Objectives/Hypothesis
Recent American Thyroid Association Guidelines recommend either near‐total/total thyroidectomy or lobectomy for patients with a thyroid nodule suspicious for papillary thyroid ...cancer (PTC) on fine‐needle aspiration (FNA) biopsy (Bethesda V). In this analysis, we aim to assess the cost‐effectiveness of lobectomy in comparison to total thyroidectomy.
Study Design
Cost‐effectiveness analysis.
Methods
A Markov model cost‐effectiveness analysis was performed for a base case followed for 20 years postoperatively. Cost and probabilities data were retrieved from the current literature. Effectiveness was represented by quality‐adjusted life year (QALY).
Results
Total thyroidectomy protocol produced an incremental cost of $2,681.36 and incremental effectiveness of −0.24 QALY as compared to lobectomy protocol (incremental cost‐effectiveness ratio ICER = −$11,188.85/QALY). Sensitivity analysis demonstrated that total thyroidectomy becomes a cost‐effective strategy only if the risk of stages III and IV PTC is 82.4% among patients with suspicious PTC on preoperative FNA. Lobectomy is cost effective and preferred over total thyroidectomy as long as lobectomy complications are less than 50%.
Conclusions
Total thyroidectomy is not just cost prohibitive but also associated with a lower effectiveness compared to lobectomy.
Level of Evidence
2c Laryngoscope, 2020
Our study aims to explore the differential impact of this pandemic on clinical presentations and outcomes in African Americans (AAs) compared to white patients.
AAs have worse outcomes compared to ...whites while facing heart diseases, stroke, cancer, asthma, influenza and pneumonia, diabetes, and HIV/AIDS. However, there is no current study to show the impact of COVID-19 pandemic on the AA communities.
This is a retrospective study that included patients with laboratory-confirmed COVID-19 from 2 tertiary centers in New Orleans, LA. Clinical and laboratory data were collected. Multivariate analyses were performed to identify the risk factors associated with adverse events.
A total of 157 patients were identified. Of these, 134 (77%) were AAs, whereas 23.4% of patients were Whites. Interestingly, AA were younger, with a mean age of 63 ± 13.4 compared to 75.7 ± 23 years in Whites (P < 0.001). Thirty-seven patients presented with no insurance, and 34 of them were AA. SOFA Score was significantly higher in AA (2.57 ± 2.1) compared to White patients (1.69 ± 1.7), P = 0.041. Elevated SOFA score was associated with higher odds for intubation (odds ratio = 1.6, 95% confidence interval = 1.32-1.93, P < 0.001). AA had more prolonged length of hospital stays (11.1 ± 13.4 days vs 7.7 ± 23 days) than in Whites, P = 0.01.
AAs present with more advanced disease and eventually have worse outcomes from COVID-19 infection. Future studies are warranted for further investigations that should impact the need for providing additional resources to the AA communities.
The aim of this study was to evaluate the related change in outcomes (mortality, complications) in patients undergoing trauma laparotomy (TL) with the implementation of damage control resuscitation ...(DCR). We hypothesized that the implementation of DCR in patients undergoing TL is associated with better outcomes.
We analyzed 1,030 consecutive patients with TL. Patients were stratified into three phases: pre-DCR (2006-2007), transient (2008-2009), and post-DCR (2010-2013). Resuscitation fluids (crystalloids and blood products), injury severity score (ISS), vital signs, and laboratory (hemoglobin, international normalized ratio, lactate) parameters were recorded. Regression analysis was performed after adjusting for age, ISS, laboratory and vital parameters, comorbidities, and resuscitation fluids to identify independent predictors for outcomes in each phase.
Patient demographics and ISS remained the same throughout the three phases. There was a significant reduction in the volume of crystalloid (p = 0.001) and a concomitant increase in the blood product resuscitation (p = 0.04) in the post-DCR phase compared to the pre-DCR and transient DCR phases. Volume of crystalloid resuscitation was an independent predictor of mortality in the pre-DCR (OR 95% CI: 1.071 1.03-1.1, p = 0.01) and transient (OR 95% CI: 1.05 1.01-1.14, p = 0.01) phases; however, it was not associated with mortality in the post-DCR phase (OR 95% CI:1.01 0.96-1.09, p = 0.1). Coagulopathy (p = 0.01) and acidosis (p = 0.02) were independently associated with mortality in all three phases.
The implementation of DCR was associated with improved outcome in patients undergoing TL. There was a decrease in the use of damage control laparotomy, with a decrease in the use of crystalloid and an increase in the use of blood products.
Prognostic study, level III.
Objective
Minimally invasive parathyroidectomy requires accurate preoperative localization techniques. There is considerable controversy about the effectiveness of selective parathyroid venous ...sampling (sPVS) in primary hyperparathyroidism (PHPT) patients. The aim of this meta‐analysis is to examine the diagnostic accuracy of sPVS as a preoperative localization modality in PHPT.
