Development of a novel nomogram to predict the risk of severe compensatory sweating following endoscopic thoracic sympathectomy.

BACKGROUNDS: Endoscopic thoracic sympathectomy (ETS) is a permanent and effective treatment for primary hyperhidrosis and facial blushing; however, severe compensatory sweating (SCS) remains a devastating complication. We aimed to (i) construct a nomogram to predict the risk of SCS, and (ii) investigate factors associated with the level of satisfaction. METHODS: From Jan 2014 to Mar 2020, 347 patients underwent ETS by a single surgeon. These patients were asked to complete an online questionnaire regarding primary symptom resolution, level of satisfaction, and development of compensatory sweating. Multivariable analysis was conducted via logistic regression and ordinal regression to predict SCS and satisfaction level respectively. Nomogram was developed based on significant predictors. RESULTS: In total, 298 (85.9%) patients responded to the questionnaire with a mean follow up of 4.9 ± 1.8 years. Significant factors associated with SCS in the nomogram included older age (OR 1.05, 95% CI 1.02-1.09, P = 0.001), primary indication other than palmar hyperhidrosis (OR 2.30, 95% CI 1.03-5.12, P = 0.04), and current smoking (OR 5.91, 95% CI 2.46-14.20, P < 0.001). The area under receiver operating characteristic curve was 0.713. Multivariable analysis revealed that longer follow up (ß = -0.201 ± 0.078, P = 0.01), gustatory hyperhidrosis (ß = -0.781 ± 0.267, P = 0.003), primary indication other than palmar hyperhidrosis (ß = -1.524 ± 0.292, P < 0.001), and SCS (ß = -3.061 ± 0.404, P < 0.001) were independently associated with a lower degree of patient satisfaction. CONCLUSION: The novel nomogram can provide a personalized numerical risk estimate to assist both the clinician and patient weigh the pros and cons as part of the decision-making process, mitigating the chance of patient dissatisfaction.

Twenty-year perspective on blunt traumatic diaphragmatic injury in level 1 trauma centre: Early versus delayed diagnosis injury patterns and outcomes.

OBJECTIVE: Blunt traumatic diaphragmatic injury (TDI) is typically associated with severe trauma and concomitant injuries. It is a diagnostic challenge in the setting of blunt trauma and can be easily overlooked especially in the acute phase often dominated by concurrent injuries. METHODS: A retrospective review was conducted of patients with blunt-TDI identified from a level 1 trauma registry. Variables associated with early versus delayed diagnosis as well as non-survivor and survivor groups were collected to examine factors associated with delayed diagnosis. RESULTS: A total of 155 patients were included (mean age 46 ± 20, 60.6% male). Diagnosis was made <24 h in 126 (81.3%), and >24 h in 29 (18.7%). Of the delayed diagnosis group, 14 (48%) were diagnosed >7 days. Overall, 27 (21.4%) patients had a diagnostic initial CXR and 64 (50.8%) had a diagnostic initial CT. Fifty-eight (37.4%) patients were diagnosed intraoperatively. Of the delayed diagnosis group, 22 (75.9%) had no initial signs on CXR or CT, 15 (52%) of this group had persistent pleural-effusions/elevated-hemidiaphragm leading to further investigation and diagnosis. No significant difference in survival was observed between early and delayed diagnoses, no clinically significant injury patterns to predict delayed diagnoses were noted. CONCLUSION: The diagnosis of TDI is challenging. Without frank signs of herniation of abdominal contents on CXR or CT, the diagnosis is often not made on initial imaging. In patients with the evidence of blunt traumatic injury in the lower-chest/upper-abdomen, a high degree of clinical suspicion should be held and follow-up CXRs/CTs arranged.

A systematic review of dengue outbreak prediction models: Current scenario and future directions.

Dengue is among the fastest-spreading vector-borne infectious disease, with outbreaks often overwhelm the health system and result in huge morbidity and mortality in its endemic populations in the absence of an efficient warning system. A large number of prediction models are currently in use globally. As such, this study aimed to systematically review the published literature that used quantitative models to predict dengue outbreaks and provide insights about the current practices. A systematic search was undertaken, using the Ovid MEDLINE, EMBASE, Scopus and Web of Science databases for published citations, without time or geographical restrictions. Study selection, data extraction and management process were devised in accordance with the 'Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies' ('CHARMS') framework. A total of 99 models were included in the review from 64 studies. Most models sourced climate (94.7%) and climate change (77.8%) data from agency reports and only 59.6% of the models adjusted for reporting time lag. All included models used climate predictors; 70.7% of them were built with only climate factors. Climate factors were used in combination with climate change factors (13.4%), both climate change and demographic factors (3.1%), vector factors (6.3%), and demographic factors (5.2%). Machine learning techniques were used for 39.4% of the models. Of these, random forest (15.4%), neural networks (23.1%) and ensemble models (10.3%) were notable. Among the statistical (60.6%) models, linear regression (18.3%), Poisson regression (18.3%), generalized additive models (16.7%) and time series/autoregressive models (26.7%) were notable. Around 20.2% of the models reported no validation at all and only 5.2% reported external validation. The reporting of methodology and model performance measures were inadequate in many of the existing prediction models. This review collates plausible predictors and methodological approaches, which will contribute to robust modelling in diverse settings and populations.

Hypotension in Posterior Retroperitoneoscopic Versus Transperitoneal Laparoscopic Adrenalectomy.

