A New Disease Severity Score for Measuring Treatment Response to Adrenalectomy in Patients with Primary Aldosteronism.

OBJECTIVE: Cure after adrenalectomy for primary aldosteronism has been reported in only 15-40% of patients, with no disease severity score available to measure response objectively. Furthermore, the criteria used to define cure are outdated. This study aims to determine the rate of cure based on the current definition of normal blood pressure and develop a disease severity score to measure clinical improvement after adrenalectomy for primary aldosteronism. METHODS: This was a retrospective single-center study that included patients who underwent adrenalectomy for primary aldosteronism between 2000 and 2023. Blood pressure, a defined daily dose of antihypertensives, and potassium supplementation were incorporated into a new Primary Aldosteronism Disease Severity Score (PADSS), which was calculated with preoperative and 6-month postoperative parameters. RESULTS: The study included 201 patients. Adrenalectomy was guided by adrenal venous sampling in 86.1% of patients. The cure rate per the new definition of normal blood pressure was 7.5% (n=15). The median PADSS was 16.3 [13.6-19.9] preoperatively and decreased to 10 [4.5-13.3] postoperatively. An improvement of the PADSS was observed in 90% (n=180) of patients at six months of adrenalectomy. The median rate of improvement in PADSS was 33.3% [13.8%-56.6%]. CONCLUSIONS: Although complete cure rates are low after adrenalectomy in primary aldosteronism, especially based on the new definition of normal blood pressure, a clinical improvement is seen in the vast majority of patients postoperatively. The newly introduced primary aldosteronism disease severity score (PADSS) can be used to assess the clinical benefit achieved with adrenalectomy.

Correlation Between Near-Infrared Autofluorescence Properties and Sestamibi Uptakes of Parathyroid Glands in Primary Hyperparathyroidism.

OBJECTIVE: Near-infrared autofluorescence (NIRAF) characteristics of parathyroid glands in primary hyperparathyroidism (pHPT) vary, with unclarity regarding the underlying mechanism. Similarly, 99mTc-sestamibi uptake in diseased parathyroid glands is variable. There is a suggestion that oxyphilic cell content may influence both imaging modalities. This study aims to analyze the relationship between NIRAF imaging characteristics, 99mTc-sestamibi uptake, and cellular composition in pHPT. STUDY DESIGN: Retrospective analysis of an Institutional Review Board-monitored prospective database. SETTING: Single tertiary referral center. METHODS: NIRAF characteristics of parathyroid glands of patients with pHPT between 2019 and 2024 were compared with 99mTc-sestamibi scan findings from a prospective database. Using third-party software, brightness intensity and heterogeneity index (HI) of the glands were calculated. A subgroup of parathyroid glands obtained from consecutive patients with pHPT in 2020 to 2021 underwent histological analysis. RESULTS: A total of 428 patients with 638 diseased parathyroid glands were analyzed. Forty-seven percent of the glands showed an uptake on 99mTc-sestamibi scans. The brightness intensity of the NIRAF signals from parathyroid glands that were seen versus not seen on sestamibi was 2.1 versus 2.3 (P = .002) and HI 0.18 versus 0.17 (P = .35), respectively. On multivariate analysis, low autofluorescence intensity, high gland volume, and single adenoma were associated with detectability on 99mTc-sestamibi scan (P < .0001). Intraglandular adipose tissue content was lower in diseased glands that were detected on 99mTc-sestamibi scans (0% vs 5%, P < .0001). CONCLUSION: Our findings indicate an inverse relationship between autofluorescence intensity and detectability on 99mTc-sestamibi scans and a lack of correlation between different cell types and autofluorescence properties.

The use of artificial intelligence to detect parathyroid tissue on ex vivo specimens during thyroidectomy and parathyroidectomy procedures using near-infrared autofluorescence signals.

