety of balloon dilation of eustachian tube in children: Systematic review and meta-analysis

OBJECTIVES

Eustachian tube dysfunction is a common condition that may lead to otitis media with effusion, hearing loss and developmental delays in children. We sought to determine the efficacy and safety of balloon dilation of the eustachian tube (BDET) in the pediatric population.

DATA SOURCES

Original studies of BDET in a pediatric population were identified in PubMed, Embase, Web of Science, Cochrane, Clinicaltrials.gov and CINAHL.

METHODS

Outcomes of efficacy included audiometric findings and adverse events were summarized for each study.

RESULTS

Seven articles were included involving 408 children with a mean age of 9.9 years old (95%CI 8.8, 11.1) and a mean follow up of 19.2 months (95%CI 15, 23). Type B tympanograms decreased after BDET from 64.2% (95%CI 53.3, 73.8) to 16.1% (95%CI 8.5, 28.4). Air-bone gap (ABG) decreased after BDET from a mean of 25.3 dB (95%CI 18.9, 31.6) to 10.2 dB (95%CI 8.9, 11.5). The pooled estimate of adverse events after BDET was 5.1% (95%CI 3.2, 8.1), the majority being self-limited epistaxis with no major adverse events reported. Three studies compared BDET to ventilation tube insertion; analysis of post-operative ABG showed a greater decrease in the BDET group (mean difference -6.4 dB; 95%CI -9.8, -3.1; p = 0.002).

CONCLUSION

Although there are no prospective randomized control trials, BDET ± tympanostomy tube placement may produce outcomes that are comparable to tympanostomy tube placement in the treatment of otitis media with effusion in the pediatric population. Most children undergoing the procedure are those with recalcitrant disease. The procedure is safe with the most common complication being epistaxis.

Trampoline Injuries in Children and Adolescents: A Jumping Threat

OBJECTIVE

As trampoline use grows more popular in the United States, the frequency of injuries continues to climb. We hypothesized that toddlers would be at the highest risk for trampoline injuries requiring hospitalization.

METHODS

The National Electronic Injury Surveillance System database was examined for trampoline injuries from 2009 to 2018. Patients were categorized into 3 main age groups: toddlers (<2 years), children (2-12 years), and adolescents (13-18 years). Regression models were used to identify patients at high risk for injury or hospitalization.

RESULTS

There was a total of 800,969 meeting inclusion criteria, with 433,827 (54.2%) occurring at their own homes and 86,372 (18.1%) at the sporting venue. Of the total, 36,789 (4.6%) were admitted to a hospital. Fractures (N = 270,884, 34%), strain/sprain injuries (N = 264,990, 33%), followed by skin contusions/abrasions (N = 115,708, 14%) were the most common diagnoses. The most frequent injury sites were lower and upper extremities accounting for 329,219 (41.1%) and 244,032 (30.5%), whereas 175,645 (21.9%) had head and neck injuries. Musculoskeletal injuries (74%) and concussions (2.6%) were more frequent in adolescents than children (67.6% and 1.6%) and toddlers (56.3% and 1.3%). Internal organ and soft tissue injuries were frequent in toddlers. There were no fatalities reported in the injured patients. Multivariate analysis showed adolescents, female sex, extremity injuries, and musculoskeletal injuries were associated with hospitalization. Injury at a sporting venue was not associated with hospitalization.

CONCLUSIONS

Adolescents and girls are at increased risk of trampoline injury, warranting hospitalization. Safety standards may help prevent extremity and musculoskeletal injuries in the pediatric population. Finally, use of trampolines at sporting venues does not appear to be particularly dangerous.

Deciphering excess healthcare burden in head and neck cancer patients with cardiovascular comorbidity

BACKGROUND

This study aimed to determine the perioperative surgical outcomes for head and neck cancer patients with cardiovascular diseases (CVDs).

METHODS

A cross-sectional analysis was performed using data from the Nationwide Readmissions Database between 2010 and 2014. Logistic regression analysis by enter and backward stepwise methods were used.

RESULTS

A total of 8346 patients met the inclusion criteria. Patients with concomitant CVD had a higher frequency of complications (57.6%) compared with those without (47.4%) (odds ratio [OR] = 1.35, 95% confidence interval [CI] = 1.23-1.48, p < 0.001). Patients with CVD comorbidities were prone to experience in-patient mortality at both admission (OR = 2.4, 95% CI = 1.42-4.05) and readmission (OR = 2.55, 95% CI = 1.10-5.87). CVD patients have prolonged hospital admission (OR = 1.14, 95% CI = 1.02-1.27, p = 0.020) and higher cost (OR = 1.28, 95% CI = 1.15-1.43, p < 0.001). Patients with congestive heart failure were prone to 30 days readmission (OR = 1.67, 95% CI = 1.10-2.53, p = 0.019) and 90 days (OR = 1.65, 95% CI = 1.14-2.39, p = 0.010).

CONCLUSION

This is the first study identifying factors predicting higher risk of perioperative complications of surgical management of head and neck cancer. Those with CVD had higher risk of adverse events.

Nuclear Localization of BRAFV600E Is Associated with HMOX-1 Upregulation and Aggressive Behavior of Melanoma Cells

Simple Summary

Despite some successes of selective anti-BRAF^V600E inhibitors, resistance remains a major challenge. The aim of our study is to determine the role of nuclear BRAF^V600E and its newly identified partner, HMOX1, in melanoma aggressiveness and drug resistance. We identified the mechanism by which drug resistance is developed via the nuclear localization of BRAF^V600E and its partner HMOX1 in melanoma tissues and cell lines. According to our studies, the outcomes of our manuscript have a direct clinical impact on establishing novel prognostic markers and therapeutic intervention strategies in metastatic melanoma. This study provides new information on the ability to selectively classify patients with cytosolic BRAF for selective BRAF inhibitors and offers an alternative treatment to patients with nuclear BRAF^V600E and high HMOX1 expressions.