INTRODUCTION: Despite preoperative optimization, hemodynamic instability can be a major challenge during adrenalectomy. Even brief episodes of intraoperative hypotension can be associated with ischemia-reperfusion injury. This study aimed to compare intraoperative hemodynamic parameters between posterior retroperitoneoscopic adrenalectomy (PRA) and transperitoneal laparoscopic adrenalectomy (TPA). METHODS: This is a retrospective study of patients undergoing PRA and TPA without conversion or concomitant intraabdominal pathology from 2008 to 2019. The primary outcome was intraoperative hypotension defined by mean arterial pressure <60 mm Hg or the need for ≥1 intravenous vasopressors at least 30 min after anesthetic induction. RESULTS: Overall, 108 patients met the inclusion criteria; 33 (30.6%) had pheochromocytoma, 26 (24.1%) had aldosterone excess, 8 (7.4%) had corticosteroid excess, and 41 (38.0%) had nonfunctioning adrenal tumors. Of these, 68 (63.0%) underwent PRA and 40 (37.0%) underwent TPA. Age, sex, body mass index, preinduction blood pressure, number of preoperative antihypertensives, and histopathological diagnosis were similar in the two groups. Tumor size was greater in the TPA group. The presence of pheochromocytoma was an independent risk factor for hypotension. Multivariate analysis revealed that PRA was associated with a higher risk of experiencing a mean arterial pressure <60 mm Hg (odds ratio 4.44, 95% confidence interval 1.27-15.54, P = 0.02) and the need for ≥1 intravenous vasopressors (odds ratio 9.97, 95% confidence interval 3.34-29.78, P < 0.001) compared with TPA. CONCLUSIONS: Although PRA offers several advantages over TPA, it carries a greater risk of intraoperative hypotension. A prospective trial is required to validate these findings. Nevertheless, institution of risk reduction strategies is encouraged to be considered for individuals undergoing PRA.

Less extensive surgery for low-risk papillary thyroid cancers post 2015 American Thyroid Association guidelines in an Australian tertiary centre.

INTRODUCTION: The 2015 American Thyroid Association guidelines (ATA15) consider hemithyroidectomy (HT) a viable treatment option for low-risk papillary thyroid cancers (PTCs) between 1 and 4 cm. We aimed to examine the impact of ATA15 in a high-volume Australian endocrine surgery unit. METHODS: A retrospective study of all patients undergoing thyroidectomy from January 2010 to December 2019. INCLUSION CRITERIA: PTC histopathology, Bethesda V-VI, size 1-4 cm, and absence of clinical evidence of lymph node or distant metastases pre-operatively. Primary outcome was rate of HT before and after ATA15. RESULTS: Of 5408 thyroidectomy patients, 339 (6.3%) met the inclusion criteria - 186 (54.9%) pre-ATA15 (2010-2015) and 153 (45.1%) post-ATA15 (2016-2019). The patient groups were similar; there were no significant differences between groups in age, sex, tumour size, proportion with Bethesda VI cytology, compressive symptoms, or thyrotoxicosis. Post-ATA15, there was a significant increase in HT rate from 5.4% to 19.6% (P = 0.0001). However, there was no corresponding increase in completion thyroidectomy (CT) rate (50.0% versus 27.6%, P = 0.2). The proportion managed with prophylactic central neck dissection (pCND) fell from 80.5% to 10.8% (P < 0.0001). Pre-ATA15, the only factor significantly associated with HT was Bethesda V. In contrast, post-ATA15, HT was more likely in patients with younger age, smaller tumours, and Bethesda V. CONCLUSION: After the release of 2015 ATA guidelines, we observed a significant increase in HT rate and a significant decrease in pCND rate for low-risk PTCs in our specialised thyroid cancer unit. This reflects a growing clinician uptake of a more conservative approach as recommended by ATA15.

Anti-Thyroid Antibodies and TSH as Potential Markers of Thyroid Carcinoma and Aggressive Behavior in Patients with Indeterminate Fine-Needle Aspiration Cytology.

BACKGROUND: Indeterminate fine-needle aspiration cytology (FNAC) imposes challenges in the management of thyroid nodules. This study aimed to examine whether preoperative anti-thyroid antibodies (Abs) and TSH are indicators of thyroid malignancy and aggressive behavior in patients with indeterminate FNAC. METHODS: This was a retrospective study of thyroidectomy patients from 2008 to 2016. We analyzed Abs and TSH levels, FNAC, and histopathology. Serum antibody levels were categorized as 'Undetectable', 'In-range' if detectable but within normal range, and 'Elevated' if above upper limit of normal. 'Detectable' levels referred to 'In-range' and 'Elevated' combined. RESULTS: There were 531 patients included. Of 402 patients with preoperative FNAC, 104 (25.9%) had indeterminate cytology (Bethesda III-V). Of these, 39 (37.5%) were malignant and 65 (62.5%) benign on histopathology. In the setting of indeterminate FNAC, an increased risk of malignancy was associated with 'Elevated' thyroglobulin antibodies (TgAb) (OR 7.25, 95% CI 1.13-77.15, P = 0.01) and 'Elevated' thyroid peroxidase antibodies (TPOAb) (OR 6.79, 95% CI 1.23-45.88, P = 0.008). Similarly, while still 'In-range', TSH ≥ 1 mIU/L was associated with an increased risk of malignancy (OR 3.23, 95% CI 1.14-9.33, P = 0.01). In all patients with malignancy, the mean tumor size was 8 mm larger in those with TSH ≥ 1 mIU/L (P = 0.03); furthermore, in PTC patients, 'Detectable' TgAb conferred a 4 × risk of lymph node metastasis (95% CI 1.03-13.77, P = 0.02). CONCLUSION: In this cohort, in indeterminate FNAC patients, Abs and TSH were associated with an increased risk of malignancy. Additionally, TgAb and TSH were potential markers of aggressive biology. As such, they may be diagnostic and prognostic adjuncts.