Collaborative Approach Toward Transplant Candidacy for Obese Patients with End-Stage Renal Disease

BACKGROUND

An elevated BMI is a major cause of transplant preclusion for patients with end-stage renal disease (ESRD). This phenomenon exacerbates existing socioeconomic and racial disparities and increases the economic burden of maintaining patients on dialysis. Metabolic bariatric surgery (MBS) in such patients is not widely available. Our center created a collaborative program to undergo weight loss surgery before obtaining a kidney transplant.

STUDY DESIGN

We studied the outcomes of these patients after MBS and transplant surgery. One hundred eighty-three patients with ESRD were referred to the bariatric team by the transplant team between January 2019 and June 2023. Of these, 36 patients underwent MBS (20 underwent Roux-en-Y gastric bypass and 16 underwent sleeve gastrectomy), and 10 underwent subsequent transplantation, with another 15 currently waitlisted. Both surgical teams shared resources, including dieticians, social workers, and a common database, for easy transition between teams.

RESULTS

The mean starting BMI for all referrals was 46.4 kg/m 2 and was 33.9 kg/m 2 at the time of transplant. The average number of hypertension medications decreased from 2 (range 2 to 4) presurgery to 1 (range 1 to 3) postsurgery. Similarly, hemoglobin A1C levels improved, with preoperative averages at 6.2 (range 5.4 to 7.6) and postoperative levels at 5.2 (range 4.6 to 5.8) All transplants are currently functioning, with a median creatinine of 1.5 (1.2 to 1.6) mg/dL (glomerular filtration rate 46 [36.3 to 71]).

CONCLUSIONS

A collaborative approach between bariatric and transplant surgery teams offers a pathway toward transplant for obese ESRD patients and potentially alleviates existing healthcare disparities. ESRD patients who undergo MBS have unique complications to be aware of. The improvement in comorbidities may lead to superior posttransplant outcomes.

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

BACKGROUND

Radiofrequency ablation is a minimally invasive treatment for thyroid nodules; however, concerns exist regarding its impact on subsequent thyroid surgery. We compared surgical outcomes and complications between patients undergoing thyroidectomy after radiofrequency ablation (post-radiofrequency ablation thyroidectomy group) and those without prior radiofrequency ablation (non-radiofrequency ablation thyroidectomy group).

METHODS

We retrospectively analyzed thyroidectomy patients, comparing post-radiofrequency ablation thyroidectomy and non-radiofrequency ablation thyroidectomy groups, examining demographics, nodule characteristics, surgical techniques, and complications.

RESULTS

The study included 96 patients (73 in the non-radiofrequency ablation thyroidectomy group and 23 in the post-radiofrequency ablation thyroidectomy group). The mean age was 53.3 ± 14.4 years, with 78.1% female patients and 36.5% African American patients. Median operative time was similar between the post-radiofrequency ablation thyroidectomy (110 minutes) and the non-radiofrequency ablation thyroidectomy (92 minutes) cohorts (P = .40). Complications were reported in 13 patients, without significant differences between groups (P = .54). No permanent complications, including nerve injury or hypoparathyroidism, were reported in either cohort. Prior radiofrequency ablation treatment did not increase the risk of complications (odds ratio = 3.48, 95% confidence interval = 0.70-17.43, P = .16).

CONCLUSION

Our work found no differences in outcomes or safety in patients undergoing thyroidectomy with or without previous radiofrequency ablation treatment, potentiating the post-radiofrequency ablation thyroidectomy group as a safe management option. Accordingly, this may reassure both clinicians and patients of the safety of radiofrequency ablation in treating patients with thyroid nodules.

Radiofrequency ablation of benign thyroid nodules: A prospective, multi-institutional North American experience

BACKGROUND

Radiofrequency ablation for benign thyroid nodules aims to achieve a volume reduction rate of ≥50%. However, factors that predict treatment success have not been defined in a large-scale study.

METHODS

A prospective cohort study of biopsy-proven benign thyroid nodules treated with radiofrequency ablation at 3 institutions was performed. Patient demographics, nodule sonographic features, procedural data, and nodule volume reduction were evaluated. Binary logistic regression analysis was performed to identify features associated with treatment response.

RESULTS

A total of 620 nodules were analyzed. The pooled median volume reduction rate at 12 months was 70.9% (interquartile range 52.9-86.6). At 1 year follow-up, 78.4% of nodules reached treatment success with a volume reduction rate ≥50%. The overall complication rate was 3.2% and included temporary voice changes (n = 14), vasovagal episodes (n = 5), nodule rupture (n = 3), and lightheadedness (n = 2). No permanent voice changes occurred. Four patients developed postprocedural hypothyroidism. Large baseline nodule volume (>20 mL) was associated with a lower rate of successful volume reduction (odds ratio 0.60 [0.37-0.976]). Large nodules achieved treatment success by 12-month follow-up at a rate of 64.5%, compared with 81.4% for small nodules and 87.2% for medium nodules.

CONCLUSION

To our knowledge, this is the largest North American cohort of patients with benign thyroid nodules treated with radiofrequency ablation. Overall, radiofrequency ablation was an effective treatment option with a low risk of procedural complications. Large volume nodules (>20 mL) may be associated with a lower rate of successful reduction with radiofrequency ablation treatment.

Electromyographic predictors of abducens nerve palsy after endoscopic skull base surgery

OBJECTIVE

Recovery of abducens nerve palsy (ANP) after endoscopic endonasal skull base surgery (ESBS) has been shown to be potentially predicted by postoperative ophthalmological examination. Triggered electromyography (t-EMG) and free-run electromyography (f-EMG) activity provide an intraoperative assessment of abducens nerve function, but associations with long-term ANP outcomes have not been explored. The objective of this study was to describe intraoperative abducens EMG characteristics and determine whether these electrophysiological profiles are associated with immediately postoperative and long-term ANP outcomes after ESBS.

METHODS

The authors conducted a 5-year (2011-2016) retrospective case-control study of patients who underwent ESBS in whom the abducens nerve was stimulated (t-EMG). Electrophysiological metrics were compared between patients with a new postoperative ANP (cases) and those without ANP (controls). Pathologies included chordoma, pituitary adenoma, meningioma, cholesterol granuloma, and chondrosarcoma. Electrophysiological data included the presence of abnormal f-EMG activity, t-EMG stimulation voltage, stimulation threshold, evoked compound muscle action potential (CMAP) amplitude, onset latency, peak latency, and CMAP duration at various stages of the dissection. Controls were selected such that pathologies were similarly distributed between cases and controls.