Abstract

Background: Previously, we have demonstrated that nuclear BRAF^V600E is associated with melanoma aggressiveness and vemurafenib resistance. However, the underlying mechanisms of how nuclear localization of BRAF^V600E promotes cell aggressiveness have not yet been investigated. Despite therapeutic advancements targeting cutaneous melanoma, unknown cellular processes prevent effective treatment for this malignancy, prompting an urgent need to identify new biological targets. This study aims to explore the association of inducible heme oxygenase 1 (HMOX-1) with nuclear BRAF^V600E in promoting melanoma aggressiveness. Methods: Proteomics analysis was performed to identify the interacting partner(s) of nuclear BRAF^V600E. Immunohistochemistry was applied to evaluate the levels of HMOX-1 and nuclear BRAF^V600E expression in melanoma and adjacent healthy tissues. Immunofluorescence assessed the nuclear localization of BRAF^V600E in vemurafenib-resistant A375R melanoma cells. Further study of HMOX-1 knockdown or BRAF^V600E overexpression in melanoma cells suggested a role for HMOX-1 in the regulation of cell proliferation in vivo and in vitro. Finally, Western blot analysis was performed to confirm the pathway by which HMOX-1 mediates Akt signaling. Results: Proteomics results showed that HMOX-1 protein expression was 10-fold higher in resistant A375R cells compared to parental counterpart cells. In vitro and in vivo results illustrate that nuclear BRAF^V600E promotes HMOX-1 overexpression, whereas HMOX-1 reduction represses melanoma cell proliferation and tumor growth. Mechanistic studies revealed that HMOX-1 was associated with nuclear BRAF^V600E localization, thus promoting melanoma proliferation via a persistent activation of the AKT pathway. Conclusions: Our results highlight a previously unknown mechanism in which the nuclear BRAF^V600E/HMOX-1/AKT axis plays an essential role in melanoma cell proliferation. Targeting HMOX-1 could be a novel method for treating melanoma patients who develop BRAF inhibitor resistance.

Altered mental status is a predictor of poor outcomes in COVID-19 patients: A cohort study

Introduction

Several studies have described typical clinical manifestations, including fever, cough, diarrhea, and fatigue with COVID-19 infection. However, there are limited data on the association between the presence of neurological manifestations on hospital admission, disease severity, and outcomes. We sought to investigate this correlation to help understand the disease burden.

Methods

We delivered a multi-center retrospective study of positive laboratory-confirmed COVID-19 patients. Clinical presentation, laboratory values, complications, and outcomes data were reported. Our findings of interest were Intensive Care Unit (ICU) admission, intubation, mechanical ventilation, and in-hospital mortality.

Results

A total of 502 patients with a mean age of 60.83 ± 15.5 years, of them 71 patients (14.14%) presented with altered mental status, these patients showed higher odds of ICU admission (OR = 2.06, 95%CI = 1.18 to 3.59, p = 0.01), mechanical ventilation (OR = 3.28, 95%CI = 1.86 to 5.78, p < 0.001), prolonged (>4 days) mechanical ventilation (OR = 4.35, 95%CI = 1.89 to 10, p = 0.001), acute kidney injury (OR = 2.18, 95%CI = 1.28 to 3.74, p = 0.004), and mortality (HR = 2.82, 95%CI = 1.49 to 5.29, p = 0.01).

Conclusion

This cohort study found that neurological presentations are associated with higher odds of adverse events. When examining patients with neurological manifestations, clinicians should suspect COVID-19 to avoid delayed diagnosis or misdiagnosis and lose the chance to treat and prevent further transmission.

Thyroid lobectomy as a cost-effective approach in low-risk papillary thyroid cancer versus active surveillance

BACKGROUND

An ongoing debate exists over the optimal management of low-risk papillary thyroid cancer. The American Thyroid Association supports the concept of active surveillance to manage low-risk papillary thyroid cancer; however, the cost-effectiveness of active surveillance has not yet been established. We sought to perform a cost-effectiveness analysis comparing active surveillance versus surgical intervention for patients in the United States.

METHODS

A Markov decision tree model was developed to compare active surveillance and thyroid lobectomy. Our reference case is a 40-year-old female who was diagnosed with unifocal (<15 mm), low-risk papillary thyroid cancer. Probabilistic outcomes, costs, and health utilities were determined using an extensive literature review. The willingness-to-pay threshold was set at $50,000/quality-adjusted life year gained. Sensitivity analyses were performed to account for uncertainty in the model's variables.

RESULTS

Lobectomy provided a final effectiveness of 21.7/quality-adjusted life years, compared with 17.3/quality-adjusted life years for active surveillance. Furthermore, incremental cost effectiveness ratio for lobectomy versus active surveillance was $19,560/quality-adjusted life year (<willing-to-pay threshold of $50,000/quality-adjusted life year), and thus surgical intervention proved to be cost-effective in patients between 40 and 69 years old. Further analysis revealed that, at the age of 69 years, active surveillance is more cost-effective than lobectomy, with a final effectiveness of 17.3/quality-adjusted life years. Compared to active surveillance, the incremental cost effectiveness ratio for lobectomy at the age of 69 was $27,235/quality-adjusted life year, which decreases quality-adjusted life years by 1.5.

CONCLUSION

Lobectomy is a cost-effective strategy in middle-aged patients with low-risk papillary thyroid cancer. In contrast, active surveillance is cost-effective beginning at the age of 69. Identification of such nuances can help physicians and patients determine the best, most individualized long-term management strategy for low-risk papillary thyroid cancer.

Cancer and COVID-19: analysis of patient outcomes

Background: We sought to investigate the outcomes associated with COVID-19 disease in cancer patients. Methods: We conducted a retrospective cohort study of laboratory-confirmed COVID-19 patients. Results: Of the 206 patients included, 57 had at least one preexisting malignancy. Cancer patients were older than noncancer patients. Of the 185 discharged cases, cancer patients had a significantly higher frequency of unplanned reintubation (7.1% vs 0.9%, p < 0.049), and required longer hospital stay (8.58 ± 6.50 days versus 12.83 ± 11.44 days, p < 0.002). Regression analysis revealed that obesity and active smoking were associated with an increased risk of mortality. Conclusion: Outcomes in COVID-19 appear to be driven by obesity as well as active smoking, with no difference in mortality between cancer and noncancer patients.