BACKGROUND: In thyroidectomy and parathyroidectomy procedures, diagnostic dilemmas related to whether an index tissue is of parathyroid or nonparathyroid origin frequently arise. Current options of frozen section and parathyroid aspiration are time-consuming. Parathyroid glands appear brighter than surrounding tissues on near-infrared autofluorescence imaging. The aim of this study was to develop an artificial intelligence model differentiating parathyroid tissue on surgical specimens based on near-infrared autofluorescence. METHODS: With institutional review board approval, an image library of ex vivo specimens obtained in thyroidectomy and parathyroidectomy procedures was created between November 2019 and April 2023 at a single academic center. Ex vivo autofluorescence images of surgically removed parathyroid glands, thyroid glands, lymph nodes, and thymic tissue were uploaded into an artificial intelligence platform. Two different models were trained, with the first model using autofluorescence images from all specimens, including thyroid, and the second model excluding thyroid, to prevent the effect of specimen size on the results. Deep-learning models were trained to detect autofluorescence signals specific to parathyroid glands. Randomly chosen 80% of data were used for training, 10% for validation, and 10% for testing. Recall, precision, and area under the curve of models were calculated. RESULTS: Surgical procedures included 377 parathyroidectomies, 239 total thyroidectomies, 97 thyroid lobectomies, and 32 central neck dissections. For the development of the model, 1151 images from a total of 678 procedures were used. The dataset comprised 648 parathyroid, 379 thyroid, 104 lymph node, and 20 thymic tissue images. The overall precision, recall, and area under the curve of the model to detect parathyroid tissue were 96.5%, 96.5%, and 0.985, respectively. False negatives were related to dark and large parathyroid glands. CONCLUSION: The visual deep-learning model developed to identify parathyroid tissue in ex vivo specimens during thyroidectomy and parathyroidectomy demonstrated a high sensitivity and positive predictive value. This suggests potential utility of near-infrared autofluorescence imaging to improve intraoperative efficiency by reducing the need for frozen sections and parathyroid hormone aspirations to confirm parathyroid tissue.

Near-Infrared Autofluorescence Signature: A New Parameter for Intraoperative Assessment of Parathyroid Glands in Primary Hyperparathyroidism.

BACKGROUND: The success of parathyroidectomy in primary hyperparathyroidism depends on the intraoperative differentiation of diseased from normal glands. Deep learning can potentially be applied to digitalize this subjective interpretation process that relies heavily on surgeon expertise. In this study, we aimed to investigate whether diseased versus normal parathyroid glands have different near-infrared autofluorescence (NIRAF) signatures and whether related deep learning models can predict normal versus diseased parathyroid glands based on intraoperative in-vivo images. STUDY DESIGN: This prospective study included patients who underwent parathyroidectomy for primary hyperparathyroidism or thyroidectomy using intraoperative NIRAF imaging at a single tertiary referral center from November 2019 to March 2024. Autofluorescence intensity and heterogeneity index of normal versus diseased parathyroid glands were compared, and a deep learning model was developed. RESULTS: NIRAF images of a total of 1,506 normal and 597 diseased parathyroid glands from 797 patients were analyzed. Normal versus diseased glands exhibited a higher median normalized NIRAF intensity [2.68 (2.19-3.23) vs 2.09 (1.68-2.56) pixels, p<.0001] and lower heterogeneity index [0.11 (0.08-0.15) vs 0.18 (0.13-0.23), p<.0001]. On receiver operating characteristics analysis, optimal thresholds to predict a diseased gland were 2.22 in pixel intensity and 0.14 in heterogeneity index. On deep learning, precision and recall of the model were 83.3% each, and area under the precision-recall curve (AUPRC) was 0.908. CONCLUSIONS: Normal and diseased parathyroid glands in primary hyperparathyroidism have different intraoperative NIRAF patterns that could be quantified with intensity and heterogeneity analyses. Visual deep learning models relying on these NIRAF signatures could be built to assist surgeons in differentiating normal from diseased parathyroid glands.

A Comparison of Near-Infrared Autofluorescence Findings in Benign Versus Malignant Adrenal Tumors.

BACKGROUND: Many adrenal tumors are deemed radiologically indeterminate and surgically removed. Adrenal tissue, like parathyroid glands, exhibits near-infrared autofluorescence (NIRAF) properties. This study was designed to investigate the potential of NIRAF to differentiate benign versus malignant adrenal tumors. METHODS: Patients undergoing adrenalectomy between October 2021 and May 2023 were prospectively studied. Adrenalectomy specimens were inspected with NIRAF imaging. Specimen autofluorescence (AF) characteristics were recorded. Comparisons were made between different tumor types and a logistic regression model was constructed to differentiate benign versus malignant tumors. A receiver operating characteristic curve was used to identify an optimal AF threshold differentiating benign versus malignant tumors. RESULTS: A total of 108 adrenal specimens were examined: adrenocortical adenomas/other benign lesions (n = 72), pheochromocytomas (n = 18), adrenocortical neoplasms of uncertain behavior (n = 4), and malignant tumors (n = 14). A significant difference in normalized AF intensity was identified when comparing adrenocortical adenomas (3.08 times background) with pheochromocytomas (1.95, p = 0.001) and malignant tumors (1.11, p < 0.0001). The Area Under the Curve differentiating benign vs malignant tumors was 0.87, with an optimal normalized AF threshold at 1.93. CONCLUSIONS: Different adrenal pathologies exhibit diverse AF properties. These findings suggest a potential intraoperative utility of NIRAF in predicting benign versus malignant nature for radiologically indeterminate adrenal tumors.