RESULTS

Fifty-six patients were included, 26 with new postoperative ANP and 30 controls without ANP. Abnormal f-EMG activity (28.0% vs 3.3%, p = 0.02) and lack of response to stimulation (27% vs 0%, p = 0.006) were more frequent in patients with immediately postoperative ANP than in controls. Patients with immediately postoperative ANP also had a lower median CMAP amplitude (35.0 vs 71.2 μV, p = 0.02) and longer onset latency (5.2 vs 2.8 msec, p = 0.04). Comparing patients with transient versus persistent ANP on follow-up, those with persistent ANP tended to have a lower CMAP amplitude (12.8 vs 57 μV, p = 0.07) and higher likelihood of not responding to stimulation at the end of the case (45.5% vs 7.1%, p = 0.06). Abnormal f-EMG was not associated with long-term ANP outcomes.

CONCLUSIONS

The presence of f-EMG activity, lack of CMAP response to stimulation, decreased CMAP amplitude, and increased CMAP onset latency were associated with immediately postoperative ANP. Long-term ANP outcomes may be associated with t-EMG parameters, including whether the nerve is able to be stimulated once identified and CMAP amplitude. Future prospective studies may be designed to standardize abducens nerve electrophysiological monitoring protocols to further refine operative and prognostic utility.

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

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

GERD-screening before bariatric surgery: the predictive value of the GERD-HRQL questionnaire score compared with preoperative EGD findings

BACKGROUND

There is an ongoing debate on how to best identify patients with gastroesophageal reflux disease (GERD) before bariatric surgery. The value of routine preoperative esophagogastroduodenoscopy (EGD) is questioned, and patient reported symptoms are commonly used for screening. The goal of this study is to determine if patient reported symptoms using a validated questionnaire correlate with preoperative EGD findings.

METHODOLOGY

A prospective cohort study at a single institution was performed. Patients undergoing bariatric surgery between December 2020 and March 2023 were required to report symptoms of reflux by completing a preoperative GERD. Health-Related Quality of Life (GERD-HRQL) questionnaire and undergo a mandatory preoperative screening EGD. Patients were stratified into two cohorts: (group A) asymptomatic (score = 0) and (group B) symptomatic (score > 0). Statistical analysis was conducted using Pearson's chi-squared test and Wilcoxon rank-sum test in RStudio version 4.2.2. The predictive value of the GERD-HRQL score was analyzed using Areas Under the Curve (AUC; AUC = 0.5 not predictive, 0.5 < AUC ≥ 6 poor prediction & AUC > 0.9 excellent prediction) calculated from Receiver Operating Characteristic (ROC) curves.

RESULTS

200 patients were included; median age was 42.0 years (IQR 36.0 to 49.2). There were 79 patients (39.5%) in Group A and 121 patients (60.5%) in Group B. There was no difference in the frequency esophagitis (27.8% vs 32.2%, p = 0.61) or hiatal hernias (49.4% vs 47.1%, p = 0. 867) between group A and group B, respectively. ROC analysis revealed that the total GERD HRQL scores, heartburn only scores and regurgitation only scores, were poor predictors of esophagitis found on EGD (AUC 0.52, 0.53, 0.52), respectively. In asymptomatic patients, higher BMI was significantly associated with esophagitis (OR 1.15, 95% CI 1.06-1.27, p = 0.002).

CONCLUSION

Symptoms, identified through the GERD-HRQL questionnaire, are a poor indicator of esophagitis or its severity in patients undergoing workup for bariatric surgery. Therefore, liberal screening upper endoscopy is recommended for pre-bariatric surgery patients to guide appropriate procedure selection.

Recommend with caution: A meta-analysis investigating papillary thyroid carcinoma tumor progression under active surveillance

BACKGROUND

Papillary thyroid carcinoma (PTC) is an indolent disease with favorable outcomes. The non-surgical treatment approach known as active surveillance (AS) has been introduced as an alternative treatment instead of the traditional thyroidectomy. However, 10-15 % of PTC tend to progress. We sought to determine factors predicting the progression of PTC under AS.

METHODS

A systematic search was performed in January 2022 using PubMed, Embase, Google Scholar, Web of Science, and ScienceDirect. PRISMA guidelines were used by multiple reviewers to extract study characteristics (author name, publication date, journal name, country, institution, and study design), as well as main outcomes and measures. A combination of utilization of thyroid replacement therapy, baseline tumor size and volume, follow-up tumor size and volume, and the presence of lymph node metastasis and its distribution, as well as surveillance duration, were the main measures of this study.

RESULTS

Nine studies with 4166 patients were included, of which 354 showed tumor progression during AS (15 %; 95%CI = 7 % - 23 %). The average follow-up period was 41.58 months. The mean tumor maximum diameter was 8.54 mm (95%CI = 7.04-10.03). Tumor progression was most commonly secondary to an increase in volume by ≥50 % (75 %; 95%CI = 68 % - 80 %), then increase in diameter by ≥3 mm (41 %; 95%CI = 13 % - 76 %), and finally the development of lymph node metastasis (13 %; 95%CI = 9 % - 19 %). Approximately only 2 % of all patients thus developed new lymph node metastasis. Patient age, sex, and tumor size were not associated with higher risks of tumor progression. 12 % of AS patients eventually underwent surgery, though only 40 % (95%CI = 27 % - 53 %) of these patients displayed tumor progression.

CONCLUSIONS

Our meta-analysis determined a tumor progression rate of 15 % in patients who underwent AS management, 13 % of which (2 % of all patients) developed lymph node metastasis. We found no protective or risk factors for tumor progression, and that almost half of all patients who underwent delayed surgery did so for reasons other than tumor progression. While not biopsying small (<1 cm) or very low suspicious nodules is already recommended, AS may be an appropriate treatment option in patients appropriately counseled, considering the low risk of advanced tumor progression but also the considerable patient population who fail to adhere to treatment. Alternatively, in aim of preventing overtreatment in patients who would rather take proactive measures against their low-risk carcinoma, minimally-invasive ablation techniques may be an attractive option.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Clinical Characterization and Outcomes of Culture- and Polymerase Chain Reaction-Negative Cases of Infectious Keratitis

PURPOSE

To examine the clinical presentation, management, and outcomes of culture and polymerase chain reaction (PCR) negative cases of infectious keratitis.

METHODS

In this retrospective case series, we evaluated the laboratory and medical records of culture- and PCR-negative cases (2016-2020) reported to a tertiary care center, which were presumed to be infectious keratitis on the basis of clinical history and presentation.

RESULTS

A total of 121 cases with culture-negative keratitis were included in this study. The mean age of the patients was 48.42 ± 1.89 years, and 53.72% were female. At presentation, the presumed etiology was viral in 38.01%, bacterial in 27.27%, fungal in 8.26%, Acanthamoeba in 6.61%, and unlisted in 28.92% of cases. The most common risk factors were a previous history of ocular surface diseases (96.69%) and contact lens use (37.19%). In total, 61.98% of the patients were already on antimicrobial medication at presentation. The initial management was altered in 79 cases (65.29%) during the treatment course. Average presenting and final (post-treatment) visual acuities (VA) were 0.98 ± 0.04 (LogMAR) and 0.42 ± 0.03 (LogMAR), respectively. A significantly higher frequency of patients with a final VA worse than 20/40 (Snellen) had worse VA at initial presentation (p < 0.0001). A history of ocular surface disease, cold sores, and recurrent infection (p < 0.05) were more commonly associated with a presumed diagnosis of viral keratitis. The patients with presumed bacterial etiology were younger and had a history of poor contact lens hygiene (p < 0.05).