Methods
Studies evaluating the diagnostic accuracy of sPVS for PHPT were electronically searched in the PubMed, EMBASE, Web of Science, and Cochrane Controlled Trials Register databases. Two independent authors reviewed the studies, and revised quality assessment of diagnostic accuracy study tool was used for the quality assessment. Study heterogeneity and pooled estimates were calculated.
Results
Two hundred and two unique studies were identified. Of those, 12 studies were included in the meta‐analysis. Pooled sensitivity, specificity, and positive likelihood ratio (PLR) of sPVS were 74%, 41%, and 1.55, respectively. The area‐under‐the‐receiver operating characteristic curve was 0.684, indicating an average discriminatory ability of sPVS. On comparison between sPVS and noninvasive imaging modalities, sensitivity, PLR, and positive posttest probability were significantly higher in sPVS compared to noninvasive imaging modalities. Interestingly, super‐selective venous sampling had the highest sensitivity, accuracy, and positive posttest probability compared to other parathyroid venous sampling techniques.
Conclusion
This is the first meta‐analysis to examine the accuracy of sPVS in PHPT. sPVS had higher pooled sensitivity when compared to noninvasive modalities in revision parathyroid surgery. However, the invasiveness of this technique does not favor its routine use for preoperative localization. Super‐selective venous sampling was the most accurate among all other parathyroid venous sampling techniques. Laryngoscope, 2662–2667, 2018
The National Trauma Triage Protocol (NTTP) is an algorithm that guides emergency medical services providers through four decision steps to identify the patients that would benefit from trauma center ...care. The NTTP defines a systolic blood pressure (SBP) of less than 90 mm Hg as one of the criteria for trauma center need. The aim of our study was to determine the impact of substituting SBP of less than 90 mm Hg with shock index (SI) on triage performance.
A 2-year (2011-2012) retrospective analysis of all trauma patients 18 years or older in the National Trauma Databank was performed. Transferred patients, patients dead on arrival, and those with missing data were excluded. Our outcome measure was trauma center need defined by Injury Severity Score greater than 15, need for emergent operation, death in the emergency department, and intensive care unit stay of more than 1 day. Area under the characteristic curve and triage characteristics were compared between SBP of less than 90 mm Hg and SI of more than 1.0. Logistic regression analysis was performed to compare the mortality between patients triaged under current protocol of SBP of less than 90 mm Hg and patients triaged using the new defined protocol (SI >1.0).
A total of 505,296 patients were included. Compared with SBP of less than 90 mm Hg, SI of more than 1.0 had a higher sensitivity (44.4% vs. 41.7%) but lower specificity (80.2% vs. 82.4%). The area under the curve was significantly higher for SI of more than 1.0 (0.623 95% confidence interval, 0.622-.625 vs. 0.620 95% confidence interval, 0.619-0.622). Substituting SBP of less than 90 mm Hg with SI of more than 1.0 resulted in a decrease in undertriage rate of 30,233 patients (5.9%) but an increase in overtriage of only 6,386 patients (1.3%).
Substituting the current criterion of SBP of less than 90 mm Hg in the NTTP with an SI of more than 1.0 results in significant reduction in undertriage rate without causing large increase in overtriage. Because of simplicity of use, better discrimination power, and minimal effect on overtriage rates, future studies should consider exploring the possibility of replacing the current SBP of less than 90 mm Hg criterion with SI of more than 1.0 in the NTTP.
Prognostic study, level III; therapeutic study, level IV.
Management of traumatic brain injury (TBI) is focused on minimizing or preventing secondary brain injury. Remote ischemic conditioning (RIC) is an established treatment modality that has been shown ...to improve patient outcomes in different clinical settings by influencing inflammatory insults. In a clinical trial, RIC showed amelioration of SB100 and neuron-specific enolase. The aim of our study was to further elucidate the mechanisms and outcome when applying RIC in a mouse model of traumatic brain injury.
We subjected 100 male C57BL mice to a closed-skull cortical-controlled impact injury. Two hours after the TBI, the animals were allocated to either the RIC group (n = 50) or the sham group (n = 50). By clamping the exposed femoral artery, we induced RIC by six 4-minute cycles of ischemia and reperfusion. Circulating levels of S100-B, neuron-specific enolase, and glial fibrillary acidic protein were measured at multiple time points. Animals were additionally observed daily for cognition and motor coordination via novel object recognition and rotarod. Brain sections were stained and evaluated for neuronal injury at post-TBI Day 5.