In this study, we aimed to investigate how COVID-19 affected cancer patients and whether this altered their survival outcomes. To do this, we examined data from a database of patients who have passed through our institution – a retrospective cohort analysis. Of the 206 patients we included in the study from this database, 57 had at least one preexisting cancer. Cancer patients tended to be older than noncancer patients. Of the 185 discharged patients, cancer patients required longer hospital stays, but there was no difference in mortality. Disease complications and intensive care unit admission with obesity and active smoking put patients in our cohort at increased risk of death. To conclude, outcomes in COVID-19 patients appear to be driven by obesity as well as active smoking, with no difference in mortality between cancer and noncancer patients.

Hyperthyroidism as an Underlying Cause of Premature Ejaculation

INTRODUCTION

Hormonal imbalances have been associated with various sexual dysfunction disorders. In particular, the connection of hyperthyroidism has been discovered to correlate to premature ejaculation (PE) but has yet to been thoroughly elucidated. As one of the most frequently self-reported sexual dysfunctions, it is imperative for health care professionals to evaluate possible underlying conditions in regard to treatment options for individuals with PE.

OBJECTIVES

To review the literature regarding hyperthyroidism effects on sexual dysfunction, with a focus on hyperthyroidism and PE.

METHODS

A literature review of articles and clinical studies was performed to define the classification, pathophysiology, diagnostic considerations, and management of hyperthyroidism on PE. Search terms included "hyperthyroidism" and/or "premature ejaculation," "treatment of premature ejaculation," "defining premature ejaculation," and "management of premature ejaculation."

RESULTS

To improve the accuracy of diagnosing PE, there needs to be a set definition amongst the different guidelines, as using these guidelines can help determine possible underlying etiologies of PE. The correlation of hyperthyroidism and PE has been described in a limited number of studies. It has been reported that individuals with hyperthyroidism are much more likely to have PE than individuals with euthryoidism. Management of hyperthyroidism has been shown to alleviate the symptoms of PE.

CONCLUSION

Further understanding of hyperthyroidism as an underlying cause of PE could lead to increased efficacy of treatment and management of PE. Tannenbaum J, Youssef M, Attia AS, et al. Hyperthyroidism as an Underlying Cause of Premature Ejaculation. Sex Med Rev 2021;XX:XXX-XXX.

Prognostic Factors of Mortality in Vibrio vulnificus Sepsis and Soft Tissue Infections: Meta-Analysis

Background: Vibrio vulnificus is a rare but life-threatening infection that effects the population near warm coastal areas. This infection could be fulminant and rapidly progress to severe sepsis and necrotizing soft tissue infection. Early diagnosis and treatment are critical to saving patients' lives. With multiple studies reporting discrepancies in prognostic factors and different treatment protocols, we aimed through this meta-analysis to assess these factors and protocols and the impact on the outcome of the infection. Materials and Methods: In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic search of PubMed, Embase, and Cochrane Library databases by two independent reviewers was reported. Studies evaluating prognostic factors and treatment outcomes of Vibrio vulnificus infections were included. Comprehensive Meta-Analysis, version 3.0 was used. Results: Two hundred eleven studies were identified. Of those, eight studies met our inclusion criteria. The following factors on presentation were associated with higher mortality rates; concomitant liver disease (odds ratio [OR], 4.38; 95% confidence interval [CI], 2.43-7.87; p < 0.001), renal disease (OR, 3.90; 95% CI, 1.37-11.12; p = 0.011), septic shock (OR, 2.82; 95% CI, 1.84-4.31; p < 0.001), higher Acute Physiology and Chronic Health Evaluation (APACHE) II score (OR, 3.40; 95% CI, 2.26-5.12; p < 0.001), elevated band cells count (OR, 2.61; 95% CI, 1.13-6.0; p = 0.024), hypoalbuminemia (OR, 3.41; 95% CI, 1.58-7.35; p = 0.002), and infection involving multiple limbs (OR, 4.36; 95% CI, 1.72-11.07; p = 0.002). Interestingly, different antibiotic regimens did not have any impact on outcomes, however, delayed surgical intervention after the first 12 or 24 hours was associated with higher mortality rates (OR, 2.64; 95% CI, 1.39-5.0; p = 0.003 and OR, 2.99; 95% CI, 1.54-5.78; p = 0.001, respectively). Conclusion: The presence of liver or renal disease, higher APACHE II scores, septic shock, hypoalbuminemia, or elevated band cell on presentation should alert the physician to the higher risk of mortality. Different antibiotic regimens did not impact the outcomes in these patients and delayed surgical intervention is associated with worsening of mortality.

Site-Specific Metastasis and Survival in Papillary Thyroid Cancer: The Importance of Brain and Multi-Organ Disease

Introduction-heterogeneity in clinical outcomes and survival was observed in patients with papillary thyroid cancer (PTC) and distant metastases. Here, we investigated the effect of distant metastases sites on survival in PTC patients. Methods-patients with a diagnosis of PTC and known metastases were identified using the Surveillance, Epidemiology, and End Results database (1975-2016). Univariate and multivariate Cox regression analyses were performed to analyze the effect of distant metastases sites on thyroid cancer-specific survival (TCSS) and overall survival (OS). Results-from 89,694 PTC patients, 1819 (2%) developed distant metastasis at the initial diagnosis, of whom 26.3% presented with the multiple-organ disease. The most common metastatic sites were lung (53.4%), followed by bone (28.1%), liver (8.3%), and brain (4.7%). In metastatic patients, thyroid cancer-specific death accounted for 73.2%. Kaplan-Meier curves showed decreased OS in patients with metastases to the brain (median OS = 5 months) and liver (median OS = 6 months) compared to lung (median OS = 10 months) and bone (median OS = 23 months). Moreover, multiple organ metastasis had a higher mortality rate (67.4%) compared to single organ metastasis (51.2%, p < 0.001). Using multivariate analysis, risk factors that significantly influence TCSS and OS were male gender (HR = 1.86, 95% CI = 1.17-2.94, p < 0.001, and HR = 1.90, 95% CI = 1.40-2.57, p = 0.009), higher tumor grade (HR = 7.31, 95% CI = 2.13-25.0, p < 0.001 and HR = 4.76, 95% CI = 3.93-5.76, p < 0.001), multiple organ involvement (HR = 6.52, 95% CI = 1.50-28.39, p = 0.026 and HR = 5.08, 95% CI = 1.21-21.30, p = 0.013), and brain metastasis (HR = 1.82, 95% CI = 1.15-2.89, p < 0.001 and HR = 4.21, 95% CI = 2.20-8.07, p = 0.010). Conclusion-the pattern of distant metastatic organ involvement was associated with variability in OS in PTC. Multi-organ metastasis and brain involvement are associated with lower survival rates in PTC. Knowledge of the patterns of distant metastasis is crucial to personalize the treatment and follow-up strategies.