CONCLUSIONS

We observed a distinct difference in clinical features among patients with culture-negative and PCR-negative keratitis managed for presumed viral and bacterial infections. Although there was significant variability in presentation and management duration in this cohort, the visual outcomes were generally favorable.

Predictive factors for docking site procedure in bone transport for large lower extremity segmental defects

BACKGROUND

Segmental bone transport is a common technique for treating large segmental bone defects. However, a docking site procedure is often necessary in segmental bone transport. To date, no prognostic factors for the need of docking site procedure have been reported. Thus, the decision is often made at random, based on the surgeon's subjective judgment and experience. The aim of this study was to identify prognostic factors for the need of docking site operation.

METHODS

Patients with segmental bone transport in lower extremity bone defects were included regardless of age, aetiology, and defect size. We excluded patients undergoing treatments that were not yet completed, and those who discontinued therapy by any reason. The need for docking site operation was modelled with logistical and linear regression as well as univariate analysis of variances (ANOVA). Receiver operating characteristics (ROC) curve analysis was also performed.

RESULTS

Twenty-seven patients from age 12 to 74 years (mean age: 39.07 ± 18.20 years) were included. The mean defect size was 76.39 ± 41.10 mm. The duration of transport (days) showed a significant influence (p = 0.049, 95%CI: 1.00-1.02) on the need for docking site operation. No other significant influences were detected.

CONCLUSION

A link between the duration of transport and the need for docking site operation was detected. Our data showed that if a threshold of about 188 days is exceeded, docking surgery should be considered.

Diagnostic Test Accuracy of Lung Ultrasound for Acute Chest Syndrome in Sickle Cell Disease: A Systematic Review and Meta-analysis

BACKGROUND

Acute chest syndrome (ACS) is a leading cause of death in patients with sickle cell disease. Lung ultrasound (LUS) is emerging as a point-of-care method to diagnose ACS, allowing for more rapid diagnosis in the ED setting and sparing patients from ionizing radiation exposure.

RESEARCH QUESTION

What is the diagnostic accuracy of LUS for ACS diagnosis, using the current reference standard of chest radiography?

STUDY DESIGN AND METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed for this systematic review and meta-analysis. Embase, MEDLINE, Web of Science, and Google Scholar were used to compile all relevant studies. Two reviewers screened the studies for inclusion in this review. Cases of discrepancy were resolved by a third reviewer. Meta-analyses were conducted using both metadta and midas STATA software packages to retrieve summary receiver operating characteristic curves, sensitivities, and specificities. Three reviewers scored the studies with QUADAS-2 for risk of bias assessment.

RESULTS

From a total of 713 unique studies retrieved, six studies were included in the final quantitative synthesis. Of these, five studies were in pediatric EDs. Two studies were conference abstracts and not published manuscripts. Data were available for 625 possible ACS cases (97% of cases in patients aged ≤ 21 years) and 95 confirmed ACS diagnoses (pretest probability of 15.2%). The summary sensitivity was 0.92 (95% CI, 0.68-0.98) and the summary specificity was 0.89 (95% CI, 0.69-0.97) with an area under the curve of the summary receiver operating characteristic curve of 0.96 (95% CI, 0.94-0.97).

INTERPRETATION

LUS has excellent sensitivity and very good specificity for ACS diagnosis and may serve as an initial point-of-care test to facilitate rapid treatment of ACS and spare pediatric patients from ionizing radiation; however, further research is warranted to improve the generalizability to the adult sickle cell disease population.

Radiofrequency ablation of an intrathyroidal parathyroid adenoma with intraoperative parathyroid hormone monitoring: a case report of a novel technique

Background

Primary hyperparathyroidism (PHPT) is classically treated by conventional parathyroidectomy, an open neck surgery. Radiofrequency ablation (RFA) has been shown as a safe minimally-invasive alternative to parathyroidectomy for the management of PHPT and has been shown to be effective in 60-90% of cases. Here, we present a patient successfully treated for persistent PHPT by RFA with simultaneous intraoperative parathyroid hormone (IOPTH) monitoring.

Case Description

A 51-year-old female with a past medical history of resistant hypertension, hyperlipidemia, and vitamin D deficiency presented to our endocrine surgery clinic with PHPT. Neck ultrasound (US) localized a 0.79 cm lesion suggestive of a parathyroid adenoma. Parathyroid exploration resulted in the excision of two masses. IOPTH levels dropped from 259.9 to 204.7 pg/mL. No ectopic parathyroid tissue was found. Three-month follow-up demonstrated elevated calcium levels, suggesting persistent disease. A repeat neck US one-year post operation localized a suspicious hypoechoic sub-centimeter thyroid nodule, which was subsequently determined to be an intrathyroidal parathyroid adenoma. The patient elected to proceed with RFA with IOPTH monitoring, citing concern for increased risk of redo open neck surgery. Operation pursued without complication and IOPTH levels dropped from 270 to 39.1 pg/mL. The patient's only three-day post-operative complaints, occasional numbness and tingling, were completely resolved by her three-month follow up. The patient had normal PTH and calcium levels at seven months post-operation visit and was without complaint.

Conclusions

To our best knowledge, this is the first reported case of RFA with IOPTH monitoring used to manage a parathyroid adenoma. Our work adds to the growing literature suggesting minimally-invasive techniques, such as RFA with IOPTH, as a potential management option for treating parathyroid adenomas.

