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Doherty GM. Jeffrey Norton and the Gateway to the West. Ann Surg Oncol 2024; 31:3615-3617. [PMID: 38409371 DOI: 10.1245/s10434-024-15076-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 02/08/2024] [Indexed: 02/28/2024]
Affiliation(s)
- Gerard M Doherty
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Phitayakorn R, Schwartz TA, Doherty GM. Practical Guide to Experimental and Quasi-Experimental Research in Surgical Education. JAMA Surg 2024; 159:578-579. [PMID: 38170499 DOI: 10.1001/jamasurg.2023.6693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
This Guide to Statistics and Methods describes the methods and pitfalls of experimental and quasi-experimental study designs in surgical education.
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Affiliation(s)
- Roy Phitayakorn
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Todd A Schwartz
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
- Statistical Editor, JAMA Surgery
| | - Gerard M Doherty
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Bilimoria KY, Haukoos JS, Doherty GM. Practical Guide to Pragmatic Clinical Trials in Surgical Education Research. JAMA Surg 2024; 159:582-583. [PMID: 38170517 DOI: 10.1001/jamasurg.2023.6690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
This Guide to Statistics and Methods provides an overview of the key features of pragmatic trials within the context of surgical education research using examples from the Flexibility in Duty-Hour Requirements for Surgical Trainees trial.
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Affiliation(s)
- Karl Y Bilimoria
- Surgical Outcomes and Quality Improvement Center (SOQIC), Indiana University School of Medicine, Indianapolis
| | - Jason S Haukoos
- Department of Emergency Medicine, University of Colorado, Aurora
- Statistical Editor, JAMA Surgery
| | - Gerard M Doherty
- Moseley Professor of Surgery, Department of Surgery, Harvard Medical School, Boston, Massachusetts
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Rosengart TK, Chen JH, Gantt NL, Angelos P, Warshaw AL, Rosen JE, Perrier ND, Kaups KL, Doherty GM, Zoumpou T, Ashley SW, Doscher W, Welsh D, Savarise M, Sutherland MJ, Sidawy AN, Kopelan AM. Sustaining Lifelong Competency of Surgeons: Multimodality Empowerment Personal and Institutional Strategy. J Am Coll Surg 2024:00019464-990000000-00939. [PMID: 38591782 DOI: 10.1097/xcs.0000000000001066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Affiliation(s)
- Todd K Rosengart
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Jennifer H Chen
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Nancy L Gantt
- Department of Surgery, Northeast Ohio Medical University, Youngstown, OH
| | - Peter Angelos
- Section of General Surgery and Surgical Oncology, Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jennifer E Rosen
- Division of Endocrine Surgery, MedStar-Washington Hospital Center, Washington, DC
| | - Nancy D Perrier
- Department of Surgical Oncology, Section of Surgical Endocrinology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Krista L Kaups
- Department of Surgery, University of California San Francisco Fresno, Fresno, CA
| | - Gerard M Doherty
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Theofano Zoumpou
- Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | - Stanley W Ashley
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - William Doscher
- Department of Surgery, Zucker School of Medicine at Hofstra, Northwell, NY
| | | | - Mark Savarise
- Section of Community General Surgery, University of Utah South Jordan Health Center, South Jordan, UT
| | | | - Anton N Sidawy
- Department of Surgery, George Washington University, Washington, DC
| | - Adam M Kopelan
- Department of Surgery, Newark Beth Israel Medical Center, RWJ Barnabas Health, Newark, NJ
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Antunez AG, Rowe KA, Bain PA, Doherty GM, Dossett LA. Behavioral Interventions on Surgeons' Preoperative Decision-Making: A Scoping Review and Critical Analysis. J Surg Res 2024; 295:547-558. [PMID: 38086255 PMCID: PMC10922393 DOI: 10.1016/j.jss.2023.11.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 10/20/2023] [Accepted: 11/12/2023] [Indexed: 01/03/2024]
Abstract
INTRODUCTION Consensus is lacking regarding the optimal strategy to influence surgeons' behaviors to reduce low-value surgical care. Comprehensively describing the existing body of literature that seeks to intervene on surgeons' preoperative decision-making may aid in structuring future behavior change strategies. METHODS We performed a scoping review using four databases (Medical Literature Analysis and Retrieval System Online, Embase, Web of Science, and Cumulated Index to Nursing and Allied Health Literature) for articles that tested the effect of behavioral-based interventions on any aspect of surgeons' decision-making in the preoperative setting. Abstracted data were characterized by summative descriptions and analyzed using the Tailored Implementation for Chronic Disease framework, mapping aspects of deimplementation strategies in the studies onto the determinant(s) that they altered. Data abstraction and mapping tools were piloted and iteratively revised before two researchers independently assessing studies and categorizing determinants, and then meeting to discuss their decisions. RESULTS There were 1460 articles identified from the initial search, with 17 full text articles ultimately included in the scoping review. Eight studies relied on a multidisciplinary preoperative conference to accomplish their aims, while five were multifaceted in their approach to deimplementation, and four studies used only a clinical decision support tool to accomplish their aims. Mapping determinants addressed in these studies onto the Tailored Implementation for Chronic Disease framework demonstrated that most strategies attempted to close knowledge gaps, leverage communication between providers, and broadcast institutional prioritization of change. CONCLUSIONS There is a small but growing field of implementation and deimplementation strategies in preoperative surgical decision-making, and different approaches may be equally effective in varied clinical contexts. Deliberate measurement and comparison of outcomes, as well as selection of control groups, are areas for improvement in future work.
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Affiliation(s)
- Alexis G Antunez
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
| | - Katherine A Rowe
- Massachusetts General Hospital Department of Surgery, Boston, Massachusetts
| | - Paul A Bain
- Countway Library, Harvard Medical School, Boston, Massachusetts
| | - Gerard M Doherty
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lesly A Dossett
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
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Hardcastle TC, Gyedu A, Doherty GM, Wren SM. Editorial commentary and call for papers-Humanitarian surgery in conflict zones. World J Surg 2024; 48:507-508. [PMID: 38407321 DOI: 10.1002/wjs.12119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Affiliation(s)
- Timothy C Hardcastle
- Department of Health KwaZulu-Natal and Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - Adam Gyedu
- Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University if Science and Technology, Kumasi, Ghana
| | | | - Sherry M Wren
- Stanford University School of Medicine, Stanford, California, USA
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Altshuler B, Bikas A, Pappa T, Marqusee E, Cho NL, Nehs MA, Liu JB, Doherty GM, Landa I, Ahmadi S, Alexander EK. Non-Operative, Active Surveillance of Larger Malignant and Suspicious Thyroid Nodules. J Clin Endocrinol Metab 2024:dgae082. [PMID: 38349208 DOI: 10.1210/clinem/dgae082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 01/05/2024] [Accepted: 02/08/2024] [Indexed: 04/05/2024]
Abstract
CONTEXT Active surveillance for papillary thyroid cancer (PTC) meeting criteria for surgical resection is uncommon. Which patients may prove reasonable candidates for this approach is not well defined. OBJECTIVE To examine the feasibility and safety of active surveillance for patients with known or suspected intrathyroidal PTC up to 4cm in diameter. DESIGN, SETTING, AND PARTICIPANTS Retrospective review of all consecutive patients who underwent non-operative active surveillance of suspicious or malignant thyroid nodules over a 20-year period from 2001-2021. We included patients with an initial US-FNA confirming either: a) Bethesda 5 or 6 cytology or, b) a "suspicious" AFIRMA molecular test. The primary outcomes and measures included the rate of adverse oncologic outcomes (mortality and recurrence), as well as the cumulative incidence of size/volume growth. RESULTS Sixty-nine patients were followed with active surveillance for 1 year or longer (average 55 months), with 26 patients (38%) having nodules ≥ 2 cm. No patients were found to develop new incident occurrence of lymph node or distant metastasis. One patient however, demonstrated concern for progression to a dedifferentiated cancer on repeat core biopsy 17 years after initial start non-operative selection. 21% of patients had an increase in maximum diameter more than 3 mm, and volume increase ≥50% was noted in 25% of patients. Thirteen patients ultimately underwent delayed (rescue) surgery, and no disease recurrence was noted after such treatment. Age and initial nodule size were not predictors of nodule growth. CONCLUSIONS These data expand consideration of active surveillance of papillary thyroid carcinoma in select patients with intrathyroidal suspected malignancy >1cm in diameter. Rescue surgery, if required at a later timepoint, appears effective.
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Affiliation(s)
- Benjamin Altshuler
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital, Boston MA. 02115
- Harvard Medical School, Boston MA
| | - Athanasios Bikas
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital, Boston MA. 02115
- Harvard Medical School, Boston MA
| | - Theodora Pappa
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital, Boston MA. 02115
- Harvard Medical School, Boston MA
| | - Ellen Marqusee
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital, Boston MA. 02115
- Harvard Medical School, Boston MA
| | - Nancy L Cho
- Department of Surgery, Brigham and Women's Hospital, Boston MA. 02115
- Harvard Medical School, Boston MA
| | - Matthew A Nehs
- Department of Surgery, Brigham and Women's Hospital, Boston MA. 02115
- Harvard Medical School, Boston MA
| | - Jason B Liu
- Department of Surgery, Brigham and Women's Hospital, Boston MA. 02115
- Harvard Medical School, Boston MA
| | - Gerard M Doherty
- Department of Surgery, Brigham and Women's Hospital, Boston MA. 02115
- Harvard Medical School, Boston MA
| | - Iñigo Landa
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital, Boston MA. 02115
- Harvard Medical School, Boston MA
| | - Sara Ahmadi
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital, Boston MA. 02115
- Harvard Medical School, Boston MA
| | - Erik K Alexander
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital, Boston MA. 02115
- Harvard Medical School, Boston MA
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Bikas A, Ahmadi S, Pappa T, Marqusee E, Wong K, Nehs MA, Cho NL, Haase J, Doherty GM, Sehgal K, Barletta JA, Alexander EK, Landa I. Additional Oncogenic Alterations in RAS-Driven Differentiated Thyroid Cancers Associate with Worse Clinicopathologic Outcomes. Clin Cancer Res 2023; 29:2678-2685. [PMID: 37260297 PMCID: PMC10524472 DOI: 10.1158/1078-0432.ccr-23-0278] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/13/2023] [Accepted: 05/12/2023] [Indexed: 05/17/2023]
Abstract
PURPOSE RAS mutations occur across the spectrum of thyroid neoplasms, and more tools are needed for better prognostication. The objective of this study was to evaluate how additional genetic events affecting key genes modify prognosis in patients with RAS-mutant thyroid cancers, and specifically differentiated thyroid cancers (DTC). EXPERIMENTAL DESIGN We performed a clinical-genomic analysis of consecutive patients with DTC, poorly differentiated (PDTC), or anaplastic thyroid cancer (ATC) between January 2014 and December 2021, in whom a custom-targeted next-generation sequencing assay was performed. Patients harboring RAS mutations were included, and we compared their clinical features and outcomes based upon the presence of additional oncogenic alterations. RESULTS Seventy-eight patients were identified, with 22% (17/78) harboring a driver RAS mutation plus an additional oncogenic alteration. All six (100%) ATCs had an additional mutation. Compared with DTCs harboring a solitary RAS mutation, patients with DTC with RAS and additional mutation(s) were more likely to be classified as American Thyroid Association high-risk of recurrence (77% vs. 12%; P < 0.001) and to have larger primary tumors (4.7 vs. 2.5 cm; P = 0.002) and advanced stage (III or IV) at presentation (67% vs. 3%; P < 0.001). Importantly, over an average 65-month follow-up, DTC-specific-mortality was more than 10-fold higher (20% vs. 1.8%; P = 0.011) when additional mutations were identified. CONCLUSIONS Identification of key additional mutations in patients with RAS-mutant thyroid cancers confers a more aggressive phenotype, increases mortality risk in DTC, and can explain the diversity of RAS-mutated thyroid neoplasia. These data support genomic profiling of DTCs to inform prognosis and clinical decision-making.