Gastroenterology manifestations and COVID-19 outcomes: A meta-analysis of 25,252 cohorts among the first and second waves

A meta-analysis was performed to identify patients with coronavirus disease 2019 (COVID-19) presenting with gastrointestinal (GI) symptoms during the first and second pandemic waves and investigate their association with the disease outcomes. A systematic search in PubMed, Scopus, Web of Science, ScienceDirect, and EMBASE was performed up to July 25, 2020. The pooled prevalence of the GI presentations was estimated using the random-effects model. Pairwise comparison for the outcomes was performed according to the GI manifestations' presentation and the pandemic wave of infection. Data were reported as relative risk (RR), or odds ratio and 95% confidence interval. Of 125 articles with 25,252 patients, 20.3% presented with GI manifestations. Anorexia (19.9%), dysgeusia/ageusia (15.4%), diarrhea (13.2%), nausea (10.3%), and hematemesis (9.1%) were the most common. About 26.7% had confirmed positive fecal RNA, with persistent viral shedding for an average time of 19.2 days before being negative. Patients presenting with GI symptoms on admission showed a higher risk of complications, including acute respiratory distress syndrome (RR = 8.16), acute cardiac injury (RR = 5.36), and acute kidney injury (RR = 5.52), intensive care unit (ICU) admission (RR = 2.56), and mortality (RR = 2.01). Although not reach significant levels, subgroup-analysis revealed that affected cohorts in the first wave had a higher risk of being hospitalized, ventilated, ICU admitted, and expired. This meta-analysis suggests an association between GI symptoms in COVID-19 patients and unfavorable outcomes. The analysis also showed improved overall outcomes for COVID-19 patients during the second wave compared to the first wave of the outbreak.

Asthma and COVID-19; different entities, same outcome: a meta-analysis of 107,983 patients

OBJECTIVE

There are varying reports of the prevalence and effect of comorbid asthma in coronavirus disease-2019 (COVID-19) patients. We sought to conduct a meta-analysis comparing asthmatic and non-asthmatic patients to determine the clinical significance of preexisting asthma in COVID-19 patients.

DATA SOURCES

Online databases PubMed, ScienceDirect, Web of Science, and Scopus, were searched up to July 15, 2020, for papers comparing asthma versus non-asthma COVID-19 patients.

STUDY SELECTION

According to prespecified inclusion criteria, this analysis included eleven retrospective studies with 107,983 COVID-19 patients. Subgroup analysis was performed based on age groups.

RESULTS

The mean age of the patients was 59.9 years (95%CI = 51.9-67.9). Across studies, the prevalence of asthma was 11.2% (95%CI: 9.1%-13.3%) among COVID-19 patients who attended the hospitals. Asthma patients were more likely to be younger (SMD = -0.36, 95%CI = -0.61 to -0.10, p = 0.005), and obese (OR = 1.98, 95%CI = 1.54-2.55, p < 0.001), there was no differential risk of hospitalization rate, ICU admission, or development of acute respiratory distress syndrome (ARDS) between asthmatic and non-asthmatic cohorts. However, asthmatic patients had increased risk of endotracheal intubation (RR = 1.27, 95%CI = 1.02-1.58, p = 0.030) especially patients aged <50 years (RR = 6.68, 95%CI = 1.76-11.13, p = 0.009). Despite this result, asthmatic patients had better recovery with a higher liability of being discharged and were less likely to die (RR = 0.80, 95%CI = 0.65-0.97, p = 0.026).

CONCLUSION

To our knowledge, our meta-analysis is the largest to shed light on preexisting asthma as a predictor of intubation in COVID-19, especially in young and obese patients. Identifying high-risk groups is crucial for designing more effective intervention plans and optimization of efficient resource allocation.

Chemoembolization Versus Radioembolization for Neuroendocrine Liver Metastases: A Meta-analysis Comparing Clinical Outcomes

BACKGROUND

Studies have shown intra-arterial therapies to be effective in controlling neuroendocrine liver metastases (NELMs), but the evidence supporting the selection of specific methods is limited. This meta-analysis is the first to compare survival outcomes between transarterial chemoembolization (TACE) and transarterial radioembolization (TARE) in the treatment of NELM.

METHODS

A systematic search according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in PubMed and Embase databases was conducted in February 2020 for published studies comparing survival outcomes between TACE and TARE in the treatment of NELM.

RESULTS

Six eligible cohort studies with a total of 643 patients were identified. The TACE and TARE groups were similar in terms of age, sex, hepatic tumor burden, tumor grade, and Eastern Cooperative Oncology Group (ECOG) score. The patients treated with TACE had significantly better overall survival (odds ratio [OR], 1.92; 95% confidence interval [CI] 1.14-3.22, p = 0.014) than those treated with TARE. Overall survival ranged from 16.8 to 81.9 months with TACE and from 14.5 to 66.8 months with TARE. No significant differences in hepatic progression-free survival (OR, 1.01; 95% CI 0.75-1.35; p = 0.96) or tumor response were observed within the first 3 months (OR, 2.87; 95% CI 0.81-10.21; p = 0.10) or thereafter (OR, 0.98; 95% CI 0.12-7.86; p = 0.99). The complication rates were similar between the two groups, with 6.9% of the TACE patients versus 8.5% of TARE patients reporting major complications (OR, 1.16; 95% CI 0.54-2.48; p = 0.71) and respectively 44.6% and 58.8% of the TACE and TARE patients reporting minor adverse events (OR, 1.08; 95% CI 0.39-2.99; p = 0.88).