A comparison of three different microwave systems for laparoscopic liver tumor ablation.

BACKGROUND: Our aim was to perform a comparison of three current microwave ablation (MWA) systems widely used for laparoscopic liver ablations in terms of ablation kinetics and geometry of ablation zones. METHODS: This was a retrospective, institutional review board-approved study comparing Emprint, Emprint HP, and NeuWave systems for laparoscopic liver ablation. Analyses were performed via Mann-Whitney U and χ2 tests. Continuous data are presented as median (interquartile range). RESULTS: For Emprint, Emprint HP, and NeuWave groups, tumor size was 1.16 (0.8), 1.21 (0.7), and 1.27 (0.9) cm (p = 0.54). Ablation time per lesion was 7 (6), 4 (2.8), and 4 (3.3) min (p < 0.0001), yielding similar ablation zone volumes and margins. The time to first ablation bubble was 1 (0.13), 1.5 (0.85), and 0.75 (0.5) min, and total ablation times were 7 (4.4), 4 (2), and 3.5 (2.8) min (p < 0.0001). The roundness index A, B, and transverse were 0.94, 0.98, and 0.79; 0.95, 0.95, and 0.78; and 1.02, 0.95, and 0.96. CONCLUSIONS: Although a saline-cooling system with Emprint system allowed for larger diameter spherical ablation zones to be created, it led to decreased efficiency compared to the CO2-cooled NeuWave system, which exposes the active antenna directly to tissue. Increased power delivered by Emprint HP improved the efficiency of saline-cooled design, as demonstrated by faster ablation times.

Assessing the efficacy of thyroid nodule radiofrequency ablation using patient-reported outcome measures.

BACKGROUND: Radiofrequency ablation has recently emerged as an alternative treatment for thyroid nodules. Most studies are centered on volume reduction, whereas a few have assessed symptom improvement mainly with nonstandardized metrics. As experience in the United States is growing, we aim to assess the efficacy of radiofrequency ablation in treating benign thyroid nodules using the validated Patient-Reported Outcomes Measurement for Parathyroid and Thyroid Disease. METHODS: This is a prospective study of a newly established radiofrequency ablation program at a single tertiary referral center in 2022. Patients who underwent radiofrequency ablation were evaluated using the Patient-Reported Outcomes Measurement for Parathyroid and Thyroid Disease, a validated metric ranging from 0 to 100 at baseline, 2 weeks, 3 months, and 6 months. In addition, a thyroid ultrasound was done at those intervals to assess size and volume reduction. Procedure complications were evaluated as well. RESULTS: A total of 25 patients underwent radiofrequency ablation during the study period for a total of 32 nodules treated; 84% were female with a mean age of 51 years. The baseline mean nodule volume and largest dimension were 13 ± 11 mL and 3.4 ± 1 cm, respectively. A significant change in the Patient-Reported Outcomes Measurement for Parathyroid and Thyroid Disease compressive score was seen at 3 months (38.9 ± 26.4 to 21.0 ± 21.4; P = .004) and 6 months (32.7 ± 19.9 to 17.5 ± 21.0; P = .02) but not at 2 weeks (41.0 ± 22.7 to 36.1 ± 21.9; P = .28). Significant volume and size reductions were seen at all 3-time points. Two complications occurred. CONCLUSION: Our initial results of the thyroid radiofrequency ablation program find that it effectively alleviates symptoms by reducing nodule size in patients with symptomatic benign thyroid nodules.

Comparison of Perioperative Outcomes in Patients with Graves' Disease Undergoing Total Thyroidectomy With or Without Near Infrared Autofluorescence Imaging.