The RIC animals had a significantly higher recognition index than did sham at 24, 48, and 72 hours after intervention. Rotarod latency was higher in the RIC animals compared to the sham animals at all-time points, and statistically significant at 120 hours after intervention. The RIC group demonstrated preserved cognitive function and motor coordination compared to the sham. On hematoxylin and eosin and immunohistochemical staining of brain sections, there was less area of neuronal degeneration and astrocytosis, respectively, in the RIC group compared to the sham group. There was no significant difference in systemic neuronal markers between the RIC and sham animals.
Remote ischemic conditioning 2 hours after injury preserved cognitive functions and motor coordination in a mouse model of TBI. Remote ischemic conditioning can preserve viability of neurons and astrocytes after TBI and has potential as a clinically noninvasive and relatively easy method to improve outcome after TBI.
Therapeutic studies, randomized controlled trial, level I.
Failure to rescue (FTR), defined as death after a major complication in surgical patients, is being used to measure outcomes for quality improvement. Major complications frequently occur in patients ...undergoing damage control laparotomy (DCL). No previous FTR studies have looked specifically into DCL patients. The aim of this study was to examine risk factors of FTR and identify potential areas for targeted quality improvement in DCL patients. A 10-year retrospective review of all consecutive adult trauma patients who underwent DCL at a Level I trauma center was performed. Demographic and clinical variables were examined for association with FTR. Multi-variate regression analysis was performed to identify risk factors of FTR in DCL patients. A total of 199 DCL patients were analyzed. Overall DCL mortality observed was 11.1 per cent (n = 22/199) and overall FTR for the cohort was n = 16/199. FTR represented 72 per cent (n = 16/22) of the total mortality. The significantly increased risk of FTR was associated with older age (P = 0.027), lower initial Glasgow Coma Scale score (P = 0.037), more units of packed red blood cells (P = 0.028), and respiratory complications (P = 0.035). Renal and infectious complications did not significantly increase the risk of FTR in this population. FTR is an important benchmark of quality for trauma patients. This study elucidates potential initial characteristics and complications related to FTR in DCL patients. Efforts in achieving zero death from FTR can potentially improve overall mortality in this subset of patients. Future quality interventions to help minimize FTR should target these specific areas.
Recent studies from Asia have reported the safety and feasibility of robotic-assisted thyroid surgery. In the United States, several small series and case reports have been published, mostly ...regarding treatment of benign disease. The aim of our study is to report the safety and feasibility of robotic surgery for well-differentiated thyroid cancer patients at a North American institution.
We performed a retrospective cohort study using a prospectively collected single-center clinical database at Tulane University Medical Center. We included all well-differentiated thyroid cancer patients who underwent robotic-assisted or conventional cervical approach thyroid surgery with or without lymph node dissections at our institution from January 2015 to June 2017. Patient demographics and perioperative data were collected and analyzed.
A total of 144 surgeries for thyroid cancer were performed; 35 (24.3%) were robotic-assisted. There were no significant differences in estimated blood loss, operative times, complication rates, specimen sizes, positive microscopic margins, number of lymph nodes removed with associated lymph node dissections, patient follow-up duration, or clinical recurrence rates between the two groups. Overall length of stay was shorter for robotic-assisted surgery, at 0.6 ± 0.9 d, versus 1.1 ± 1.2 d for conventional open surgery (P = 0.009). For robotic-assisted surgery, 19 patients (54.3%) were discharged on the day of procedure, and only one patient was admitted as inpatient to the hospital (2.9%).
Robot-assisted thyroid surgery is a safe, feasible, and oncologically sound approach for a select group of well-differentiated thyroid cancer patients. However, long-term studies are needed.
I-131 therapy is a common treatment modality for adults with Graves’ Disease (GD). Utilizing meta-analysis, we examined patient specific factors that predict I-131 therapy failure.
Literature search ...followed PRISMA. Comprehensive Meta-analysis (version 3.0) was used. Mantel-Haenszel test with accompanying risk ratio and confidence intervals evaluated categorical variables. Continuous data was analyzed using inverse variance testing yielding mean difference or standardized mean difference. Decision tree algorithms identified variables of high discriminative performance.
4822 collective patients across 18 studies were included. Male sex (RR = 1.23, 95%CI = 1.08–1.41, p = 0.002), I-131 therapy 6 months after GD diagnosis (RR = 2.10, 95%CI = 1.45–3.04, p < 0.001) and history of anti-thyroid drugs (RR = 2.05, 95%CI = 1.49–2.81, p < 0.001) increased the risk of I-131 therapy failure. Elevated free thyroxine, 24-h radioactive iodine uptake scan ≥60.26% and thyroid volume ≥35.77 mL were also associated with failure.
Patient characteristics can predict the likelihood of I-131 therapy failure in GD. Definitive surgical treatment may be a reasonable option for those patients.
•Patient characteristics can predict the likelihood of I-131 therapy failure.•I-131 uptake of ≥60.26% and thyroid volume ≥35.77 mL are therapy failure predictors.•Radioactive iodine dose has no significant association with treatment outcome.
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