Hashimoto's Thyroiditis: A Protective Factor against Recurrence in BRAF-Wild Type Differentiated Thyroid Carcinoma

A recent work analyzing the concomitant factors BRAF mutation (risk factor) and Hashimoto's thyroiditis (HT) (protective factor) found that the presence of HT reduced lymph node metastasis in BRAF-mutated papillary thyroid carcinoma. Whether this notion is upheld with respect to disease recurrence and differentiated thyroid carcinoma (DTC), however, is unknown. We aimed to investigate the effect of underlying HT in DTC patients and its influence on recurrence with a specific emphasis in BRAF-mutated tumors. A total of 469 patients were included. Patients were stratified according to BRAF and HT status. Multivariate regression analysis was conducted to determine protective and risk factors of disease recurrence in patients with DTC. HT was associated with less-aggressive carcinomas including more frequent microcarcinomas (HT: 45.0% vs. no-HT: 34.0%, p = 0.02), less lymph node involvement (HT: 16.4% vs. no-HT: 26.1%, p = 0.02), and less disease recurrence (HT: 2.9% vs. no-HT: 11.9%, p = 0.002). BRAF mutation was also significantly associated with higher rates of lymph node involvement (BRAF-mutant: 41.9% vs. BRAF-wild type: 14.6%, p < 0.001) and almost two times the rate of recurrence (BRAF-mutant: 14.9% vs. BRAF-wild type: 6.5%, p = 0.004). Underlying HT was the only protective factor determined, reducing the odds of developing recurrence by 70% (HR: 0.30, 95%CI: 0.11-0.88). In the BRAF-wild type cohort, regression analysis continued to determine HT as a protective factor (p = 0.03). However, in the BRAF-mutant cohort, HT was no longer an independent protective factor (p = 0.20) against recurrence. Sub-group regression analysis, including PTC patients, similarly found HT as a protective factor only in BRAF-wild type patients (p = 0.039) and not BRAF-mutant (p = 0.627). The presence of underlying HT is associated with less aggressive tumors and is an independent protective factor against DTC recurrence, reducing the risk by 70%. HT remains a protective factor in BRAF-wild type carcinoma, but not in patients with BRAF-mutant carcinoma. HT may potentially be considered as a parameter which enhances American Thyroid Association patient risk stratification.

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

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

COVID-19 infection immediately post-transplant in an unvaccinated patient: Clinical observations and ethical implications

We report the case of a 28-year-old woman who presented with acute liver failure from suspected drug-induced liver injury. She was not vaccinated against COVID-19 and expressed considerable reluctance to become vaccinated, prompting discussions within the transplant group regarding her candidacy. She received a liver transplant and acquired COVID-19 immediately post-operatively that was treated with sotrovimab. She recovered well and was discharged shortly following her transplant. This case suggests that unwillingness to receive COVID-19 vaccination pre-transplant should not represent an absolute contraindication to a life-saving liver transplantation.

COVID-19 infection in liver transplant recipients: Clinical features and outcomes from a Canadian multicentre cohort

BACKGROUND: Prior studies have assessed risk factors and clinical outcomes in liver transplant (LT) recipients infected with COVID-19 globally; however, there is a paucity of Canadian data. Our multicentre study aims to examine the characteristics and clinical outcomes of LT patients with COVID-19 infection in Canada. METHODS: Adult LT recipients with reverse transcription-polymerase chain reaction (RT-PCR) confirmed COVID-19, from Canadian tertiary care centres between March 2020 and June 2021 were included. RESULTS: A total of 49 patients with a history of LT and COVID-19 infection were identified. Twenty-nine patients (59%) were male, median time from LT was 66 months (IQR 1-128), and median age was 59 years (IQR 52-65). At COVID-19 diagnosis, the median alanine transaminase (ALT) was 37 U/L (IQR 21-41), aspartate aminotransferase (AST) U/L was 34 (IQR 20-37), alkaline phosphatase (ALP) U/L was 156 (IQR 88-156), total bilirubin was 11 μmol/L (IQR 7-14), and international normalized ratio (INR) was 1.1 (IQR 1.0-1.1). The majority of patients (86%) were on tacrolimus (monotherapy or combined with mycophenolate mofetil); median tacrolimus level at COVID-19 diagnosis was 5.3 μg/L (IQR 4.0-8.1). Immunosuppression was modified in eight (16%) patients post-infection. Eighteen patients (37%) required hospitalization, and three (6%) required intensive care unit (ICU) admission and mechanical ventilation. Four patients (8%) died from complications related to COVID-19 infection. On univariate analysis, neither age, sex, comorbidities, nor duration post-transplant were associated with risk of hospitalization or ICU admission. CONCLUSIONS: LT recipients with COVID-19 have high rates of hospitalization but fortunately have low rates of ICU admission and mortality in this national registry.

Liver Transplant Recipients Speak Out on Public Awareness and Education Surrounding Alcohol-Related Health Effects: A Survey Study

BACKGROUND

Compared to other recreational substances in Canada, alcohol consumption incurs the highest healthcare costs. Liver transplant recipients are unique stakeholders as members of the general public with lived experiences of liver disease. We sought to explore their perspectives on the current state of public education on alcohol-related health effects.

METHODS

The most recent 400 liver transplant recipients at Vancouver General Hospital, Canada, were invited to participate in an anonymous online survey on alcohol-related health effects by mail, email, and phone.

RESULTS

Of 372 contacted patients, 212 (57%) completed the survey. Most patients were between 60-79 years, 63% were male, and 69% were Caucasian. The most common liver conditions leading to transplant were viral hepatitis (33%), alcohol-related liver disease (16%), autoimmune liver disease (14%), and non-alcoholic fatty liver disease (15%). Most patients knew that alcohol leads to liver failure (85%), but fewer knew about alcohol leading to cancer (54%), heart disease (50%), and damage to other organs (58%). Most common sources of information included public media (61%), family and friends (52%), and physicians (49%), with narrative comments about learning of alcohol-related health effects after liver diagnosis. Most patients believed that public health education at a middle/high school level would have long-term efficacy (72%) compared to health warning labels (33%) and safety messaging in commercials (39%). Current public education was felt to be adequate by only 20% of patients and 73% of patients supported health warning labels.

CONCLUSIONS

Liver transplant patients reported a high, but not universal, awareness of alcohol-related health effects. A majority thought that current public health efforts were inadequate; it is critical to implement public health interventions to ensure consumers are able to make an informed decision on alcohol consumption.

Ruptured gastro-intestinal stromal tumor as a surgical emergency: A case report and literature review

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. GISTs of the small bowel are rare, and often present with an abdominal mass and/or bleeding. Chemotherapy and surgery are the mainstay of therapy. Here, we discuss an unusual case of a ruptured jejunal GIST with hemoperitoneum and recurrence despite surgical excision followed by Imatinib treatment. Forty-five cases of ruptured small intestinal GISTs were identified in the literature. Most cases were in males and were found to be at the site of the jejunum.

Radiofrequency Ablation of Indeterminate Thyroid Nodules: The First North American Comparative Analysis

Thyroid nodules can be classified as benign, malignant, or indeterminate, the latter of which make up 10-30% of nodules. Radiofrequency ablation (RFA) has become an attractive and promising therapy for the treatment of benign thyroid nodules. However, few studies have investigated the safety and efficacy of RFA for the management of indeterminate thyroid nodules. In this study, 178 patients with thyroid nodules diagnosed as benign (Bethesda II) or indeterminate (Bethesda III/IV) by preoperative cytopathological analysis were included. Patients in the benign and indeterminate cohorts had similar thyroid nodule volume reduction rates at 65.60% and 64.20%, respectively (p = 0.68). The two groups had similar nodular regrowth rates, at 11.2% for benign nodules and 9.40% for indeterminate nodules (p = 0.72). A total of three cases of transient dysphonia were reported. RFA of indeterminate thyroid nodules was comparable to that of benign thyroid nodules in all parameters of interest, including volume reduction rate. To our best knowledge, our work is the first North American analysis comparing benign and indeterminate thyroid nodules and suggests RFA to be a promising modality for the management of indeterminate thyroid nodules.