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Affiliation(s)
- Athanasios Bikas
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women’s Hospital, Boston Massachusetts
- Harvard Medical School, Boston Massachusetts
| | - Sara Ahmadi
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women’s Hospital, Boston Massachusetts
- Harvard Medical School, Boston Massachusetts
| | - Theodora Pappa
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women’s Hospital, Boston Massachusetts
- Harvard Medical School, Boston Massachusetts
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston Massachusetts
| | - Ellen Marqusee
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women’s Hospital, Boston Massachusetts
- Harvard Medical School, Boston Massachusetts
| | - Kristine Wong
- Harvard Medical School, Boston Massachusetts
- Department of Pathology, Brigham and Women’s Hospital, Boston Massachusetts
| | - Matthew A. Nehs
- Harvard Medical School, Boston Massachusetts
- Department of Surgery, Brigham and Women’s Hospital, Boston Massachusetts
| | - Nancy L. Cho
- Harvard Medical School, Boston Massachusetts
- Department of Surgery, Brigham and Women’s Hospital, Boston Massachusetts
| | - Jacob Haase
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women’s Hospital, Boston Massachusetts
- Harvard Medical School, Boston Massachusetts
| | - Gerard M. Doherty
- Harvard Medical School, Boston Massachusetts
- Department of Surgery, Brigham and Women’s Hospital, Boston Massachusetts
| | - Kartik Sehgal
- Harvard Medical School, Boston Massachusetts
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston Massachusetts
| | - Justine A. Barletta
- Harvard Medical School, Boston Massachusetts
- Department of Pathology, Brigham and Women’s Hospital, Boston Massachusetts
| | - Erik K. Alexander
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women’s Hospital, Boston Massachusetts
- Harvard Medical School, Boston Massachusetts
| | - Iñigo Landa
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women’s Hospital, Boston Massachusetts
- Harvard Medical School, Boston Massachusetts
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Wrenn SM, Moore AL, Shah HJ, Barletta JA, Vaidya A, Kilbridge KL, Doherty GM, Jacene HA, Nehs MA. Higher SUV max on FDG-PET is associated with shorter survival in adrenocortical carcinoma. Am J Surg 2023; 225:309-314. [PMID: 36137821 DOI: 10.1016/j.amjsurg.2022.08.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 07/29/2022] [Accepted: 08/27/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Adrenocortical carcinoma (ACC) is an aggressive, rare malignancy. 2-deoxy-2-[18F]-fluoro-d-glucose positron emission tomography (FDG-PET) assesses tumor metabolism and glucose utilization. We hypothesized that higher maximum standard uptake value (SUVmax) is associated with decreased survival. METHODS We performed a retrospective analysis of patients with ACC. Included patients (n = 26) had an FDG-PET scan available with a documentable SUVmax. Patients were dichotomized into "High" (≥8.4, n = 12) and "Low" (<8.4, n = 14) SUVmax. Univariate analysis and survival analysis were performed to compare groups. RESULTS Demographics between groups were equivalent. The high SUVmax cohort demonstrated lower survival (median 479 days or 15.7 months) compared to the low group (median 1490 days or 48.6 months, p = .01). Log-Rank curve confirmed differences in survival (p = .007). CONCLUSIONS Higher SUVmax was associated with significantly worse survival in ACC and may reflect a more aggressive phenotype. FDG-PET may provide clinically useful information to determine prognosis and treatment. Further studies should prospectively evaluate using FDG-PET/CT in ACC.
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Affiliation(s)
- Sean M Wrenn
- .Brigham and Women's Hospital, Boston, MA, USA; .Rush University Medical Center, Chicago, IL, USA
| | | | - Hina J Shah
- .Brigham and Women's Hospital, Boston, MA, USA
| | | | | | - Kerry L Kilbridge
- .Brigham and Women's Hospital, Boston, MA, USA; .Dana-Farber Cancer Institute Lank Center for Genitourinary Oncology, USA.
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Antunez AG, Doherty GM. Accuracy of Fine-Needle Aspiration for Cytologic Categorization of Thyroid Nodules-Incremental Progress vs Quantum Improvement. JAMA Surg 2022; 157:1113-1114. [PMID: 36223131 DOI: 10.1001/jamasurg.2022.4997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Koelker M, Krimphove M, Alkhatib K, Nabi J, Kuo LE, Lipsitz SR, Choueiri TK, Chang SL, Doherty GM, Kibel AS, Trinh QD, Cole AP. Understanding Hospital-Level Patterns of Nonoperative Management for Low-risk Thyroid and Kidney Cancer. JAMA Netw Open 2022; 5:e2242210. [PMID: 36378306 PMCID: PMC9667332 DOI: 10.1001/jamanetworkopen.2022.42210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IMPORTANCE There is a growing trend toward conservative management for certain low-risk cancers. Hospital and health-system factors may play a role in determining how these patients are managed. OBJECTIVE To explore the contribution of hospitals on patients' odds of nonoperative management for low-risk cancer. DESIGN, SETTING, AND PARTICIPANTS In this cross-sectional study, individuals with low-risk papillary thyroid cancer and solitary kidney masses were identified, and those receiving nonoperative management vs surgery were compared. Patients with low-risk thyroid cancer and kidney cancer from 2015 to 2017 eligible for nonoperative management according to National Comprehensive Cancer Network guidelines within the National Cancer Database were included. Data were analyzed from October 2021 to March 2022. MAIN OUTCOMES AND MEASURES For each facility, the proportion of these patients who received operative and nonoperative management was calculated. A mixed-effects logistic regression model with a hospital-level random effects term was used to calculate factors associated with nonoperative management. Between-hospital variability was assessed using ranked caterpillar plots. RESULTS There were 19 570 individuals with low-risk thyroid cancer (15 344 women [78.4%]; mean [SD] age, 51.74 [95% CI, 51.39-52.08] years) and 41 403 with kidney cancer (25 253 men [61.0%]; mean [SD] age, 61.93 [95% CI, 61.70-62.17] years). In the group with low-risk thyroid cancer, 2.1% (419 patients) received nonoperative management, and in the group with kidney cancer, 9.5% (3928 patients) received nonoperative management. This varied between hospitals from 1.1% (95% CI, 1.0%-1.1%) in the bottom decile to 10.3% (95% CI, 8.0%-12.4%) in the top decile for low-risk thyroid cancer, and from 4.3% (95% CI, 4.1%-4.4%) in the bottom decile to 24.6% (95% CI, 22.7%-26.5%) in the top decile for small kidney masses. For both cancers, age was associated with increased odds of nonoperative treatment. The hospital-level odds of nonoperative management of thyroid and kidney cancer using unadjusted probabilities (observed proportions) were minimally correlated (Spearman ρ = .33; P < .001). CONCLUSIONS AND RELEVANCE The findings of this study suggest that although health systems factors may be associated with the tendency to pursue nonoperative management, hospital-level factors may differ when comparing unrelated cancers.
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Affiliation(s)
- Mara Koelker
- Center of Surgery and Public Health, Division of Urological Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marieke Krimphove
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt, Germany
| | - Khalid Alkhatib
- Center of Surgery and Public Health, Division of Urological Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Junaid Nabi
- Center of Surgery and Public Health, Division of Urological Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Lindsay E. Kuo
- Department of Surgery, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania
| | - Stuart R. Lipsitz
- Center of Surgery and Public Health, Division of Urological Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Toni K. Choueiri
- Lank Center for Genitourinary Oncology, Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Steven Lee Chang
- Center of Surgery and Public Health, Division of Urological Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Gerard M. Doherty
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Adam S. Kibel
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Quoc-Dien Trinh
- Center of Surgery and Public Health, Division of Urological Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Alexander P. Cole
- Center of Surgery and Public Health, Division of Urological Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
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Mahvi DA, Witt RG, Lyu HG, Gawande AA, Nehs MA, Doherty GM, Cho NL. Increased BMI is Associated With Lower Risk of Hypocalcemia in Total Thyroidectomy Patients. J Surg Res 2022; 279:240-246. [DOI: 10.1016/j.jss.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 05/01/2022] [Accepted: 06/07/2022] [Indexed: 11/29/2022]
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Abstract
In the past 30 years, there has been a substantial rise in the detection of thyroid nodules. Largely asymptomatic, thyroid nodules are most often incidental findings that typically pose minimal risk. Data supporting these findings show a rapid rise in the incidental detection of thyroid nodules and cancer, but minimal effect on mortality rates, despite treatment. These data imply that historical approaches to thyroid nodule and cancer care might at times include unnecessary or excessive care. To address this issue, the past decade has witnessed an increasingly conservative approach to nodule management, seeking to individualise care and provide the most focused intervention that leads to favourable outcomes. Benign nodules can be safely monitored with minimal, or long-interval follow-up imaging. Molecular testing should be considered for cytologically indeterminate nodules because of its ability to improve preoperative cancer risk determination and reduce unnecessary surgery. The treatment of biopsy-proven malignant nodules has become increasingly nuanced, since recommendations for near-total thyroidectomy are no longer routine. Hemithyroidectomy is now commonly considered when operative intervention is favoured. Some patients with small volume, isolated cancerous nodules are safely managed non-operatively with active monitoring. In summary, modern management strategies for thyroid nodular disease seek to incorporate the growing amount of available diagnostic and prognostic data, inclusive of demographic, radiological, pathological and molecular findings. Once obtained, an individualised management plan can be effectively formulated.