CONCLUSIONS

Despite similar tumor responses, an overall survival benefit was associated with TACE treatment of NELM compared with TARE treatment. Randomized controlled trials are warranted to confirm this finding and clarify whether certain subpopulations benefit from different transarterial methods.

Asthma in COVID-19 patients: An extra chain fitting around the neck?

Introduction

The novel coronavirus disease 2019 (COVID-19) has rapidly spread across the globe. Pre-existing comorbidities have been found to have a dramatic effect on the disease course. We sought to analyze the effect of asthma on the disease progression and outcomes of COVID-19 patients.

Methods

We conducted a multi-center retrospective study of positively confirmed COVID-19 patients. The primary outcome of interest was in-hospital mortality. Secondary outcomes were the Intensive Care Unit (ICU) admission, intubation, mechanical ventilation, and length of hospital stay.

Results

A total of 502 COVID-19 adult patients (72 asthma and 430 non-asthma cohorts) with mean age of 60.7 years were included in the study. The frequency of asthma in hospitalized cohorts was 14.3%. Univariate analysis revealed that asthma patients were more likely to be obese (75% versus 54.2%, p = 0.001), with a higher frequency of intubation (40.3% versus 27.8%, p = 0.036), and required a longer duration of hospitalization (15.1 ± 12.5 versus 11.5 ± 10.6, p = 0.015). After adjustment, multivariable analysis showed that asthmatic patients were not associated with higher risk of ICU admission (OR = 1.81, 95%CI = 0.98–3.09, p = 0.06), endotracheal intubation (OR = 1.77, 95%CI = 0.99–3.04, p = 0.06) or complications (OR = 1.37, 95%CI = 0.82–2.31, p = 0.23). Asthmatic patients were not associated with higher odds of prolonged hospital length of stay (OR = 1.48, 95%CI = 0.82–2.66, p = 0.20) or with ICU stay (OR = 0.76, 95%CI = 0.28–2.02, p = 0.58). Kaplan-Meier curve showed no significant difference in the overall survival of the two groups (p = 0.65).

Conclusion

Despite the increased prevalence of hospitalization in elder asthmatic COVID-19 patients, after adjustment for other variables, it was neither associated with increased severity nor worse outcomes.

•

Asthma is more prevalent in COVID-19 cohort than in the general population.

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Asthma was neither associated with disease severity nor negative outcomes.

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Asthma does not imply a worse outcome as compared to non-asthmatics.

Obesity and the prevention of thyroid cancer: Impact of body mass index and weight change on developing thyroid cancer - Pooled results of 24 million cohorts

BACKGROUND

Body weight may be a modifiable risk factor predisposing to different cancers. To establish a potential impact of weight change on thyroid cancer risk, we conducted a meta-analysis to evaluate the effect of body mass index (BMI) and weight change over time as a risk of developing thyroid cancer (TC).

METHODS

A systematic search was performed up to February 25, 2020. Pooled relative risk (RR) were estimated using fixed and random models. Heterogeneity between articles was examined using Q-test and I² index. Evaluation of publication bias was conducted with Egger's regression test.

RESULTS

A total of 31 studies including 24,489,477 cohorts were eligible. Pooled analysis revealed that normal and underweight cohorts were associated with a decreased risk of TC (RR = 0.68, 95%CI = 0.65-0.71, p < 0.001) and (RR = 0.92, 95%CI = 0.91-0.93, p < 0.001), respectively. In contrast, overweight and obese cohorts were more likely to develop TC (RR = 1.26, 95%CI = 1.24-1.28, p < 0.001 and RR = 1.50, 95%CI = 1.45-1.55, p < 0.001, respectively). Obesity was associated with higher risk of developing TC among women (RR = 1.29, 95%CI = 1.14-1.46, p < 0.001), but not men (RR = 1.25, 95%CI = 0.97-1.62, p = 0.08). Furthermore, weight gain increased the risk of developing TC (RR = 1.18, 95%CI = 1.14-1.22, p < 0.001), while weight loss decreased the risk (RR = 0.89, 95%CI = 0.85-0.93, p < 0.001). Results showed similar trends of weight change effect in both males and females.

CONCLUSIONS

Obesity is associated with higher risk of developing TC in women. However, maintaining a healthy weight is associated with reduced risk of TC in both women and men. Shifting our practice to include weight control strategies will help lead to cancer prevention.

Robotic and Laparoscopic Approaches for Adrenal Surgery in Obese Patients

OBJECTIVE

Minimally invasive adrenalectomy is a challenging procedure in obese patients. Few recent studies have advocated against robot-assisted adrenalectomy, particularly in obese patients. This study aims to compare operative outcomes between the robotic and laparoscopic adrenalectomy, particularly in obese patients.

MATERIALS AND METHODS

A retrospective analysis was performed on all consecutive patients undergoing adrenalectomy for benign disease by a single surgeon using either a laparoscopic or robotic approach. Adrenal surgeries for adrenal cancer were excluded. Demographics, operative time, length of hospital stays, estimated blood loss (EBL), and intraoperative and postoperative complications were evaluated. Patients were divided into 2 groups; obese and nonobese. A sub-analysis was performed comparing robotic and laparoscopic approaches in obese and nonobese patients.

RESULTS

Out of 120, 55 (45.83%) were obese (body mass index ≥ 30 kg/m²). 14 (25.45%) of the obese patients underwent a laparoscopic approach, and 41 (74.55%) underwent a robotic approach. Operative times were longer in the obese vs. nonobese groups (173.30 ± 72.90 minutes and 148.20 ± 61.68 minutes, P = .04) and were associated with less EBL (53.77 ± 82.48 vs. 101.30 ± 122, P = .01). The robotic approach required a longer operative time when compared to the laparoscopic approach (187 ± 72.42 minutes vs. 126.60 ± 54.55 minutes, P = .0102) in the obese but was associated with less blood loss (29.02 ± 51.05 mL vs. 138.30 ± 112.20 mL, P < .01) and shorter hospital stay (1.73 ± 1.23 days vs. 3.17 ± 1.27 days, P < .001).