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

Background

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

Case Description

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

Conclusions

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

Hashimoto’s Thyroiditis Minimizes Lymph Node Metastasis in BRAF Mutant Papillary Thyroid Carcinomas

Hashimoto’s thyroiditis (HT) (autoimmune thyroiditis) is a clinicopathological entity associated with chronic lymphocytic infiltration resulting in hypothyroidism. HT is a double-edged sword that increases the risk of papillary thyroid cancer (PTC), yet it serves as a protective factor for PTC progression. BRAF mutation in PTCs is associated with rapid cell growth, aggressive tumor characteristics, and higher mortality rates. Here, we aimed to analyze the influence of HT in patients with PTCs and its effect on lymph node metastasis (LNM) in BRAF mutant tumors. Adults diagnosed with PTC between 2008 and January 2021 were retrospectively included. A total of 427 patients, 128 of whom had underlying HT, were included. The HT group had significantly higher rates of microcarcinoma (49.2% vs. 37.5%, p = 0.025) and less lateral LNM (8.6% vs. 17.1%, p = 0.024). Interestingly, BRAF-mutated PTCs were found to have significantly less overall LNM (20.9% vs. 51%, p = 0.001), central LNM (25.6% vs. 45.1%, p = 0.040) and lateral LNM (9.3% vs. 29.4%, p = 0.010) in patients with HT when compared to those without underlying HT. HT was found to be an independent protective predictor of overall and lateral LNM. Altogether, HT was able to neutralize the effect of BRAF mutation and was determined to be an independent protective factor against LNM. Specifically, our work may influence treatment-aggressiveness decision making for endocrinologists, oncologists and surgeons alike.

Emerging inflammatory bowel disease demographics, phenotype, and treatment in South Asia, South-East Asia, and Middle East: Preliminary findings from the Inflammatory Bowel Disease-Emerging Nations' Consortium

BACKGROUND AND AIM

Inflammatory bowel disease (IBD) is emerging in the newly industrialized countries of South Asia, South-East Asia, and the Middle East, yet epidemiological data are scarce.

METHODS

We performed a cross-sectional study of IBD demographics, disease phenotype, and treatment across 38 centers in 15 countries of South Asia, South-East Asia, and Middle East. Intergroup comparisons included gross national income (GNI) per capita.

RESULTS

Among 10 400 patients, ulcerative colitis (UC) was twice as common as Crohn's disease (CD), with a male predominance (UC 6678, CD 3495, IBD unclassified 227, and 58% male). Peak age of onset was in the third decade, with a low proportion of elderly-onset IBD (5% age > 60). Familial IBD was rare (5%). The extent of UC was predominantly distal (proctitis/left sided 67%), with most being treated with mesalamine (94%), steroids (54%), or immunomodulators (31%). Ileocolic CD (43%) was the commonest, with low rates of perianal disease (8%) and only 6% smokers. Diagnostic delay for CD was common (median 12 months; interquartile range 5-30). Treatment of CD included mesalamine, steroids, and immunomodulators (61%, 51%, and 56%, respectively), but a fifth received empirical antitubercular therapy. Treatment with biologics was uncommon (4% UC and 13% CD), which increased in countries with higher GNI per capita. Surgery rates were 0.1 (UC) and 2 (CD) per 100 patients per year.

CONCLUSIONS

The IBD-ENC cohort provides insight into IBD in South-East Asia and the Middle East, but is not yet population based. UC is twice as common as CD, familial disease is uncommon, and rates of surgery are low. Biologic use correlates with per capita GNI.

Large uterine leiomyoma presenting as pseudo-Meigs’ syndrome with an elevated ca125: a case report and literature review

Ascites, pelvic mass and elevated CA-125 in females carry a grim prognosis, likely an ovarian carcinoma. However, more benign etiologies such as Meigs’ and pseudo-Meigs’ syndrome must be considered. Pseudo-Meigs’ syndrome presenting with an elevated CA-125 is rare and presents a diagnostic challenge. Medline and PubMed were queried for pseudo-Meigs’ syndrome cases. We present a 35-year-old female patient who presented with abdominal swelling and weight gain. Imaging demonstrated a 29-cm large intraabdominal mass with significant ascites with elevation of CA-125. Surgical resection was performed, and pathology identified uterine leiomyoma. Twenty-one cases of pseudo-Meigs’ syndrome were identified in the literature. Most patients presented with abdominal distention, and some also reported dyspnea. All patients, including our case, were treated surgically. No recurrence reported among these cases. Surgery is the mainstay for radical treatment in pseudo-Meigs’ syndrome. Resolution of the ascites and hydrothorax occurs following resection of the tumor.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Floor plants’ leaf shape and Phyllagathis rotundifolia’s soil organic matter in Kuala Keniam Trail, Pahang National Park

Kuala Keniam forest in the Pahang National Park is a part of the oldest and most complex ecosystem in the world with multispecies of plants and structures. Unfortunately, near to none information was documented on the geometrical aspects of leaves. Thus, this study aims to pre-document on the variety of shapes of leaves along the trail and classify them. Photographs of the plants and all site activities were taken and documented by using the digital single-lens reflex (DSLR) and smartphone-digital cameras. Secondly, this study also aims at understanding this one particular herbaceous plant, known as Phyllagathis rotundifolia (tapak sulaiman) which is commonly found along the trail, and traditionally used to relieve gastrointestinal problems and fever. The composition of the soil organic matter of the plant were collected for better understanding of the type of soil needed for mass-cultivation and medical purposes. The Walkley-Black (WB) titration method was used to analyse the soil, where the oxidation of organic matter by potassium dichromate (K2Cr2O7)-sulfuric acid mixture followed by back titration of the excessive dichromate by ferrous ammonium sulphate (Fe (NH4)2(SO4)2.6H2O) were monitored. Findings from the Kuala Keniam trails were documented and analysed. Thirty distinct-leaves have been identified and classified into 10-distinct leaf shape categories. Rich soil contents such as iron, carbon and phosphorous were also detected, thus creating Kuala Keniam as an excellent environment for the growth of beneficial shrubs and herbs

A224 COVID-19 INFECTION IN LIVER TRANSPLANT RECIPIENTS: CLINICAL FEATURES, HOSPITALIZATION, AND MORTALITY FROM A CANADIAN MULTICENTRE COHORT

Background

The COVID-19 pandemic has brought significant challenges to clinicians caring for liver transplant (LT) recipients. Researchers have sought to better understand the risk and clinical outcomes of LT recipients infected with COVID-19 globally, however, there is a paucity of data from within Canada.