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Affiliation(s)
- Erik K Alexander
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Gerard M Doherty
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Justine A Barletta
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Abstract
This survey study assesses physicians’ recommendations regarding overdiagnosis and overtreatment of thyroid nodules and low-risk papillary thyroid cancer.
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Affiliation(s)
- Priya H. Dedhia
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus
| | - Megan C. Saucke
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | - Kristin L. Long
- Division of Endocrine Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | - Gerard M. Doherty
- Brigham and Women’s Hospital, Brigham Health, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Susan C. Pitt
- Department of Surgery, University of Michigan, Ann Arbor
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Abstract
Importance Surgery plays a critical role in the management of all stages of gastric cancer. Observations For patients with early gastric cancer and low risk of lymph node metastasis, endoscopic therapy or surgery alone is potentially curative. Novel techniques, such as sentinel lymph node biopsy, may allow for greater use of stomach-sparing procedures that could improve quality of life without compromising oncologic outcomes; however, experience with these techniques is rare outside of East Asia, and studies of long-term outcomes are still ongoing. Patients with later-stage localized gastric cancer benefit from more extensive lymphadenectomy and multimodality therapy, as they are at risk for nodal and distant metastases. There have been recent advances in chemotherapy that have led to improved survival, but the optimal sequencing of multimodality therapy is still being investigated. Better systemic therapy may also increase the role of surgery for patients with oligometastatic disease. There are ongoing studies examining the efficacy of peritoneal-directed therapies in both patients with low-volume peritoneal disease and patients at high risk of peritoneal recurrence. Conclusions and Relevance The management of gastric cancer continues to evolve. Surgeons should be aware of novel surgical approaches currently under investigation as well as how surgery fits into the contemporary multidisciplinary approach to this disease.
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Affiliation(s)
- George Z Li
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Gerard M Doherty
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jiping Wang
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Center for Gastrointestinal Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
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16
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Tsai TC, Doherty GM. Site of Care Optimization Through Home Hospital for Surgical Patients: The Next Frontier for Health Care Value and Population Health Management. Ann Surg 2022; 275:e278-e279. [PMID: 34387212 DOI: 10.1097/sla.0000000000005172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Thomas C Tsai
- Department of Surgery, Brigham and Women's Hospital, Boston, MA
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA
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17
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Affiliation(s)
- Gerard M Doherty
- Crowley Family Distinguished Chair of Surgery, Brigham and Women's Hospital, Boston, MA, USA. .,Dana-Farber Cancer Institute, Boston, MA, USA. .,Harvard Medical School, Boston, MA, USA.
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18
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Pappa T, Ahmadi S, Marqusee E, Johnson HL, Nehs MA, Cho NL, Barletta JA, Lorch JH, Doherty GM, Lindeman NI, Alexander EK, Landa I. Oncogenic Mutations in PI3K/AKT/mTOR Pathway Effectors Associate with Worse Prognosis in BRAFV600E -Driven Papillary Thyroid Cancer Patients. Clin Cancer Res 2021; 27:4256-4264. [PMID: 34088725 DOI: 10.1158/1078-0432.ccr-21-0874] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/28/2021] [Accepted: 05/28/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE The extent to which routine genomic sequencing can identify relevant secondary genomic alterations among BRAFV600E -mutant papillary thyroid carcinoma (PTC) is unknown. Such markers would prove highly valuable for prognostic purposes. EXPERIMENTAL DESIGN We reviewed clinicopathologic data of 225 patients with BRAFV600E -mutant PTC and integrated them with genomic data derived from targeted next-generation sequencing (NGS) on tumor specimens. We defined patient subgroups based on bona fide secondary oncogenic events (separate from BRAFV600E ) and compared their clinical features and outcomes with those without additional oncogenic alterations. RESULTS Additional oncogenic alterations were identified in 16% of tumors. Patients in the "BRAF+additional mutations" group were more likely to be at high American Thyroid Association (ATA) risk of recurrence (48.6% vs. 17.6%; P = 0.0009), had larger baseline tumor (2.7 vs. 1.9 cm; P = 0.0005) and more advanced stage at presentation (14.3% vs. 1.1% stage 4; P < 0.0001). Importantly, over a 65-month follow-up, disease-specific mortality (DSM) was increased when additional mutations were identified (13.8% vs. 1.4% in the BRAF-only group; P = 0.005). Separately, we identified a subcluster of patients harboring oncogenic mutations in key effectors of the PI3K/AKT/mTOR pathway, which were independently associated with DSM (OR = 47.9; 95% confidence interval, 3.5-1,246.5; P = 0.0043). CONCLUSIONS Identification of additional PIK3/AKT/mTOR alterations in patients with BRAFV600E -mutant PTC provides important and actionable prognostic risk stratification. These data support genomic profiling of PTC tumors to inform prognosis and clinical strategy.
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Affiliation(s)
- Theodora Pappa
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Sara Ahmadi
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Ellen Marqusee
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Hannah L Johnson
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Matthew A Nehs
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Nancy L Cho
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Justine A Barletta
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Jochen H Lorch
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Gerard M Doherty
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Neal I Lindeman
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Erik K Alexander
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts. .,Harvard Medical School, Boston, Massachusetts
| | - Iñigo Landa
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts. .,Harvard Medical School, Boston, Massachusetts
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19
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Wong KS, Dong F, Telatar M, Lorch JH, Alexander EK, Marqusee E, Cho NL, Nehs MA, Doherty GM, Afkhami M, Barletta JA. Papillary Thyroid Carcinoma with High-Grade Features Versus Poorly Differentiated Thyroid Carcinoma: An Analysis of Clinicopathologic and Molecular Features and Outcome. Thyroid 2021; 31:933-940. [PMID: 33143568 DOI: 10.1089/thy.2020.0668] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background: Similar to poorly differentiated thyroid carcinoma (PDTC), papillary thyroid carcinoma with high-grade features (PTC HGF) demonstrates increased mitotic activity and/or necrosis; however, PTC HGF is excluded from the World Health Organization (WHO) definition of PDTC based on maintained nuclear features of PTC. Methods: Consecutive tumors that met criteria for PTC HGF, defined as tumors with maintained nuclear features of PTC and mitoses numbering 5 or more per 10 contiguous high-power fields and/or tumor necrosis, and PDTC (defined as per the WHO criteria) were identified. Clinicopathologic characteristics, follow-up data, and targeted next-generation sequencing results were compared between groups. Results: There were 15 PTC HGF and 47 PDTC. PTC HGF was associated with a higher rate of pT4 disease (53% vs. 13%, p = 0.0027) and lymph node metastases (73% vs. 38%, p = 0.049). The disease-specific survival was worse for patients with PTC HGF compared with those with PDTC using Kaplan-Meier estimation (p < 0.001) and was worse in subgroup analysis evaluating patients with widely invasive PDTC (i.e., those with a similar rate of pT4 disease) and PTC HGF (p = 0.040). PTC HGF had a higher BRAFV600E mutation rate (42% vs. 3%; p = 0.003), a trend toward more gene fusions (25% vs. 3%; p = 0.052), and a higher rate of relative gain of 1q (67% vs. 15%; p = 0.002) than PDTC. Conclusions: Our results demonstrate that PTC HGF are important to recognize based on their aggressive behavior. The molecular differences between PTC HGF and PDTC suggest that PTC HGF should be considered a distinct group from PDTC.
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Affiliation(s)
- Kristine S Wong
- Department of Pathology, Harvard Medical School, Boston, Massachusetts, USA
| | - Fei Dong
- Department of Pathology, Harvard Medical School, Boston, Massachusetts, USA
| | - Milhan Telatar
- Department of Pathology, City of Hope Comprehensive Cancer Center, Duarte, California, USA
| | - Jochen H Lorch
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Erik K Alexander
- Division of Endocrinology, Harvard Medical School, Boston, Massachusetts, USA
| | - Ellen Marqusee
- Division of Endocrinology, Harvard Medical School, Boston, Massachusetts, USA
| | - Nancy L Cho
- Division of Endocrinology, Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew A Nehs
- Department of Surgery; Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gerard M Doherty
- Department of Surgery; Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michelle Afkhami
- Department of Pathology, City of Hope Comprehensive Cancer Center, Duarte, California, USA
| | - Justine A Barletta
- Department of Pathology, Harvard Medical School, Boston, Massachusetts, USA
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20
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Bose SK, Dasani S, Roberts SE, Wirtalla C, DeMatteo RP, Doherty GM, Kelz RR. The Cost of Quarantine: Projecting the Financial Impact of Canceled Elective Surgery on the Nation's Hospitals. Ann Surg 2021; 273:844-849. [PMID: 33491974 DOI: 10.1097/sla.0000000000004766] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We sought to quantify the financial impact of elective surgery cancellations in the US during COVID-19 and simulate hospitals' recovery times from a single period of surgery cessation. BACKGROUND COVID-19 in the US resulted in cessation of elective surgery-a substantial driver of hospital revenue-and placed patients at risk and hospitals under financial stress. We sought to quantify the financial impact of elective surgery cancellations during the pandemic and simulate hospitals' recovery times. METHODS Elective surgical cases were abstracted from the Nationwide Inpatient Sample (2016-2017). Time series were utilized to forecast March-May 2020 revenues and demand. Sensitivity analyses were conducted to calculate the time to clear backlog cases and match expected ongoing demand in the post-COVID period. Subset analyses were performed by hospital region and teaching status. RESULTS National revenue loss due to major elective surgery cessation was estimated to be $22.3 billion (B). Recovery to market equilibrium was conserved across strata and influenced by pre- and post-COVID capacity utilization. Median recovery time was 12-22 months across all strata. Lower pre-COVID utilization was associated with fewer months to recovery. CONCLUSIONS Strategies to mitigate the predicted revenue loss of $22.3B due to major elective surgery cessation will vary with hospital-specific supply-demand equilibrium. If patient demand is slow to return, hospitals should focus on marketing of services; if hospital capacity is constrained, efficient capacity expansion may be beneficial. Finally, rural and urban nonteaching hospitals may face increased financial risk which may exacerbate care disparities.