CONCLUSION

Robot-assisted adrenal surgery is safe in obese patients and appears to be longer; however, it provides improvements in postoperative outcomes, including EBL and shorter hospital stay.

Vitamin D insufficiency as a potential culprit in critical COVID-19 patients

BACKGROUND

As an immune modulator, vitamin D has been implicated in the coronavirus disease-2019 (COVID-19) outcome. We aim to systematically explore the association of vitamin D serum levels with COVID-19 severity and prognosis.

METHODS

The standardized mean difference (SMD) or odds ratio and 95% confidence interval (CI) were applied to estimate pooled results from six studies. The prognostic performance of vitamin D serum levels for predicting adverse outcomes with detection of the best cutoff threshold was determined by receiver operating characteristic curve analysis. Decision tree analysis by combining vitamin D levels and clinical features was applied to predict severity in COVID-19 patients.

RESULTS

Mean vitamin D serum level of 376 patients, was 21.9 nmol/L (95% CI = 15.36-28.45). Significant heterogeneity was found (I²  = 99.1%, p < .001). Patients with poor prognosis (N = 150) had significantly lower serum levels of vitamin D compared with those with good prognosis (N = 161), representing an adjusted standardized mean difference of -0.58 (95% Cl = -0.83 to -0.34, p < .001).

CONCLUSION

Serum vitamin D levels could be implicated in the COVID-19 prognosis. Diagnosis of vitamin D deficiency could be a helpful adjunct in assessing patients' potential of developing severe COVID-19. Appropriate preventative and/or therapeutic intervention may improve COVID-19 outcomes.

African Americans Struggle With the Current COVID-19

OBJECTIVES

Our study aims to explore the differential impact of this pandemic on clinical presentations and outcomes in African Americans (AAs) compared to white patients.

BACKGROUND

AAs have worse outcomes compared to whites while facing heart diseases, stroke, cancer, asthma, influenza and pneumonia, diabetes, and HIV/AIDS. However, there is no current study to show the impact of COVID-19 pandemic on the AA communities.

METHODS

This is a retrospective study that included patients with laboratory-confirmed COVID-19 from 2 tertiary centers in New Orleans, LA. Clinical and laboratory data were collected. Multivariate analyses were performed to identify the risk factors associated with adverse events.

RESULTS

A total of 157 patients were identified. Of these, 134 (77%) were AAs, whereas 23.4% of patients were Whites. Interestingly, AA were younger, with a mean age of 63 ± 13.4 compared to 75.7 ± 23 years in Whites (P < 0.001). Thirty-seven patients presented with no insurance, and 34 of them were AA. SOFA Score was significantly higher in AA (2.57 ± 2.1) compared to White patients (1.69 ± 1.7), P = 0.041. Elevated SOFA score was associated with higher odds for intubation (odds ratio = 1.6, 95% confidence interval = 1.32-1.93, P < 0.001). AA had more prolonged length of hospital stays (11.1 ± 13.4 days vs 7.7 ± 23 days) than in Whites, P = 0.01.

CONCLUSION

AAs present with more advanced disease and eventually have worse outcomes from COVID-19 infection. Future studies are warranted for further investigations that should impact the need for providing additional resources to the AA communities.

Impact of psychiatric comorbidities on outcomes related to thyroid and parathyroid operations

BACKGROUND

We examined the effect of psychiatric comorbidities on perioperative surgical outcomes and the leading causes of readmissions in patients who underwent thyroid and parathyroid operations.

METHOD

Patient information was retrieved from the Nationwide Readmission Database (2010-2017). Multivariate analysis was used to identify predictors for hospital readmissions.

RESULTS

A total of 181,007 and 53,808 patients underwent thyroid and parathyroid operations, respectively. Of those, 8,468 (4.7%) and 6,112 (11.4%) patients were readmitted within 30 days. Psychiatric comorbidities were more frequent in readmitted cohorts after thyroidectomies (14.9% vs 10.4%; P < .001) and parathyroidectomies (16.8% vs 11.5%; P < .001), with anxiety being the most frequent cause (thyroid: 7.87%, parathyroid: 6.8%). Psychiatric comorbidities were associated with greater risk of in-hospital mortality (thyroid: odds ratio = 2.07, 95% confidence interval = 1.13-3.53; P = .015 and parathyroid: odds ratio = 1.67, 95% confidence interval = 1.04-2.70; P = .005), postoperative complications (thyroid: odds ratio = 1.528, 95% confidence interval = 1.473-1.585; P < .001 and parathyroid: odds ratio = 3.26, 95% confidence interval = 2.84-3.73; P < .001), prolonged duration of stay (thyroid: beta coefficient = 1.142, 95% confidence interval = 1.076-1.207; P < .001 and parathyroid: beta coefficient = 2.15, 95% confidence interval = 1.976-2.32; P < .001), and 30-day readmissions (thyroid: hazard ratio = 1.18, 95% confidence interval = 1.03-1.18; P = .047 and parathyroid: hazard ratio = 1.23, 95% confidence interval = 1.11-1.36; P < .001). Psychosis had the greatest risk of readmission (thyroid: hazard ratio = 1.51 and parathyroid: hazard ratio = 1.42), and dementia (odds ratio = 2.58) had the greatest risk of postoperative complications.

CONCLUSION

Concomitant psychiatric conditions after thyroid and parathyroid operations were associated with increased risk of postoperative complications, prolonged hospital stays, and greater rates of readmissions.