Aims

Our multi-center study aims to examine the characteristics and clinical outcomes of LT patients with COVID-19 in Canada.

Methods

We identified a retrospective cohort of adult LT recipients with RT-PCR confirmed COVID-19 from 7 Canadian tertiary care centers between March 2020 and June 2021. Demographic and clinical data were compiled by clinicians within those centers. We identified liver enzyme profile at the time of COVID-19 infection, immunosuppression type and post-infection adjustments, rate of hospitalization, ICU admission, mechanical ventilation, and death.

Results

A total of 49 patients with a history of LT and COVID-19 infection were identified. Twenty nine patients (59%) were male, the median time from LT was 66 months (1, 128) and the median age at COVID-19 infection was 59 years (52, 65). At COVID-19 diagnosis, the median ALT was 37 U/L (21, 41), AST U/L was 34 (20, 37), ALP U/L was 156 (88, 156), Total Bilirubin was 11 umol/L (7, 14), and INR was 1.1 (1.0, 1.1). The majority of patients (92%) were on tacrolimus monotherapy or a combination of tacrolimus and mycophenolate mofetil (MMF); median tacrolimus level at COVID-19 diagnosis was 5.3 ug/L (4.0, 8.1). Immunosuppression was modified in 8 (16%) patients post-infection; either the tacrolimus dose was reduced or MMF was held. One patient developed acute cellular rejection which recovered after re-initiation of the prior regimen. Eighteen patients (37%) required hospitalization, 6 (12%) were treated with dexamethasone, and 3 (6%) required ICU admission and mechanical ventilation. Four patients (8%) died due to complications of COVID-19. On univariate analysis, neither age, sex, co-morbidities nor duration post-transplant were associated with risk of hospitalization.

Conclusions

In our national retrospective study, approximately 40% of patients required hospitalization with a mortality rate of &lt; 10%. Previous studies have shown proximity to LT as an independent factor for mortality with COVID-19; the median time from LT for our patients was 5 years, which may explain the lower mortality rate. Of note, the median tacrolimus levels were much lower in comparison to the target of 8–10 ug/L used in the first year post-transplant. As the landscape of COVID-19 changes with vaccination, evolving treatments, and increasing rates of variant transmission, additional studies are required to continue identifying trends in clinical outcomes.

Funding Agencies

None

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Intraoperative neurophysiologic monitoring prevented iatrogenic spinal cord injury during robotic-assisted transabdominal adrenalectomy: a case report

Cervical spondylotic myelopathy (CSM) is the most common disease of the cervical spinal cord in patients older than 55 and is characterized by an initial asymptomatic period followed by progressive neurological deficit from degenerative changes of the cervical vertebrae. These changes cause compression and vascular compromise to the cervical spinal cord. Because there are no pathognomonic symptoms, its diagnosis is commonly delayed. Herein we report the first case of the use of IONM during a transabdominal adrenalectomy in a patient with CSM, which prevented an iatrogenic spinal cord injury (SCI). The patient is a 74-year-old male with what was proven later as cervical spinal stenosis who presented for robotic-assisted transabdominal adrenalectomy. When positioned supine on the operating table, he exhibited upper and lower extremity neurological symptoms, prompting awake fiberoptic intubation and the use of IONM secondary to suspicion for CSM. After being positioned into lateral decubitus, IONM showed a loss of transcranial motor evoked potentials (TcMEP) and attenuated somatosensory evoked potentials (SSEP) from the right lower extremities and the procedure was aborted and the patient returned supine. TcMEPs returned to baseline, but SSEPs remained attenuated. The patient exhibited normal movement and sensation in post-anesthesia care. A high index of suspicion for CSM is required for older patients, as early diagnosis allows for spinal surgery treatment before acute worsening during anesthesia or non-spinal surgery. Furthermore, a low threshold for the use of IONM in patients with a high likelihood of CSM who require a non-spinal surgery can successfully prevent iatrogenic SCI.

Effect of postsurgical chronic hypoparathyroidism on morbidity and mortality: a systematic review and meta-analysis

Background

Hypoparathyroidism (HypoPT) is a common sequela of anterior neck surgeries. While the acute risks of HypoPT are well known, emerging evidence is beginning to define the risks chronic HypoPT poses to patients. This meta-analysis aims to evaluate that risk and give more insight into its consequences.

Methods

A systematic review and meta-analysis were performed, searching EMBASE, Web of Science, and Scopus for studies published up to July 1, 2020 and reported following PRISMA guidelines. Pooled analysis was estimated using the Mantel-Haenszel method and a random-effects model. A sub-analysis of the pooled data for each morbidity was performed and demonstrated in forest plots.

Results

Patients with postsurgical chronic HypoPT had a high risk of cardiac morbidities [odds ratio (OR) =1.43; 95% confidence interval (95% CI): 1.21 to 1.70; P<0.001] in the absence of elevated risk of cardiac arrhythmias (OR =1.35, 95% CI: 0.96 to 1.79, P=0.08). Analysis also showed higher odds of developing renal disease (OR =4.85, 95% CI: 3.54 to 6.67, P<0.001), renal stones (OR =3.86, 95% CI: 1.81 to 8.23, P<0.001), seizures (OR =2.41, 95% CI: 1.66 to 3.5, P<0.001), mental health problems (OR =1.46, 95% CI: 1.21 to 1.77, P<0.001), and infections (OR =1.51, 95% CI: 1.28 to 1.78, P<0.001). Conversely, HypoPT has no effect on mortality risk (OR =1.19, 95% CI: 0.96 to 1.49, P=0.12).

Conclusions

Postsurgical HypoPT patients are vulnerable to a variety of medical and psychiatric diseases. This meta-analysis should guide surgeons in preoperative counseling and postoperative care for patients undergoing anterior neck surgeries.

Effects of Parathyroidectomy on Normocalcemic Primary Hyperparathyroidism and the Role of Intraoperative PTH Measurement

BACKGROUND

Normocalcemic primary hyperparathyroidism (NCpHPT) and normohormonal primary hyperparathyroidism (NHpHPT) are recently recognized variants of primary hyperparathyroidism. Current guidelines for the management hyperparathyroidism recognize NCpHPT as one of the areas that are recommended for more research due to limited available data.

METHODS

A retrospective review of patients who had parathyroidectomy between 2014 and 2019. We excluded patients with multiple endocrine neoplasia syndromes and secondary and tertiary hyperparathyroidism. Included patients were classified based on the biochemical profile into classic or normocalcemic hyperparathyroidism group. Collected data included demographics, preoperative localizing imaging, intraoperative parathyroid hormone levels, and postoperative cure rates.