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Affiliation(s)
- Sourav K Bose
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Serena Dasani
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sanford E Roberts
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Chris Wirtalla
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ronald P DeMatteo
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gerard M Doherty
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Rachel R Kelz
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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21
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Doherty GM, Gartland RM, Duh QY. Choosing Wisely in the Workup of Primary Hyperaldosteronism. JAMA Surg 2021; 156:171-172. [PMID: 33146686 DOI: 10.1001/jamasurg.2020.5025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Gerard M Doherty
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rajshri M Gartland
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Quan-Yang Duh
- Department of Surgery, University of California, San Francisco, San Francisco
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22
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Niederle B, Selberherr A, Bartsch DK, Brandi ML, Doherty GM, Falconi M, Goudet P, Halfdanarson TR, Ito T, Jensen RT, Larghi A, Lee L, Öberg K, Pavel M, Perren A, Sadowski SM, Tonelli F, Triponez F, Valk GD, O'Toole D, Scott-Coombes D, Thakker RV, Thompson GB, Treglia G, Wiedenmann B. Multiple Endocrine Neoplasia Type 1 and the Pancreas: Diagnosis and Treatment of Functioning and Non-Functioning Pancreatic and Duodenal Neuroendocrine Neoplasia within the MEN1 Syndrome - An International Consensus Statement. Neuroendocrinology 2021; 111:609-630. [PMID: 32971521 DOI: 10.1159/000511791] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 09/18/2020] [Indexed: 11/19/2022]
Abstract
The better understanding of the biological behavior of multiple endocrine neoplasia type 1 (MEN1) organ manifestations and the increase in clinical experience warrant a revision of previously published guidelines. Duodenopancreatic neuroendocrine neoplasias (DP-NENs) are still the second most common manifestation in MEN1 and, besides NENs of the thymus, remain a leading cause of death. DP-NENs are thus of main interest in the effort to reevaluate recommendations for their diagnosis and treatment. Especially over the last 2 years, more clinical experience has documented the follow-up of treated and untreated (natural-course) DP-NENs. It was the aim of the international consortium of experts in endocrinology, genetics, radiology, surgery, gastroenterology, and oncology to systematically review the literature and to present a consensus statement based on the highest levels of evidence. Reviewing the literature published over the past decade, the focus was on the diagnosis of F- and NF-DP-NENs within the MEN1 syndrome in an effort to further standardize and improve treatment and follow-up, as well as to establish a "logbook" for the diagnosis and treatment of DP-NENs. This shall help further reduce complications and improve long-term treatment results in these rare tumors. The following international consensus statement builds upon the previously published guidelines of 2001 and 2012 and attempts to supplement the recommendations issued by various national and international societies.
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Affiliation(s)
- Bruno Niederle
- Department of Surgery, Medical University of Vienna, Vienna, Austria,
| | | | - Detlef K Bartsch
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
| | - Maria L Brandi
- Firmo Lab, Fondazione F.I.R.M.O. and University Florence, Florence, Italy
| | - Gerard M Doherty
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Massimo Falconi
- Pancreatic Surgery, San Raffaele Scientific Institute, "Vita-Salute" University, Milan, Italy
| | - Pierre Goudet
- Service de Chirurgie Viscérale et Endocrinienne, Centre Hospitalier Universitaire François Mitterand, Dijon, France
| | | | - Tetsuhide Ito
- Neuroendocrine Tumor Centre, Fukuoka Sanno Hospital and Department of Gastroenterology, Graduate School of Medical Sciences, International University of Health and Welfare, Sawara-ku, Fukuoka, Japan
| | - Robert T Jensen
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico A. Gemelli IRCCS and Center for Endoscopic Research, Therapeutics and Training, Catholic University, Rome, Italy
| | - Lingaku Lee
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Kjell Öberg
- Endocrine Oncology, Department of Medical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Marianne Pavel
- Endocrinology and Diabetology, Department of Medicine 1, University Clinic of Erlangen, Erlangen, Germany
| | - Aurel Perren
- Institute of Pathology, University of Bern, Bern, Switzerland
| | - Samira M Sadowski
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Francesco Tonelli
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - Frédéric Triponez
- Thoracic and Endocrine Surgery, University Hospital of Geneva, Geneva, Switzerland
| | - Gerlof D Valk
- Department of Endocrine Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Dermot O'Toole
- Department of Clinical Medicine, St. James's Hospital and St Vincent's University Hospital and Trinity College, Dublin, Ireland
| | - David Scott-Coombes
- Department of Endocrine Surgery, University Hospital of Wales, Cardiff, United Kingdom
| | - Rajesh V Thakker
- Academic Endocrine Unit, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - Geoffrey B Thompson
- Section of Endocrine Surgery, Department of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Giorgio Treglia
- Imaging Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Bertram Wiedenmann
- Department of Gastroenterology and Hepatology, Campus Virchow-Klinikum and Campus Charité Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany
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23
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Ghazani AA, Breen KM, Dwan M, Barletta JA, Vatnick DR, Stokes SM, Block C, Doherty GM, Cohn AY, Marqusee E, Garber JE, Rana HQ. Unexpected Pathogenic RET p.V804M Variant Leads to the Clinical Diagnosis and Management of Medullary Thyroid Carcinoma. Am J Case Rep 2020; 21:e927415. [PMID: 33361738 PMCID: PMC7774021 DOI: 10.12659/ajcr.927415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Patient: Female, 62-year-old Final Diagnosis: Medullary thyroid microcarcinoma Symptoms: No pain or swelling in her neck • no dysphagia or odynophagia • no changes in voice Medication: — Clinical Procedure: Genetic analysis Specialty: Genetics
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Affiliation(s)
- Arezou A Ghazani
- Division of Genetics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA
| | - Katelyn M Breen
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.,Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Meaghan Dwan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.,Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Justine A Barletta
- Harvard Medical School, Boston, MA, USA.,Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA
| | - Donna R Vatnick
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.,Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Samantha M Stokes
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.,Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Caroline Block
- Harvard Medical School, Boston, MA, USA.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Gerard M Doherty
- Harvard Medical School, Boston, MA, USA.,Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Aviva Y Cohn
- Thyroid Section, Division of Endocrinology, Diabetes and Hypertension, Brigham and Woman's Hospital, Boston, MA, USA
| | - Ellen Marqusee
- Harvard Medical School, Boston, MA, USA.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.,Thyroid Section, Division of Endocrinology, Diabetes and Hypertension, Brigham and Woman's Hospital, Boston, MA, USA
| | - Judy E Garber
- Harvard Medical School, Boston, MA, USA.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.,Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Huma Q Rana
- Harvard Medical School, Boston, MA, USA.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.,Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
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24
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Kuo LE, Lyu HG, Jarman MP, Melnitchouk N, Doherty GM, Smink DS, Cho NL. Gender Disparity in Awards in General Surgery Residency Programs. JAMA Surg 2020; 156:2769845. [PMID: 32876660 PMCID: PMC7489428 DOI: 10.1001/jamasurg.2020.3518] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 05/31/2020] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Women are disproportionately underrecognized as award winners within medical societies. The presence of this disparity has not been investigated in training programs. OBJECTIVE To determine the presence of a gender disparity in award winners in general surgery residency programs. DESIGN, SETTING, AND PARTICIPANTS In this retrospective survey study, 32 geographically diverse academic and independent general surgery residency programs were solicited for participation. The 24 participating programs (75.0%) submitted deidentified data regarding the gender distribution of residents and trainee award recipients for the period from July 1, 1996, to June 30, 2017. Data were analyzed from September 11, 2017, to December 21, 2018. EXPOSURES Time and the proportion of female trainees. MAIN OUTCOMES AND MEASURES The primary outcome was the percentage of female award winners. A multilevel logistic regression model accounting for the percentage of female residents in each program compared the odds of a female resident winning an award relative to a male resident. This analysis was repeated for the first and second decades of the study. Award winners were further analyzed by type of award (clinical excellence, nonclinical excellence, teaching, or research) and selection group (medical students, residents, or faculty members). RESULTS A total of 5030 of 13 760 resident person-years (36.6%) and 455 of 1447 award winners (31.4%) were female. Overall, female residents were significantly less likely to receive an award compared with male residents (odds ratio [OR], 0.44; 95% CI, 0.37-0.54; P < .001). During the first decade of the study, female residents were 70.8% less likely to receive an award compared with male residents (OR, 0.29; 95% CI, 0.19-0.45; P < .001); this improved to 49.9% less likely in the second decade (OR, 0.50; 95% CI, 0.42-0.61; P < .001). Female residents were less likely to receive an award for teaching (OR, 0.33; 95% CI, 0.26-0.42; P < .001), clinical excellence (OR, 0.44; 95% CI, 0.31-0.61; P < .001), or nonclinical excellence (OR, 0.69; 95% CI, 0.48-0.98; P = .04). No statistical difference was observed for research award winners (OR, 0.76; 95% CI, 0.42-1.12; P = .17). The largest discrepancies were observed when award recipients were chosen by residents (OR, 0.23; 95% CI, 0.14-0.39; P < .001) and students (OR, 0.32; 95% CI, 0.25-0.42; P < .001) compared with faculty members (OR, 0.52; 95% CI, 0.42-0.66; P < .001). CONCLUSIONS AND RELEVANCE This study found that female residents were significantly underrepresented as award recipients. These findings suggest the presence of ongoing implicit bias in surgery departments and training programs.
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Affiliation(s)
- Lindsay E. Kuo
- Department of Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Heather G. Lyu
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Nelya Melnitchouk
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Gerard M. Doherty
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Review Editor, JAMA Surgery
| | - Douglas S. Smink
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Nancy L. Cho
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
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25
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Wong KS, Lorch JH, Alexander EK, Marqusee E, Cho NL, Nehs MA, Doherty GM, Barletta JA. Histopathologic Features and Clinical Outcome of Anaplastic Thyroid Carcinoma with a Minor Anaplastic Component. Endocr Pathol 2020; 31:283-290. [PMID: 32445173 DOI: 10.1007/s12022-020-09627-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Although prior studies have reported that patients with anaplastic thyroid carcinoma (ATC) with a focal anaplastic component may have a prolonged survival compared to other ATC patients, the outcome data are limited. We evaluated a cohort of ATC resected between 2003 and 2018. Tumor slides were reviewed to confirm the diagnosis and to identify cases with a minor ATC component (defined as comprising < 10% of the tumor). We evaluated the clinical outcome of these patients compared to that of all other cohort patients (characterized as having conventional ATC). Our cohort was composed of 24 cases of ATC that underwent resection, including 8 (33%) with a minor ATC component. Tumors with a minor ATC component were predominantly associated with papillary thyroid carcinoma. For patients with tumors with a minor ATC component, the 1-year and 2-year survival rates and median survival for patients who died of disease were 88%, 43%, and 17 months (range 6-73 months), respectively. In comparison, for patients with conventional ATC, the 1-year and 2-year survival rates and median survival for patients who died of disease were 56%, 44%, and 7 months (range 2-26 months), respectively. There was no difference in 1- and 2-year survival or overall survival by Kaplan-Meier analysis for patients with tumors with a minor ATC component and those with conventional ATC. In conclusion, the difference in overall survival between ATC groups in our cohort was not significant; however, this could be due to the small cohort size or due to characteristics of our group with a minor ATC component; that is, no tumors in this group were limited to the thyroid (stage IVA), resectability with negative margins was infrequent, and 38% of this group had distant metastases at diagnosis (stage IVC).