COVID-19 and liver dysfunction: A systematic review and meta-analysis of retrospective studies

Recently, Coronavirus Disease 2019 (COVID‐19) pandemic is the most significant global health crisis. In this study, we conducted a meta‐analysis to find the association between liver injuries and the severity of COVID‐19 disease. Online databases, including PubMed, Web of Science, Scopus, and Science direct, were searched to detect relevant publications up to 16 April 2020. Depending on the heterogeneity between studies, a fixed‐ or random‐effects model was applied to pool data. Publication bias Egger's test was also performed. Meta‐analysis of 20 retrospective studies (3428 patients), identified that patients with a severe manifestation of COVID‐19 exhibited significantly higher levels of alanine aminotransferase, aspartate aminotransferase, and bilirubin values with prolonged prothrombin time. Furthermore, lower albumin level was associated with a severe presentation of COVID‐19. Liver dysfunction was associated with a severe outcome of COVID‐19 disease. Close monitoring of the occurrence of liver dysfunction is beneficial in early warning of unfavorable outcomes.

Liver dysfunction was associated with a severe outcome of COVID‐19

Sever cases of COVID‐19 patients have high serum levels of ALT, AST and bilirubin with prolonged prothrombin time.

Low serum albumin is associated with a severe presentation of COVID‐19

Close monitoring of the occurrence of liver dysfunction is beneficial in early warning of unfavorable COVID‐19 outcomes.

Impact of surgery versus medical management on cardiovascular manifestations in Graves disease

BACKGROUND

Graves disease is well known to have multiple adverse effects on the cardiovascular system. We compared the cardiovascular outcomes after surgical intervention versus medical treatment in patients with Graves disease.

METHODS

We performed a retrospective study of all Graves disease patients with a cardiovascular comorbidity who underwent either surgical or medical management (N = 151). Perioperative biochemical and cardiovascular outcomes from the surgical versus the medical groups were analyzed.

RESULTS

Of 151 patients, 69 (45.6%) patients underwent total thyroidectomy and 82 (54.3%) patients received medical treatment. Hypertension resolved in 44.7% of the patients from the surgical group vs 18% in the medical group (P = .03). Tachyarrhythmias, including atrial fibrillation and tachycardia, improved in 85.9% of patients in the surgical group vs 66% in the medical group (P = .01). All cardiovascular manifestations examined, hypertension, tachyarrhythmias, and heart failure, improved in 69% of patients in the surgical group and 42.6% of patients in the medical group during the follow-up period (P < .01).

CONCLUSION

Surgical treatment offers a significant and rapid clinical improvement of cardiovascular manifestations in Graves disease patients, such as hypertension, tachyarrhythmias, and heart failure. Surgery should be considered and recommended in Graves disease patients with known cardiovascular manifestations.

Montelukast, a cysteinyl leukotriene receptor-1 antagonist protects against hippocampal injury induced by transient global cerebral ischemia and reperfusion in rats

Cysteinyl leukotrienes (CysLTs) are potent pro-inflammatory and immune modulating lipid mediators involved in inflammatory diseases and were boosted in human brain after acute phase of cerebral ischemia. The antagonism of CysLTs receptors may offer protection against ischemic damage. Therefore it seemed interesting to study the possible neuroprotective effect of Montelukast, a CysLTR1 antagonist in global cerebral ischemia/reperfusion (IR) injury in rats. Global cerebral ischemia-reperfusion was induced by bilateral carotid artery occlusion for 15 min followed by 60 min reperfusion period. Animals were randomly allocated into three groups (n = 30 per group): Sham operated, I/R control and rats treated with montelukast (0.5 mg/kg, po) daily for 7 days then I/R was induced 1 h after the last dose of montelukast. After reperfusion rats were killed by decapitation, brains were removed and both hippocampi separated and the following biochemical parameters were estimated; lactate dehydrogenase activity, oxidative stress markers (lipid peroxides, nitric oxide and reduced glutathione), inflammatory markers (myeloperoxidase, tumor necrosis factor-alpha, nuclear factor kappa-B, interleukin-6 and interleukin-10), apoptotic biomarkers (caspase 3 and cytochrome C), neurotransmitters (glutamate, gamma aminobutyric acid), Cys-LTs contents and CysLT1 receptor expression; as well as total brain infarct size and histopathological examination of the hippocampus were assessed. Montelukast protected hippocampal tissue by reducing oxidative stress, inflammatory and apoptotic markers. Furthermore, it reduced glutamate and lactate dehydrogenase activity as well as infarct size elevated by I/R. These results were consistent with the histopathological findings. Montelukast showed a neuroprotective effects through antioxidant, anti-inflammatory and antiapoptotic mechanisms.

Behavioral effects of acute and chronic triazolam treatments in albino rats

Previous behavioral studies on triazolam (TZ), which are small in number, could only speculate about tolerance to the anxiolytic effect of TZ, as the experiments did not cover sufficient time (of 4 to 7 days) for tolerance to develop. Therefore longer time for chronic TZ administration is used. We investigated the effects of TZ on motor activity and exploratory behavior using plus maze and open field. Three experiments were conducted. In the first, five groups of rats were acutely treated with different doses of TZ (0.25 mg/kg-4.0 mg/kg). In the second set of experiments, rats were treated chronically with a single daily dose of TZ (started with 0.25 mg/kg and increased by time to 1.0 mg/kg) for 5 weeks (representing clinical use). In the third, rats were treated chronically with three daily doses of TZ (started with 0.25 mg/kg and increased by time to 0.5 mg/kg) for 20 days (mimicking drug abuse). Acute TZ administration produced dose dependent anxiolytic effects and a decrease in motor activity with higher doses. Chronically treated rats, either once daily or three times daily doses, showed tolerance to both anxiolytic and sedative effects of TZ. It may be concluded that tolerance to the anxiolytic and sedative effects of TZ would develop after chronic administration either with clinical use or its abuse.

Brain glycine levels in triazolam-treated albino rats

The present study investigates the effects of acute and chronic administration of triazolam in albino rats on glycine levels in different brain areas. Three experiments were conducted. In the first, five groups of rats were acutely treated with different doses of triazolam (0.25 mg/kg-4.0 mg/kg i.p.). In the second experiment, rats were treated chronically by a single daily dose of triazolam (started by 0.25 mg/kg and increased by time to 1.0 mg/kg) for 5 weeks, simulating clinical use. In the third, rats were treated chronically three daily doses of triazolam (started by 0.25 mg/kg and increased by time to 0.5 mg/kg) for 20 days, simulating a form of drug abuse. Brain levels of glycine and plasma levels of triazolam were measured using HPLC technique. The acute triazolam administration produced an increase in glycine levels in almost all brain areas studied. The chronic administration of single daily dose of triazolam produced normal glycine levels in most of the brain areas; this indicates the development of tolerance to glycine content increasing action of triazolam. The chronic administration of three daily doses of triazolam produced a decrease in glycine levels in almost all brain regions studied, which might be a prerequisite for oncoming withdrawal syndrome.