RESULTS

261 patients were included: 160 patients in the classic and 101 patients in the normocalcemic group. Patients in the normocalcemic group had significantly more negative sestamibi scans (n = 58 [8.2%] vs 78 [51.3%], P = <.01), smaller parathyroid glands (mean weight 436.0 ± 593.0 vs 742.4 ± 1109.0 mg, P = .02), higher parathyroid hyperplasia rates (n = 51 [50.5%] vs 69 [43.1%]), and significantly higher intraoperative parathyroid hormone at 10 minutes (78.1 ± 194.6 vs 43.9 ± 62.4 1, P = .04). Positive predictive value of both intraoperative parathyroid hormone and cure rate was lower in the normocalcemic group (84.2% vs 95.7%) and (80.5% vs 95%), respectively.

CONCLUSION

Normocalcemic hyperparathyroidism is a challenging disease. Surgeons should be aware of the lower cure rate in this group, interpret intraoperative parathyroid hormone with caution, and have a lower threshold for bilateral neck exploration and 4 glands visualization.

Quantitative vestibular function tests in posterior circulation stroke patients: A review

While specific bedside examinations are known to be sensitive in identifying stroke among acute vestibular syndrome patients, complementary quantitative vestibular function testing can be helpful to quantify vestibular loss due to stroke. In contrast to peripheral vestibular dysfunction, diagnosis of central vestibular dysfunction can be challenging for unskilful clinicians. This article presents a comprehensive overview of quantitative vestibular function test findings such as the video head impulse test (vHIT), cervical vestibular evoked myogenic potentials (cVEMPs), ocular vestibular evoked myogenic potentials (oVEMPs), videonystagmography (VNG) and caloric test among stroke patients. Vestibulo-ocular reflex (VOR) gain is usually found normal among posterior inferior cerebellar artery (PICA) stroke patients but varies among anterior inferior cerebellar artery (AICA) stroke patients. Abnormal contralesional posterior semicircular canal VOR gain can be observed due to lesions in the medial longitudinal fasciculus (MLF). AICA and PICA stroke can impair cVEMPs, oVEMPs, and VNG (i.e., smooth pursuit and saccade functions). Strokes, particularly those involving the vestibular nucleus, including both upper, lower brainstem and cerebellum, can result in various abnormalities of smooth pursuit, saccade or calorics testing. The combined evaluations of VNG, vHIT, and VEMPs can be accurately used to complement and quantify bedside vestibular evaluation in diagnosing central vestibular dysfunction. In addition, as most studies were conducted amongst acute vestibular syndrome (AVS) patients, future studies that investigate the prevalence of vestibular dysfunction in recovering stroke patients are required.

Bioaccumulation and biomagnification in elasmobranchs: A concurrent assessment of trophic transfer of trace elements in 12 species from the Indian Ocean

We provided the first multi-species study investigating the presence and organotropism of trace elements in three tissues of 12 elasmobranch species. Shark species showed comparable TE loads, although milk sharks and juvenile scalloped hammerhead sharks exhibited the highest Cd and Hg levels, respectively. Fins accumulated higher levels of Pb, Co, and Cr; muscles higher V, As, and Hg; livers higher Se and Cd levels. The organotropism of TEs calls for cautious when choosing a tissue to be sampled since certain tissues, like fin clips, do not provide reliable surrogate for the internal loads of some TEs. Strong correlations between essential and toxic TEs indicated detoxification mechanisms, while the TMF provided evidence for Hg, As and Se biomagnification along the food-web. Considering the difficulties in assessing elasmobranchs contamination from different areas, the proposed multi-species approach represents a valuable way to estimate the species-specific accumulation and transfer of pollutants in sharks.

Challenges of delivering reproductive health services to forced displaced populations

Background

Of the 80 million forced displaced persons worldwide, women and children bear greater morbidity and mortality, especially in conflict-affected regions. This is due to disruption in health service provision, breakdown of social institutions and increase in sexual and gender-based violence. Reproductive health (RH) service delivery as part of humanitarian health cluster services is outlined in the Minimum Initial Service Package (MISP). This study explores the challenges of delivering RH services to forced-displaced populations, focussing on field level stakeholders in humanitarian settings.

Methods

Qualitative semi-structured interviews were conducted with stakeholders from non-governmental and United Nations agencies involved in delivering RH services to conflict-affected populations. Additionally, a scoping review, using the Arksey and O'Malley framework, of the literature was also conducted reviewing challenges of delivering RH programmes to women in forced displaced populations. An inductive and deductive thematic approach was used in data analysis.

Results

Eleven key informants (KIs) were interviewed from six conflict-affected countries including Syria, Afghanistan and Libya. Main emerging themes were: 1. Poor awareness of international guidelines (including the MISP) 2. Service provision barriers including lack of human resources 3. Attitudes towards SRH and women's rights 4. Disruption of health services due to COVID-19.

Conclusions

This study has highlighted the main challenges that the humanitarian actors delivering RH programmes in conflict-affected settings face. Implementation of international guidelines remains a key barrier. Key policy recommendations would be to standardise training for all RH providers, prioritise training in the MISP and address cultural attitudes towards RH. Further research exploring the use of WHO's essential medicines for RH and the long-term impact of COVID-19 on forced displaced females needs to be conducted.

Key messages

Providing basic essential reproductive health services to conflict affected populations remains a challenge, including implementation of standardised international guidance through the MISP.

One key policy recommendation would be to prioritise training in MISP for conflict-affected humanitarian settings to ensure it is offered as part of the essential package.

Resting and exercise hemodynamic determinants of daily activity measured by accelerometer in stable heart failure patients

Background

Patient-worn accelerometer is increasingly used in patients with heart failure and reduced ejection fraction (HFrEF) to assess daily activity and and as surrogate endpoint. We examined the association between cardiac physiology and daily activity by patient-worn accelerometer recordings in stable HFrEF patients.

Methods

In this descriptive study, physical average daily accelerometer units (PADA) and total average daily accelerometer unit (TADA) were assessed by a accelerometer recordings. Sixty three stable ambulatory patients with HFrEF, mainly men (92%), mean age 58±10 years, and ejection-fraction 26±4% underwent hemodynamic exercise testing, and accelerometry (Table 1). Patients were divided by PADA in a low and high activity level groups based on counts per minute physical activity.

Results

Patients in the low activity group were older and more frequently treated with diuretics. At rest, the low activity group was characterized by a lower cardiac index (CI) (2.2±0.4 vs. 2.4±0.4 l/min/m2, p=0.01), Stroke volume (SV) (70±19 vs. 81±17 ml, p=0.02) but not pulmonary capillary wedge pressure (PCWP) (12±5 vs. 11±5 mmHg, p=0.3) (Figure 1). Low activity group reached a lower CI (4.8±1.7 vs. 6.6±1.7 l/min/m2, p&lt;0.001) and SV (94±32 vs. 121±29 ml, p&lt;0.001), but not in PCWP (31±12 vs. 27±8 mmHg, p=0.2) or arterial-venous O2 content difference (A-VO2 diff) (13.00±2.32 vs. 12.96±1.65 ml O2/dl, p=0.9) at peak exercise. The attenuated increase was associated with attenuated increase in SV rther than increase in heart rate (42±23 vs. 52±21 bpm, p=0.07). Finally, CI at peak exercise was the only independent variable associated with PADA after adjusting for age, gender, and BMI (p&lt;0.0001). The PADA and TADA were associated to functional assessments using Kansas City Cardiomyopathy Questionnaire, but not with New York Heart Association class or N-terminal pro brain natriuretic peptide (NT-proBNP) (Table 1).