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Affiliation(s)
- Kristine S Wong
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jochen H Lorch
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Erik K Alexander
- Division of Endocrinology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ellen Marqusee
- Division of Endocrinology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nancy L Cho
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Matthew A Nehs
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Gerard M Doherty
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Justine A Barletta
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Kuo LE, Angell TE, Pandian TK, Moore AL, Alexander EK, Barletta JA, Gawande AA, Lorch JH, Marqusee E, Moore FD, Nehs MA, Doherty GM, Cho NL. Completion Thyroidectomy is Less Common Following Updated 2015 American Thyroid Association Guidelines. Ann Surg Oncol 2020; 28:484-491. [PMID: 32583197 DOI: 10.1245/s10434-020-08709-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND The 2015 American Thyroid Association (ATA) guidelines recommended that low-risk, differentiated thyroid cancers (DTC) between 1 and 4 cm may be treated with thyroid lobectomy alone. We sought to determine the effect of these guideline changes on the rate of completion thyroidectomy (CT) for low-risk DTC and factors influencing surgical decision-making. METHODS All patients from 2014 to 2018 who received an initial thyroid lobectomy at our institution with final pathology demonstrating DTC were included. Patients were divided into "pre" and "post" guideline cohorts (2014-2015 and 2016-2018, respectively). The rate of CT was compared between the two cohorts. Patient demographics and tumor characteristics were examined for association with CT. RESULTS A total of 163 patients met study criteria: 63 patients in the 2014-2015 ("pre") and 100 in the 2016-2018 ("post") group. In the "pre" period, 41 (65.1%) patients received CT compared with 43 (43.0%) in the "post" period (p < 0.01)-a 34% decrease in the rate of completion surgery (p < 0.01). Of low-risk patients with DTC between 1 and 4 cm in size, 17 of 35 (48.6%) received CT in the "pre" period compared with 15 of 60 (25.0%) in the post period-a 48.6% decrease in the rate of completion surgery (p = 0.02). Greater tumor size, capsular invasion, and multifocality were associated with CT in low-risk "post" guideline patients (p < 0.05 for all). CONCLUSIONS The rate of CT decreased significantly by 48.6% for low-risk patients with DTC between 1 and 4 cm, demonstrating recognition of the 2015 ATA guidelines. However, 25% of these patients underwent CT, suggesting additional factors influencing the decision for further treatment.
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Affiliation(s)
- Lindsay E Kuo
- Department of Surgery, Temple University Lewis Katz School of Medicine, Philadelphia, PA, USA
| | - Trevor E Angell
- Department of Medicine, University of Southern California, Los Angeles, CA, USA
| | - T K Pandian
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Erik K Alexander
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Atul A Gawande
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Jochen H Lorch
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Ellen Marqusee
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Francis D Moore
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Matthew A Nehs
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Gerard M Doherty
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Nancy L Cho
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
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Wong KS, Chen TY, Higgins SE, Howitt BE, Lorch JH, Alexander EK, Marqusee E, Cho NL, Nehs MA, Doherty GM, Barletta JA. A potential diagnostic pitfall for hobnail variant of papillary thyroid carcinoma. Histopathology 2020; 76:707-713. [DOI: 10.1111/his.14042] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 12/04/2019] [Indexed: 12/24/2022]
Affiliation(s)
- Kristine S Wong
- Department of Pathology Brigham and Women's Hospital Harvard Medical School Boston MA USA
| | - Tiffany Y Chen
- Department of Pathology Brigham and Women's Hospital Harvard Medical School Boston MA USA
| | - Sara E Higgins
- Department of Pathology Brigham and Women's Hospital Harvard Medical School Boston MA USA
| | - Brooke E Howitt
- Department of Pathology Stanford University Medical Center Palo Alto CA USA
| | - Jochen H Lorch
- Department of Medical Oncology Dana‐Farber Cancer Institute Boston MA USA
| | - Erik K Alexander
- Division of Endocrinology Brigham and Women's Hospital Harvard Medical School Boston MA USA
| | - Ellen Marqusee
- Division of Endocrinology Brigham and Women's Hospital Harvard Medical School Boston MA USA
| | - Nancy L Cho
- Department of Surgery Brigham and Women's Hospital Harvard Medical School Boston MA USA
| | - Matthew A Nehs
- Department of Surgery Brigham and Women's Hospital Harvard Medical School Boston MA USA
| | - Gerard M Doherty
- Department of Surgery Brigham and Women's Hospital Harvard Medical School Boston MA USA
| | - Justine A Barletta
- Department of Pathology Brigham and Women's Hospital Harvard Medical School Boston MA USA
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Lyu HG, Doherty GM, Landman AB. Surgical Informatics: Defining the Role of Informatics in the Current Surgical Training Paradigm. J Surg Educ 2020; 77:9-12. [PMID: 31477548 PMCID: PMC6944755 DOI: 10.1016/j.jsurg.2019.07.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 07/27/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Clinical Informatics is a large part of the current surgical practice, yet, there is no formal curriculum to teach residents about informatics. The purpose of this article is to describe the field of clinical informatics, describe the potential of informatics to improve surgical care, and propose a framework to train surgical informaticians. DESIGN This is a perspective summarizing the role of clinical informatics in current surgical training. CONCLUSIONS The manuscript concisely discusses the potential impact of novel technologies and information systems on surgical care delivery. We demonstrate the importance of informatics training for surgeons and describe the relatively new fellowship program as well as the various pathways to obtain board certification in clinical informatics.
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Affiliation(s)
- Heather G Lyu
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Gerard M Doherty
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Adam B Landman
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School Boston, Massachusetts
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Angell TE, Maurer R, Wang Z, Kim MI, Alexander CA, Barletta JA, Benson CB, Cibas ES, Cho NL, Doherty GM, Doubilet PM, Frates MC, Gawande AA, Krane JF, Marqusee E, Moore FD, Nehs MA, Larsen PR, Alexander EK. A Cohort Analysis of Clinical and Ultrasound Variables Predicting Cancer Risk in 20,001 Consecutive Thyroid Nodules. J Clin Endocrinol Metab 2019; 104:5665-5672. [PMID: 31310316 DOI: 10.1210/jc.2019-00664] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 07/10/2019] [Indexed: 11/19/2022]
Abstract
CONTEXT Assessing thyroid nodules for malignancy is complex. The impact of patient and nodule factors on cancer evaluation is uncertain. OBJECTIVES To determine precise estimates of cancer risk associated with clinical and sonographic variables obtained during thyroid nodule assessment. DESIGN Analysis of consecutive adult patients evaluated with ultrasound-guided fine-needle aspiration for a thyroid nodule ≥1 cm between 1995 and 2017. Demographics, nodule sonographic appearance, and pathologic findings were collected. MAIN OUTCOME MEASURES Estimated risk for thyroid nodule malignancy for patient and sonographic variables using mixed-effect logistic regression. RESULTS In 9967 patients [84% women, median age 53 years (range 18 to 95)], thyroid cancer was confirmed in 1974 of 20,001 thyroid nodules (9.9%). Significant ORs for malignancy were demonstrated for patient age <52 years [OR: 1.82, 95% CI (1.63 to 2.05), P < 0.0001], male sex [OR: 1.68 (1.45 to 1.93), P < 0.0001], nodule size [OR: 1.30 (1.14 to 1.49) for 20 to 19 mm, OR: 1.59 (1.34 to 1.88) for 30 to 39 mm, and OR: 1.71 (1.43 to 2.04) for ≥40 mm compared with 10 to 19 mm, P < 0.0001 for all], cystic content [OR: 0.43 (0.37 to 0.50) for 25% to 75% cystic and OR: 0.21 (0.15 to 0.28) for >75% compared with predominantly solid, P < 0.0001 for both], and the presence of additional nodules ≥1 cm [OR: 0.69 (0.60 to 0.79) for two nodules, OR: 0.41 (0.34 to 0.49) for three nodules, and OR: 0.19 (0.16 to 0.22) for greater than or equal to four nodules compared with one nodule, P < 0.0001 for all]. A free online calculator was constructed to provide malignancy-risk estimates based on these variables. CONCLUSIONS Patient and nodule characteristics enable more precise thyroid nodule risk assessment. These variables are obtained during routine initial thyroid nodule evaluation and provide new insights into individualized thyroid nodule care.
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Affiliation(s)
- Trevor E Angell
- Thyroid Section, Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Rie Maurer
- Center for Clinical Investigation, Brigham and Women's Hospital, Boston, Massachusetts
| | - Zhihong Wang
- Thyroid Section, Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
- Department of Thyroid Surgery, First Hospital of China Medical University, Shenyang, China
| | - Matthew I Kim
- Thyroid Section, Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Caroline A Alexander
- Thyroid Section, Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Justine A Barletta
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Carol B Benson
- Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Edmund S Cibas
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Nancy L Cho
- Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Gerard M Doherty
- Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Peter M Doubilet
- Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Mary C Frates
- Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Atul A Gawande
- Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jeff F Krane
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ellen Marqusee
- Thyroid Section, Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Francis D Moore
- Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Matthew A Nehs
- Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - P Reed Larsen
- Thyroid Section, Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Erik K Alexander
- Thyroid Section, Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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Rangel EL, Lyu H, Haider AH, Castillo-Angeles M, Doherty GM, Smink DS. Factors Associated With Residency and Career Dissatisfaction in Childbearing Surgical Residents. JAMA Surg 2019; 153:1004-1011. [PMID: 30073246 DOI: 10.1001/jamasurg.2018.2571] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Previous work shows women who have children during surgical residency face difficulty balancing childbearing with training, which negatively affects residency and career satisfaction. Little is known about the factors that drive professional discontent. Objective To determine factors associated with professional dissatisfaction for childbearing residents. Design, Setting, and Participants Self-administered survey questionnaire electronically distributed through the Association of Program Directors in Surgery, the Association of Women Surgeons, and targeted Twitter and Facebook platforms. The survey was distributed in January 2017 to surgeons who delivered at least 1 child during a US general surgery residency and was available online for 4 weeks. Main Outcomes and Measures Respondents were reported to be dissatisfied with their residency if they indicated agreement that they considered leaving residency owing to challenges surrounding childbearing (considered leaving). Respondents were reported to be unhappy with their career if they indicated agreement with statements that (1) given an opportunity to revisit their job choice, they would choose a nonsurgical career more accommodating of motherhood (revisit career choice) or (2) they would advise a female medical student against a surgical career owing to difficulties balancing motherhood with the profession (advise against surgery). Logistic regression was used to determine predictors of agreement with each of the 3 statements of professional dissatisfaction. Results In total, 347 women responded to the survey and reported 452 pregnancies, and the mean (SD) age was 30.5 (2.7) years. One hundred seventy-nine respondents (51.6%) agreed with at least 1 statement of residency or career dissatisfaction. Lack of a formal maternity leave policy was associated with "considered leaving" (odds ratio [OR], 1.83; 95% CI, 1.07-3.10). Perception of stigma during pregnancy was associated with "revisit career choice" (OR, 1.79; 95% CI, 1.01-3.19). Changing fellowship plans owing to perceived difficulty balancing motherhood with the originally chosen subspecialty was associated with all 3 markers of residency and career dissatisfaction ("considered leaving" OR, 2.68; 95% CI, 1.30-5.56; "revisit career choice" OR, 2.23; 95% CI, 1.13-4.43; and "advise against surgery" OR, 2.44; 95% CI, 1.23-4.84). Conclusions and Relevance Surgery residents who perceived stigma during pregnancy, did not have a formal institutional maternity leave policy, or altered their fellowship training plans because of challenges of childbearing expressed greater professional dissatisfaction. Mentorship in subspecialty selection and work-life integration, interventions to reduce workplace bias, and identification of obstacles to establishment of maternity leave policies are needed to enhance professional fulfillment for childbearing residents.