Effects of acute and chronic triazolam treatments on brain GABA levels in albino rats

The present study investigated the effects of acute and chronic intraperitoneal administration of Triazolam on g-aminobutyric acid (GABA) levels in different brain areas of albino rats. Three experiments were conducted. In the first, five groups of rats were acutely treated with different doses of Triazolam (0.25 mg/kg-4.0 mg/kg). In the second experiment, rats were treated chronically with a single daily dose of Triazolam (started with 0.25 mg/kg and increased by time to 1.0 mg/kg) for 5 weeks, simulating clinical use. In the third, rats were treated chronically with three daily doses of Triazolam (started with 0.25 mg/kg and increased by time to 0.5 mg/kg) for 20 days, representing a form of drug abuse. Brain levels of GABA and plasma levels of Triazolam were measured using high performance liquid chromatography (HPLC). The acute Triazolam administration produced an increase in GABA levels in all brain areas studied. The chronic administration of single daily dose of Triazolam produced normal GABA levels in all brain areas except brain stem where the levels were significantly decreased; this indicates the development of tolerance to Triazolam action on increasing GABA content. The chronic administration of three daily doses of Triazolam produced a decrease in GABA levels in all brain regions studied. In conclusion, chronic single daily dose treatment (representing normal use) produces tolerance to Triazolam effects on brain GABA levels, while chronic three daily doses administration (akin to drug abuse) causes a fall in GABA levels.

PREVENTION OF CISPLATIN-INDUCED NEPHROTOXICITY BY METHIMAZOLE

Nephrotoxicity is a dose-limiting factor in the use of cisplatin against solid tumours. Methimazole, an antithyroid drug containing a free SH group, has a nephroprotective potential against chemically-induced nephrotoxicity. We tried to explore the nephrotoxic effect of the experimentally therapeutic dose of cisplatin (7 mg kg(-1), i.p.), particularly on the nuclear level of kidney cells in male albino rats, as well as the possible protective effect of methimazole. Furthermore, the drug interaction regarding the oncolytic effect of cisplatin was examined in Ehrlich ascites carcinoma (EAC)-bearing mice. A single dose of cisplatin caused kidney damage, 6 days after injection, manifested by 219% increase in serum creatinine, 384% increase in blood urea nitrogen and 170% increase in kidney content of lipid peroxides. Kidney DNA showed clear fragmentations detected by gel electrophoresis. However, kidney reduced glutathione was unchanged at that time period. Histological examination of kidney confirmed the toxic effect of cisplatin. Methimazole (40 mg kg(-1), i.p., 30 min before cisplatin injection) significantly protected the kidney from the nephrotoxic effect of cisplatin as judged from the biochemical parameters investigated as well as the histopathological examination. On the other hand, the survival data in EAC-bearing mice treated with both drugs indicated the persistence of an effective cytotoxic action. This study points to a promising use of this combination and necessitates further experimental and clinical studies. 2000 Academic Press@p$hr Copyright 2000 Academic Press.

A study on the reproductive toxicity of erythrosine in male mice

Worldwide usage of different colouring agents in the food industry prompted us to study their toxicity. The potential adverse effects of erythrosine (ER, FD & C Red No. 3) on the spermatogenesis process were investigated in adult mice. Testicular lactic dehydrogenase isoenzyme activity (LDH-X), a pachytene spermatocyte marker of testicular toxicity, was significantly decreased to 71.8% and 68.6% of the control value after daily p.o. administration of ER (21 days) in doses of 68 and 136 mg kg-1 respectively. At the same time, the normal average epididymal sperm count as well as the percentage of motile sperms were significantly inhibited by about 50% and 57% respectively. Moreover, ER was shown to disrupt the normal morphology of the sperm head. Thus, after 5 daily p.o administrations of ER in doses of 680 and 1360 mg kg-1 (equivalent to 10 and 20% of its LD50) it increased the incidence of sperms with abnormal head by about 57% and 65% respectively. The induced increase in sperm abnormalities could enhance the spermatogenic dysfunction and germ cell mutagenicity. These findings indicate that ER in the used doses has a potential toxic effect on spermatogenesis in mice and in turn, it may affect its testicular function and reproductive performance.

Influence of certain calcium-channel blockers on some aspects of lorazepam-dependence in mice

The effect of acute and chronic treatments of the calcium-channel blockers, isradipine, diltiazem and flunarizine in protecting against lorazepam dependence has been demonstrated in mice. Dependence was induced by twice-daily administration of lorazepam (1 mg kg-1) for 10 days, doubling the dose during the next 10 days. Withdrawal symptoms and changes in the noradrenaline, dopamine and 5-hydroxytryptamine content of different regions of the brain were observed after either 24-h withdrawal or flumazenil administration. Isradipine inhibited lorazepam withdrawal symptoms, the effect being accompanied in the 24-h withdrawal group by significant decreases in the noradrenaline and dopamine content of the thalamus and hypothalamus and in the noradrenaline content of the mid-brain. In the flumazenil-treated group isradipine produced significant decreases in mid-brain noradrenaline and dopamine levels and in the dopamine content of the thalamus and hypothalamus. Diltiazem did not, on the other hand, afford significant protection against lorazepam withdrawal symptoms and did not induce any significant change in the neurotransmitters studied. Flunarizine significantly inhibited lorazepam withdrawal symptoms, an effect accompanied by significant reduction in noradrenaline and dopamine levels in the thalamus and hypothalamus. Dopamine was also significantly reduced in the cerebral cortex. Similar effects were produced in the flumazenil-treated group, and the noradrenaline content was reduced in the medulla, pons and cerebellum. It was concluded that isradipine and flunarizine might be of value in ameliorating lorazepam withdrawal symptoms.