Conclusion

Accelerometer-assessed activity in patients with HFrEF are associated with impairments in LV performance, SV reserve and cardiac output during exercise, to a greater extent than changes in arterial-venous O2 content difference or pulmonary vascular pressures. Accelerometer data may provide information about the functional status that we do not nessecary find in the widely used tools in both research and daily clinical practice.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): This work was supported by the Danish Heart Foundation [grant numbers 17-R116-A7714-22076, 18-R124-A8573-22107]; Steno Diabetes Center Odense, Denmark [grant number 3363] and A.P. Møller Foundation for the Advancement of Medical Science [grant number 17-L-0339]. Table 1. Baseline and regression analysisFigure 1. Change in PCWP and CI by exercise

Effect of empagliflozin in hfref patients treated with angiotensin receptor neprilysin inhibitor an analysis of EMPIRE HF

Introduction

Inhibition of neprilysin/valsartan (ARNi) or sodium glucose cotransporter 2 (SGLT2) in patients with heart failure (HF) and reduced ejection fraction (HFrEF) has been shown to reduce the risk of Cardiovascular death and hospitalization for HF. Recent trails suggested that SGLT2 reduces the risk for cardiovascular death or hospitalization for HF, regardless of underlying ARNi treatment and that the effect may even be greater in those receiving the combination. Whether there exist an interaction between effect of ARNi and SGLT2 on functional endpoints related to mechanism of action is unknown.

Purpose

This post-hoc analysis of the randomized double-blinded Empire HF trial evaluated the influence of ARNi on the effect of the SGLT2 Empagliflozin on N-terminal prohormone B-type natriuretic peptide (NT-proBNP), pulmonary capillary wedge pressure (PCWP), Left ventricular end-systolic and end-diastolic volumes index; (LVESVI) (LVEDVI), left atrial volume index (LAVI), Left ventricular ejection fraction (LVEF), and Kansas City Cardiomyopathy Questionnaire (KCCQ) HFrEF patients.

Methods

Empire HF trial randomized 190 patients with HFrEF (LVEF ≤40%) to placebo or empagliflozin (10 mg/day), on top of recommended treatment for HFrEF, for 12 weeks of treatment. A total of 58 (31%) received ARNi at baseline and no patients initiated ARNi during study period.

Results

Patients on ARNi were well-treated with a similar baseline characteristic as those who were not treated with ARNi (Table 1). Patients with ARNi had a lower systolic blood pressure (P=0.01), with a higher NT-proBNP (P&lt;0.001) when compared with those not receiving ARNi. When compared to placebo, empagliflozin did not reduce the ratio of change of NT-proBNP with or without ARNi (0.94 [95% CI, 0.75 to 1.19] pg/ml; P=0.62) and (1.02 [95% CI, 0.86 to 1.22] pg/ml; P=0.78), respectively, adjusted (age, atrial fibrillation) interaction P=0.57. Empagliflozin reduced PCWP regardless of ARNi treatment (with ARNi; −4.9 [95% CI, −9.1 to −0.6] mmHg; P=0.02) and (without ARNi; −2.1 [95% CI, −3.8 to −0.4] mmHg; P=0.01), adjusted interaction P=0.20. Overall, empagliflozin was associated with a reduction in LVESVI, LVEDVI, and LAVI volumes, but no effect on LVEF. However, Empagliflozin combined with ARNi at baseline, significantly reduced LVEDVI (−11.2 [95% CI, −21.2 to −1.2] ml/m2; P=0.03), but not without ARNI (−2.9 [95% CI, −8.7 to 2.9] ml/m2; P=0.32), adjusted interaction P=0.13. Treatment-by-subgroup interaction P-values for LVESVI, LAVI, and LVEF analysis were &gt;0.05 (Figure 1). KCCQ total symptom score were significantly increased in those not receiving ARNi (5.4 [95% CI, 1.1 to 9.6]; P=0.013), but not with ARNi (−4.0 [95% CI, −10.3 to 2.3]; P=0.22), adjusted P=0.02.

Conclusion

In this post hoc analysis the effects on empagliflozin to reduce PCWP and LV volumes were not diminished in patients receiving ARNi, however KCCQ change were diminished in patients receiving ARNi.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): This work was supported by the Danish Heart Foundation [grant numbers 17-R116-A7714-22076, 18-R124-A8573-22107]; Steno Diabetes Center Odense, Denmark [grant number 3363] and A.P. Møller Foundation for the Advancement of Medical Science [grant number 17-L-0339]. Table 1. Baseline characteristicsFigure 1. Change in echo variables +/− ARNi

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

Introduction

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

Methods

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

Results

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

Conclusion

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

Repeat tympanostomy tubes in children with Down syndrome

OBJECTIVES

Children with Down syndrome (DS) have a higher incidence of tympanostomy tube insertion (TTI) than children in the general population. As there were no studies investigating factors that are associated with multiple TTIs in children with DS, we sought to determine what factors increase or decrease the likelihood of repeat TTI in children with DS.

METHODS

A retrospective case-control study was performed on consecutive children with DS from 2007 to 2018 with first TTI at a large tertiary children's hospital and follow-up duration at least 27 months since first TTI.

RESULTS

277 patients met the inclusion criteria. Repeat TTI rate was 61.4%. Having an indication of chronic otitis media with effusion (COME) at first TTI was an adjusted risk factor for increased rate of repeat TTI (OR: 2.01, 95%CI: 1.15-3.51, p = .014), while being older at first TTI was an adjusted protective factor for decreased rate of repeat TTI (OR: 0.84, 95%CI: 0.74-0.95, p = .004). Adenotonsillectomy at or before first TTI was not an adjusted protective factor for decreased rate of repeat TTI (OR: 0.915, 95%CI: 0.448-1.872, p = .809) and bilateral intra-operative fluid was not an adjusted risk factor for repeat TTI (OR: 1.97, 95%CI: 0.99-3.90, p = .054).

CONCLUSION

Children with DS were more likely to undergo repeat TTI if they were of younger age and if the indication for surgery was COME. The repeat TTI rate for children with DS was high at 61.4%. Prospective studies are warranted to more precisely investigate factors associated with repeat TTIs in this unique patient population.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Cancer and COVID-19: analysis of patient outcomes

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

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