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Affiliation(s)
- Erika L Rangel
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Heather Lyu
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Adil H Haider
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Harvard T. H. Chan School of Public Health, Boston, Massachusetts.,Deputy Editor
| | - Manuel Castillo-Angeles
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Gerard M Doherty
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Harvard T. H. Chan School of Public Health, Boston, Massachusetts.,Review Editor
| | - Douglas S Smink
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Harvard T. H. Chan School of Public Health, Boston, Massachusetts
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Kuo L, Lyu H, Jarman M, Melnitchouk N, Doherty GM, Smink D, Cho NL. Mind the Gap: Female Residents Are Underrepresented as Award Recipients in General Surgery Programs. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.1248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Dedhia PH, Saucke M, McDow AD, Long KL, Doherty GM, Pitt SC. Overtreatment of Patients with Low-Risk Thyroid Cancer. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Wong KS, Lorch JH, Alexander EK, Marqusee E, Cho NL, Nehs MA, Doherty GM, Barletta JA. Prognostic Significance of Extent of Invasion in Poorly Differentiated Thyroid Carcinoma. Thyroid 2019; 29:1255-1261. [PMID: 31397224 DOI: 10.1089/thy.2019.0263] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background: The 2017 World Health Organization (WHO) Classification of Tumors of Endocrine Organs defines poorly differentiated thyroid carcinoma (PDTC) as a tumor with conventional criteria of malignancy (capsular penetration or vascular invasion) with solid, insular, or trabecular growth, a lack of nuclear features of papillary thyroid carcinoma, and increased mitotic activity, tumor necrosis, or convoluted nuclei. The extent of invasion has been shown to be prognostic in follicular thyroid carcinoma and Hürthle cell carcinoma. Our aim was to evaluate how extent of invasion impacts clinical outcome for PDTC. Methods: We retrospectively identified 47 consecutively diagnosed cases of PDTC that were resected between 2005 and 2018. All cases were reviewed to confirm that the tumors met the 2017 Endocrine WHO criteria of PDTC. In addition, tumors were categorized as follows: encapsulated with capsular penetration only, encapsulated with focal vascular invasion (fewer than four foci), encapsulated with extensive vascular invasion (four or more foci), or widely invasive. Histopathologic characteristics and clinical outcome data were recorded. Results: A total of 47 cases of PDTC, including 15 oncocytic tumors, were identified from 28 (60%) women and 19 (40%) men (mean age of 57 years at diagnosis). The mean tumor size was 4.3 cm. Mitoses numbered 8 per 10 high-power fields (HPF) on average (range: 1-34), and necrosis was present in 21 (45%) cases. Eight (17%) cases were encapsulated with capsular penetration only, 5 (11%) were encapsulated with focal vascular invasion, 18 (38%) were encapsulated with extensive vascular invasion, and 16 (34%) were widely invasive. Of the 42 (89%) patients with follow-up data, 7 (17%) died of disease (with a mean survival time of 6.4 years), 11 (26%) have distant metastatic disease, and 24 (57%) have no evidence of disease (mean follow-up 5.6 years). Eight (19%) patients presented with M1 disease at diagnosis. The 5-year disease-free survival (DFS) for patients with M0 disease at diagnosis was 100% for patients with tumors with capsular invasion only or focal vascular invasion (n = 7), 73% for patients with encapsulated tumors with extensive vascular invasion (n = 11), and 17% for patients with widely invasive PDTCs (n = 6). DFS estimates by Kaplan-Meier analysis were significantly different between these groups (p = 0.0016). Conclusions: Extent of invasion appears to be an important parameter that affects clinical outcome for patients with PDTC. In our cohort, patients with encapsulated PDTC with capsular invasion only or focal vascular invasion had an excellent outcome.
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Affiliation(s)
- Kristine S Wong
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jochen H Lorch
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Erik K Alexander
- Division of Endocrinology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ellen Marqusee
- Division of Endocrinology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nancy L Cho
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Matthew A Nehs
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Gerard M Doherty
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Justine A Barletta
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Sulibhavi A, Rohlfing ML, Jalisi SM, McAneny DB, Doherty GM, Holick MF, Noordzij JP. Vitamin D deficiency and its relationship to cancer stage in patients who underwent thyroidectomy for papillary thyroid carcinoma. Am J Otolaryngol 2019; 40:536-541. [PMID: 31036419 DOI: 10.1016/j.amjoto.2019.04.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 04/22/2019] [Indexed: 02/08/2023]
Abstract
PURPOSE As imaging technology improves and more thyroid nodules and malignancies are identified, it is important to recognize factors associated with malignancy and poor prognosis. Vitamin D has proven useful as a prognostic tool for other cancers and may be similarly useful in thyroid cancer. This study explores the relationship of Vitamin D to papillary thyroid carcinoma stage while accounting for socioeconomic covariates. MATERIALS AND METHODS The medical records of all patients who underwent thyroidectomy at one institution between 2000 and 2015 were reviewed. Subjects with non-papillary thyroid cancer pathology, prior malignancy, and without Vitamin D levels were excluded. The remaining 334 patient records were examined for cancer stage, Vitamin D levels, Vitamin D deficiency listed in history, and demographic and comorbid factors. RESULTS Vitamin D laboratory values showed no significant relationship to cancer stage (p = 0.871), but patients with Vitamin D deficiency documented in the medical record were more likely to have advanced disease (28.6% versus 14.7%; p = 0.028). The patients with documented Vitamin D deficiency also had lower 25-hydroxyvitamin D nadirs (21.5 ng/mL versus 26.5 ng/mL, p = 0.008) and were more likely to be on Vitamin D supplementation (92.6% versus 41.8%, p < 0.001). CONCLUSIONS The results suggest that Vitamin D deficiency may have value as a negative prognostic indicator in papillary thyroid cancer and that pre-operative laboratory evaluation may be less useful. This is important because Vitamin D deficiency is modifiable. While different racial subgroups had different rates of Vitamin D deficiency, neither race nor socioeconomic status showed correlation with cancer stage.
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Lindeman BM, Nehs MA, Angell TE, Alexander EK, Gawande AA, Moore FD, Doherty GM, Cho NL. Effect of Noninvasive Follicular Thyroid Neoplasm with Papillary-Like Nuclear Features (NIFTP) on Malignancy Rates in Thyroid Nodules: How to Counsel Patients on Extent of Surgery. Ann Surg Oncol 2018; 26:93-97. [DOI: 10.1245/s10434-018-6932-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Indexed: 02/06/2023]
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Affiliation(s)
- H Gilbert Welch
- From the Department of Medicine, Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH (H.G.W.); and the Department of Surgery, Brigham and Women's Hospital, Boston (G.M.D.)
| | - Gerard M Doherty
- From the Department of Medicine, Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH (H.G.W.); and the Department of Surgery, Brigham and Women's Hospital, Boston (G.M.D.)
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Rangel EL, Smink DS, Castillo-Angeles M, Kwakye G, Changala M, Haider AH, Doherty GM. Pregnancy and Motherhood During Surgical Training. JAMA Surg 2018; 153:644-652. [PMID: 29562068 PMCID: PMC5875346 DOI: 10.1001/jamasurg.2018.0153] [Citation(s) in RCA: 222] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 12/30/2017] [Indexed: 11/14/2022]
Abstract
Importance Although family priorities influence specialty selection and resident attrition, few studies describe resident perspectives on pregnancy during surgical training. Objective To directly assess the resident experience of childbearing during training. Design, Setting, and Participants A self-administered 74-question survey was electronically distributed in January 2017 to members of the Association of Women Surgeons, to members of the Association of Program Directors in Surgery listserv, and through targeted social media platforms. Surgeons who had 1 or more pregnancies during an Accreditation Council for Graduate Medical Education-accredited US general surgery residency program and completed training in 2007 or later were included. Important themes were identified using focus groups of surgeons who had undergone pregnancy during training in the past 7 years. Additional topics were identified through MEDLINE searches performed from January 2000 to July 2016 combining the keywords pregnancy, resident, attrition, and parenting in any specialty. Main Outcomes and Measures Descriptive data on perceptions of work schedule during pregnancy, maternity leave policies, lactation and childcare support, and career satisfaction after childbirth. Results This study included 347 female surgeons (mean [SD] age, 30.5 [2.7] years) with 452 pregnancies. A total of 297 women (85.6%) worked an unmodified schedule until birth, and 220 (63.6%) were concerned that their work schedule adversely affected their health or the health of their unborn child. Residency program maternity leave policies were reported by 121 participants (34.9%). A total of 251 women (78.4%) received maternity leave of 6 weeks or less, and 250 (72.0%) perceived the duration of leave to be inadequate. The American Board of Surgery leave policy was cited as a major barrier to the desired length of leave by 268 of 326 respondents (82.2%). Breastfeeding was important to 329 (95.6%), but 200 (58.1%) stopped earlier than they wished because of poor access to lactation facilities and challenges leaving the operating room to express milk. Sixty-four women (18.4%) had institutional support for childcare, and 231 (66.8%) reported a desire for greater mentorship on integrating a surgical career with motherhood and pregnancy. A total of 135 (39.0%) strongly considered leaving surgical residency, and 102 (29.5%) would discourage female medical students from a surgical career, specifically because of the difficulties of balancing pregnancy and motherhood with training. Conclusions and Relevance The challenges of having children during surgical residency may have significant workforce implications. A deeper understanding is critical to prevent attrition and to continue recruiting talented students. This survey characterizes these issues to help design interventions to support childbearing residents.
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Affiliation(s)
- Erika L. Rangel
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Douglas S. Smink
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Manuel Castillo-Angeles
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Gifty Kwakye
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis
| | - Marguerite Changala
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- University of California, San Francisco School of Medicine, San Francisco
| | - Adil H. Haider
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Gerard M. Doherty
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
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Affiliation(s)
- Gerard M. Doherty
- Department of Surgery, Harvard Medical School, Brigham and Women’s Hospital & Dana-Farber Cancer Institute, Boston, Massachusetts
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40
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Wang Z, Vyas CM, Van Benschoten O, Nehs MA, Moore FD, Marqusee E, Krane JF, Kim MI, Heller HT, Gawande AA, Frates MC, Doubilet PM, Doherty GM, Cho NL, Cibas ES, Benson CB, Barletta JA, Zavacki AM, Larsen PR, Alexander EK, Angell TE. Quantitative Analysis of the Benefits and Risk of Thyroid Nodule Evaluation in Patients ≥70 Years Old. Thyroid 2018; 28:465-471. [PMID: 29608439 DOI: 10.1089/thy.2017.0655] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND In older patients, thyroid nodules are frequently detected and referred for evaluation, though usually prove to be benign disease or low-risk cancer. Therefore, management should be guided not solely by malignancy risk, but also by the relative risks of any intervention. Unfortunately, few such data are available for patients ≥70 years old. METHODS All consecutive patients ≥70 years old assessed by ultrasound (US) and fine-needle aspiration (FNA) between 1995 and 2015 were analyzed. Clinical, US, and histologic data, including patient comorbidities and outcomes, were obtained. Imaging and cytology results from initial evaluation were reviewed to detect significant-risk thyroid cancer (SRTC), which was defined as anaplastic, medullary, or poorly differentiated carcinoma, or the presence of distant metastases. Overall survival analyses were then performed to assist with risk-to-benefit assessment. RESULTS A total of 1129 patients ≥70 years old with 2527 nodules ≥1 cm were evaluated. FNA was safe in all, and cytology proved benign in 67.3% of patients. However, FNA led to surgery in 208 patients, of whom 93 (44.7%) had benign histopathology. Among all patients who underwent FNA, only 17 (1.5%) SRTC were identified, all of which were preoperatively identifiable by imaging and/or cytology. These SRTC were responsible for all (n = 10; 0.9%) thyroid cancer deaths. Among all other patients (n = 1112), 160 deaths (14.4%) were confirmed during a median follow-up of four years. None of these were thyroid cancer related. Survival analysis for these 1112 patients demonstrated that a separate non-thyroidal malignancy or coronary artery disease at the time of nodule evaluation was associated with increased mortality compared to those without these diagnoses (hazard ratio = 2.32 [confidence interval 1.66-3.26]; p < 0.01), confirming these are important variables to identify prior to thyroid nodule evaluation. CONCLUSIONS For patients ≥70 years old, US and FNA are safe and prove helpful in identifying SRTC and benign cytology. However, the surgical management of patients ≥70 years old presenting without high-risk findings should be tempered, especially when comorbid illness is identified.
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Affiliation(s)
- Zhihong Wang
- 1 Department of Thyroid Surgery, the First Hospital of China Medical University , Shenyang, China
- 2 The Thyroid Section, Division of Endocrinology, Diabetes, and Hypertension, The Brigham and Women's Hospital and Harvard Medical School , Boston, Massachusetts
| | - Chirag M Vyas
- 2 The Thyroid Section, Division of Endocrinology, Diabetes, and Hypertension, The Brigham and Women's Hospital and Harvard Medical School , Boston, Massachusetts
| | - Olivia Van Benschoten
- 2 The Thyroid Section, Division of Endocrinology, Diabetes, and Hypertension, The Brigham and Women's Hospital and Harvard Medical School , Boston, Massachusetts
| | - Matt A Nehs
- 3 Department of Surgery, The Brigham and Women's Hospital and Harvard Medical School , Boston, Massachusetts
| | - Francis D Moore
- 3 Department of Surgery, The Brigham and Women's Hospital and Harvard Medical School , Boston, Massachusetts
| | - Ellen Marqusee
- 2 The Thyroid Section, Division of Endocrinology, Diabetes, and Hypertension, The Brigham and Women's Hospital and Harvard Medical School , Boston, Massachusetts
| | - Jeffrey F Krane
- 4 Department of Pathology, The Brigham and Women's Hospital and Harvard Medical School , Boston, Massachusetts
| | - Matthew I Kim
- 2 The Thyroid Section, Division of Endocrinology, Diabetes, and Hypertension, The Brigham and Women's Hospital and Harvard Medical School , Boston, Massachusetts
| | - Howard T Heller
- 5 Department of Radiology, The Brigham and Women's Hospital and Harvard Medical School , Boston, Massachusetts
| | - Atul A Gawande
- 3 Department of Surgery, The Brigham and Women's Hospital and Harvard Medical School , Boston, Massachusetts
| | - Mary C Frates
- 5 Department of Radiology, The Brigham and Women's Hospital and Harvard Medical School , Boston, Massachusetts
| | - Peter M Doubilet
- 5 Department of Radiology, The Brigham and Women's Hospital and Harvard Medical School , Boston, Massachusetts
| | - Gerard M Doherty
- 3 Department of Surgery, The Brigham and Women's Hospital and Harvard Medical School , Boston, Massachusetts
| | - Nancy L Cho
- 3 Department of Surgery, The Brigham and Women's Hospital and Harvard Medical School , Boston, Massachusetts
| | - Edmund S Cibas
- 4 Department of Pathology, The Brigham and Women's Hospital and Harvard Medical School , Boston, Massachusetts
| | - Carol B Benson
- 5 Department of Radiology, The Brigham and Women's Hospital and Harvard Medical School , Boston, Massachusetts
| | - Justine A Barletta
- 4 Department of Pathology, The Brigham and Women's Hospital and Harvard Medical School , Boston, Massachusetts
| | - Ann Marie Zavacki
- 2 The Thyroid Section, Division of Endocrinology, Diabetes, and Hypertension, The Brigham and Women's Hospital and Harvard Medical School , Boston, Massachusetts
| | - P Reed Larsen
- 2 The Thyroid Section, Division of Endocrinology, Diabetes, and Hypertension, The Brigham and Women's Hospital and Harvard Medical School , Boston, Massachusetts
| | - Erik K Alexander
- 2 The Thyroid Section, Division of Endocrinology, Diabetes, and Hypertension, The Brigham and Women's Hospital and Harvard Medical School , Boston, Massachusetts
| | - Trevor E Angell
- 2 The Thyroid Section, Division of Endocrinology, Diabetes, and Hypertension, The Brigham and Women's Hospital and Harvard Medical School , Boston, Massachusetts
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41
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Angell TE, Vyas CM, Barletta JA, Cibas ES, Cho NL, Doherty GM, Gawande AA, Howitt BE, Krane JF, Marqusee E, Strickland KC, Alexander EK, Moore FD, Nehs MA. Reasons Associated with Total Thyroidectomy as Initial Surgical Management of an Indeterminate Thyroid Nodule. Ann Surg Oncol 2018. [DOI: 10.1245/s10434-018-6421-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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42
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Hamidi M, Sullivan M, Hunter G, Hamberg L, Cho NL, Gawande AA, Doherty GM, Moore FD, Nehs MA. 4D-CT is Superior to Ultrasound and Sestamibi for Localizing Recurrent Parathyroid Disease. Ann Surg Oncol 2018; 25:1403-1409. [PMID: 29484563 DOI: 10.1245/s10434-018-6367-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Recurrent primary hyperparathyroidism (PHPT) presents a diagnostic challenge in localizing a hyperfunctioning gland. Although several imaging modalities are available for preoperative localization, 4D-CT is increasingly utilized for its ability to locate both smaller and previously unlocalized lesions. Currently, there is a paucity of data evaluating the utility of 4D-CT in the reoperative setting compared with ultrasound (US) and sestamibi. We aimed to determine the sensitivity of 4D-CT in localizing parathyroid adenomas in recurrent or persistent PHPT. METHODS We performed a retrospective review of prospectively collected data from a tertiary-care hospital, and identified 58 patients who received preoperative 4D-CT with US and/or sestamibi between May 2008 and March 2016. Data regarding the size, shape, and number of parathyroid lesions were collected for each patient. RESULTS A total of 62 lesions were identified intraoperatively among the 58 patients (6 with multigland disease) included in this investigation. 4D-CT missed 13 lesions identified intraoperatively, compared with 32 and 22 lesions missed by US and sestamibi, respectively. Sensitivity for correct lateralization of culprit lesions was 77.4% for 4D-CT, 38.5% for US, and 46% for sestamibi. 4D-CT was superior in lateralizing adenomas (49/62) compared with US (20/52; p < 0.001) and sestamibi (18/47; p < 0.001). The overall cure rate (6-month postoperative calcium < 10.7 mg/dL) was 89.7%. All patients with lesions correctly lateralized by 4D-CT were cured at 6 months. CONCLUSION 4D-CT localized parathyroid adenomas with higher sensitivity among patients with recurrent or persistent PHPT compared with sestamibi or US-based imaging.
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Affiliation(s)
- Moska Hamidi
- Division of General Surgery, London Health Sciences Center, London, ON, Canada
| | - Michael Sullivan
- Division of General Surgery, Jersey Shore University Medical Center, Neptune City, NJ, USA
| | - George Hunter
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Leena Hamberg
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Nancy L Cho
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Atul A Gawande
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Gerard M Doherty
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Francis D Moore
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Matthew A Nehs
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA. .,General and Endocrine Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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43
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Snyder SK, Angelos P, Carty SE, Doherty GM, Howe JR, Lee JA, Libutti SK, Miller BS, Parangi S, Patel KN, Sippel RC, Sturgeon C, Wang TS, Yip L, Zeiger MA. Injection of bulking agents for laryngoplasty. Surgery 2018; 163:6-8. [DOI: 10.1016/j.surg.2017.08.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 07/31/2017] [Accepted: 08/01/2017] [Indexed: 10/18/2022]
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44
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Angell TE, Vyas CM, Medici M, Wang Z, Barletta JA, Benson CB, Cibas ES, Cho NL, Doherty GM, Doubilet PM, Frates MC, Gawande AA, Heller HT, Kim MI, Krane JF, Marqusee E, Moore FD, Nehs MA, Zavacki AM, Larsen PR, Alexander EK. Differential Growth Rates of Benign vs. Malignant Thyroid Nodules. J Clin Endocrinol Metab 2017; 102:4642-4647. [PMID: 29040691 DOI: 10.1210/jc.2017-01832] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 10/09/2017] [Indexed: 02/05/2023]
Abstract
CONTEXT Thyroid nodule growth was once considered concerning for malignancy, but data showing that benign nodules grow questioned the use of this paradigm. To date, however, no studies have adequately evaluated whether growth rates differ in malignant vs. benign nodules. OBJECTIVE To sonographically evaluate growth rates in benign and malignant thyroid nodules ≥1 cm. DESIGN Prospective, cohort study of patients with tissue diagnosis of benign or malignant disease, with repeated ultrasound evaluation six or more months apart. MAIN OUTCOMES Growth rate in largest dimension of malignant compared with benign thyroid nodules. Regression models were used to evaluate predictors of growth. RESULTS Malignant nodules (126) met inclusion criteria (≥6-month nonoperative followup) and were compared with 1363 benign nodules. Malignant nodules were not found to be uniquely selected or prospectively observed solely for low-risk phenotype. Median ultrasound intervals were similar (21.8 months for benign nodules; 20.9 months for malignant nodules). Malignant nodules were more likely to grow >2 mm/y compared with benign nodules [relative risk (RR) = 2.5, 95% confidence interval (CI), 1.6 to 3.1; P < 0.001], which remained true after adjustment for clinical factors. The RR of a nodule being malignant increased with faster growth rates. Malignant nodules growing >2 mm/y had greater odds of being more aggressive cancers [intermediate risk: odds ratio (OR) = 2.99; 95% CI, 1.20 to 7.47; P = 0.03; higher risk: OR = 8.69; 95% CI, 1.78 to 42.34; P = 0.02]. CONCLUSIONS Malignant nodules, especially higher-risk phenotypes, grow faster than benign nodules. As growth >2 mm/y predicts malignant compared with benign disease, this clinical parameter can contribute to the assessment of thyroid cancer risk.
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Affiliation(s)
- Trevor E Angell
- Thyroid Section, Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, and Harvard Medical School
| | - Chirag M Vyas
- Thyroid Section, Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, and Harvard Medical School
| | - Marco Medici
- Rotterdam Thyroid Center, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Zhihong Wang
- Thyroid Section, Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, and Harvard Medical School
- Department of Thyroid Surgery, First Hospital of China Medical University, Shenyang, China
| | - Justine A Barletta
- Department of Pathology, Brigham and Women's Hospital, and Harvard Medical School
| | - Carol B Benson
- Department of Radiology, Brigham and Women's Hospital, and Harvard Medical School
| | - Edmund S Cibas
- Department of Pathology, Brigham and Women's Hospital, and Harvard Medical School
| | - Nancy L Cho
- Department of Surgery, Brigham and Women's Hospital, and Harvard Medical School
| | - Gerard M Doherty
- Department of Surgery, Brigham and Women's Hospital, and Harvard Medical School
| | - Peter M Doubilet
- Department of Radiology, Brigham and Women's Hospital, and Harvard Medical School
| | - Mary C Frates
- Department of Radiology, Brigham and Women's Hospital, and Harvard Medical School
| | - Atul A Gawande
- Department of Surgery, Brigham and Women's Hospital, and Harvard Medical School
| | - Howard T Heller
- Department of Radiology, Brigham and Women's Hospital, and Harvard Medical School
| | - Matthew I Kim
- Thyroid Section, Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, and Harvard Medical School
| | - Jeffrey F Krane
- Department of Pathology, Brigham and Women's Hospital, and Harvard Medical School
| | - Ellen Marqusee
- Thyroid Section, Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, and Harvard Medical School
| | - Francis D Moore
- Department of Surgery, Brigham and Women's Hospital, and Harvard Medical School
| | - Matt A Nehs
- Department of Surgery, Brigham and Women's Hospital, and Harvard Medical School
| | - Ann Marie Zavacki
- Thyroid Section, Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, and Harvard Medical School
| | - P Reed Larsen
- Thyroid Section, Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, and Harvard Medical School
| | - Erik K Alexander
- Thyroid Section, Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, and Harvard Medical School
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45
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Castillo-Angeles M, Smink DS, Changala M, Kwakye G, Doherty GM, Haider AH, Rangel E. Pregnancy and Motherhood During Surgical Training: A Qualitative Assessment. J Am Coll Surg 2017. [DOI: 10.1016/j.jamcollsurg.2017.07.409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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46
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Haugen BR, Sawka AM, Alexander EK, Bible KC, Caturegli P, Doherty GM, Mandel SJ, Morris JC, Nassar A, Pacini F, Schlumberger M, Schuff K, Sherman SI, Somerset H, Sosa JA, Steward DL, Wartofsky L, Williams MD. American Thyroid Association Guidelines on the Management of Thyroid Nodules and Differentiated Thyroid Cancer Task Force Review and Recommendation on the Proposed Renaming of Encapsulated Follicular Variant Papillary Thyroid Carcinoma Without Invasion to Noninvasive Follicular Thyroid Neoplasm with Papillary-Like Nuclear Features. Thyroid 2017; 27:481-483. [PMID: 28114862 DOI: 10.1089/thy.2016.0628] [Citation(s) in RCA: 205] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
American Thyroid Association (ATA) leadership asked the ATA Thyroid Nodules and Differentiated Thyroid Cancer Guidelines Task Force to review, comment on, and make recommendations related to the suggested new classification of encapsulated follicular variant papillary thyroid carcinoma (eFVPTC) without capsular or vascular invasion to noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP). The task force consists of members from the 2015 guidelines task force with the recusal of three members who were authors on the paper under review. Four pathologists and one endocrinologist were added for this specific review. The manuscript proposing the new classification and related literature were assessed. It is recommended that the histopathologic nomenclature for eFVPTC without invasion be reclassified as a NIFTP, given the excellent prognosis of this neoplastic variant. This is a weak recommendation based on moderate-quality evidence. It is also noted that prospective studies are needed to validate the observed patient outcomes (and test performance in predicting thyroid cancer outcomes), as well as implications on patients' psychosocial health and economics.
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Affiliation(s)
- Bryan R Haugen
- 1 University of Colorado School of Medicine , Aurora, Colorado
| | - Anna M Sawka
- 2 University Health Network, University of Toronto , Toronto, Canada
| | - Erik K Alexander
- 3 Brigham and Women's Hospital , Harvard Medical School, Boston, Massachusetts
| | | | | | | | - Susan J Mandel
- 7 Perelman School of Medicine, University of Pennsylvania , Philadelphia, Pennsylvania
| | | | | | | | | | - Kathryn Schuff
- 11 Oregon Health and Science University , Portland, Oregon
| | - Steven I Sherman
- 12 University of Texas M.D. Anderson Cancer Center , Houston, Texas
| | - Hilary Somerset
- 1 University of Colorado School of Medicine , Aurora, Colorado
| | - Julie Ann Sosa
- 13 Duke University School of Medicine , Durham, North Carolina
| | - David L Steward
- 14 University of Cincinnati Medical Center , Cincinnati, Ohio
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47
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Doherty GM. Safety-Net Hospitals Care: Not the Same Care in a Different Place. JAMA Surg 2016; 151:1192. [PMID: 27784049 DOI: 10.1001/jamasurg.2016.3646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Gerard M Doherty
- Department of Surgery, Boston University, Boston Medical Center, Boston, Massachusetts
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48
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Kapoor A, Shaffer NS, McDonough CM, White DK, Wang N, Rosenkranz P, Glantz A, McAneny D, Doherty GM, Cabral HJ, Gurwitz JH, Fielding RA, Jette AM, Silliman RA. Examining New Preoperative Assessment Tools. J Am Geriatr Soc 2016; 64:e102-e104. [PMID: 27590632 DOI: 10.1111/jgs.14349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Alok Kapoor
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,Meyers Primary Care Institute, Worcester, Massachusetts.,Department of Medicine, School of Medicine, Boston University, Boston, Massachusetts
| | - Nicholas S Shaffer
- Department of Medicine, School of Medicine, Boston University, Boston, Massachusetts
| | - Christine M McDonough
- Department of Health Law, Policy & Management, School of Public Health, Boston University, Boston, Massachusetts
| | - Daniel K White
- Department of Physical Therapy, University of Delaware, Newark, Delaware
| | - Na Wang
- Data Coordinating Center, School of Public Health, Boston University, Boston, Massachusetts
| | - Pamela Rosenkranz
- Department of Surgery, School of Medicine, Boston University, Boston, Massachusetts
| | - Andrew Glantz
- Department of Surgery, School of Medicine, Boston University, Boston, Massachusetts
| | - David McAneny
- Department of Surgery, School of Medicine, Boston University, Boston, Massachusetts
| | - Gerard M Doherty
- Department of Surgery, School of Medicine, Boston University, Boston, Massachusetts
| | - Howard J Cabral
- Department of Biostatistics, School of Public Health, Boston University, Boston, Massachusetts
| | - Jerry H Gurwitz
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,Meyers Primary Care Institute, Worcester, Massachusetts
| | - Roger A Fielding
- Nutrition, Exercise Physiology, and Sarcopenia Laboratory, Tufts University, Boston, Massachusetts
| | - Alan M Jette
- Department of Health Law, Policy & Management, School of Public Health, Boston University, Boston, Massachusetts
| | - Rebecca A Silliman
- Department of Medicine, School of Medicine, Boston University, Boston, Massachusetts
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49
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50
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Wilhelm SM, Wang TS, Ruan DT, Lee JA, Asa SL, Duh QY, Doherty GM, Herrera MF, Pasieka JL, Perrier ND, Silverberg SJ, Solórzano CC, Sturgeon C, Tublin ME, Udelsman R, Carty SE. The American Association of Endocrine Surgeons Guidelines for Definitive Management of Primary Hyperparathyroidism. JAMA Surg 2016; 151:959-968. [DOI: 10.1001/jamasurg.2016.2310] [Citation(s) in RCA: 612] [Impact Index Per Article: 76.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Scott M. Wilhelm
- Department of Surgery, University Hospitals/Case Medical Center, Cleveland, Ohio
| | - Tracy S. Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee
| | - Daniel T. Ruan
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - James A. Lee
- Department of Surgery, Columbia University College of Physicians and Surgeons, New York, New York
| | - Sylvia L. Asa
- Department of Pathology, University of Toronto, Toronto, Ontario, Canada
| | - Quan-Yang Duh
- Department of Surgery, University of California San Francisco Medical Center, San Francisco
| | | | - Miguel F. Herrera
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Janice L. Pasieka
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Nancy D. Perrier
- Department of Surgery, MD Anderson Cancer Center, Houston, Texas
| | - Shonni J. Silverberg
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - Carmen C. Solórzano
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Cord Sturgeon
- Department of Surgery, Northwestern University, Chicago, Illinois
| | - Mitchell E. Tublin
- Department of Radiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert Udelsman
- Department of Surgery, Yale University, New Haven, Connecticut
| | - Sally E. Carty
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
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