Background: The impact of near-infrared autofluorescence (NIRAF) imaging on postthyroidectomy hypocalcemia is controversial. As patients with Graves' disease are at increased risk, our aim was to compare postoperative parathyroid function in these patients undergoing total thyroidectomy (TT) with or without NIRAF imaging. Methods: This was a retrospective "before and after" study, comparing outcomes of patients who underwent TT without or with NIRAF imaging at a single center. Primary outcome was the incidence of temporary hypocalcemia and secondary outcomes, rates of incidental parathyroidectomy on final specimens and permanent hypocalcemia. Analyses were performed using Mann-Whitney U and chi-Square tests. Continuous data are expressed as median (interquartile range). Results: There were 85 patients in NIRAF and 100 patients in non-NIRAF group. Groups were comparable regarding age, gender, body-mass index, and thyroid weight. Number of parathyroid glands identified intraoperatively was 3 in both groups (p = 0.47). Intraoperative parathyroid implantation rate was 16.5% in NIRAF and 6% in non-NIRAF group (p = 0.02). Incidental parathyroidectomy rate on final pathology was 12.9% in NIRAF and 32% in non-NIRAF group (p = 0.002). The rates of temporary (11.7% vs. 16%) and permanent hypocalcemia (2.4% vs. 2%) were similar between the two groups, respectively (p = 0.66). Conclusion: To our knowledge, this is the first comparative study investigating the impact of NIRAF on postoperative parathyroid function after thyroidectomy for Graves' disease. The rate of incidental parathyroidectomy on final pathology was lower with use of NIRAF, without an impact on temporary or permanent hypocalcemia rates compared to conventional technique.

Laparoscopic versus robotic lateral transabdominal adrenalectomy.

BACKGROUND AND OBJECTIVES: Despite an increased adaptation of robotic adrenalectomy, its advantages over laparoscopic adrenalectomy (LA) have not been defined. The aim of the study was to compare perioperative outcomes of robotic versus laparoscopic lateral transabdominal adrenalectomy using a large single-center experience. METHODS: This was a retrospective single center study. Within 22 years, patients who underwent laparoscopic and robotic transabdominal lateral adrenalectomy were identified from a prospective institutional review board-approved database. Clinical and perioperative outcomes were compared using Mann-Whitney U and χ2  tests. RESULTS: There were 190 patients who underwent laparoscopic and 281 patients who underwent robotic transabdominal lateral adrenalectomy. The groups were comparable except for a higher percentage of female patients in the robotic group. For robotic versus LA, operative time and hospital stay were shorter, in addition to less blood loss, conversion to open and margin positivity, for pheochromocytoma and malignant tumors. Morbidity rates were similar between the two groups. CONCLUSIONS: Despite the limitations of a retrospective design, this large study demonstrates significant advantages of robotic versus laparoscopic transabdominal lateral adrenalectomy in terms of perioperative outcomes and margin clearance.

Three reasons why parental burnout is more prevalent in individualistic countries: a mediation study in 36 countries.

PURPOSE: The prevalence of parental burnout, a condition that has severe consequences for both parents and children, varies dramatically across countries and is highest in Western countries characterized by high individualism. METHOD: In this study, we examined the mediators of the relationship between individualism measured at the country level and parental burnout measured at the individual level in 36 countries (16,059 parents). RESULTS: The results revealed three mediating mechanisms, that is, self-discrepancies between socially prescribed and actual parental selves, high agency and self-directed socialization goals, and low parental task sharing, by which individualism leads to an increased risk of burnout among parents. CONCLUSION: The results confirm that the three mediators under consideration are all involved, and that mediation was higher for self-discrepancies between socially prescribed and actual parental selves, then parental task sharing, and lastly self-directed socialization goals. The results provide some important indications of how to prevent parental burnout at the societal level in Western countries.

Comparison of incidental parathyroid tissue detection rates on pathology after total thyroidectomy performed with or without near-infrared autofluorescence imaging.

BACKGROUND: Near-infrared autofluorescence imaging is an adjunct to parathyroid identification. As it does not show perfusion, it is important to study its impact during thyroidectomy by measuring quantifiable data on parathyroid detection rather than function. The aim of this study was to compare incidental parathyroidectomy rates in patients undergoing total thyroidectomy with or without near-infrared autofluorescence. METHODS: Retrospective study of patients who underwent total thyroidectomy between 2014 and 2022 at one center. Clinical parameters, including rates of incidental parathyroid tissue on pathology reports, were compared between near-infrared autofluorescence and non-near-infrared autofluorescence groups. Near-infrared autofluorescence was used to guide dissection (identification) and/or to confirm tissue as parathyroid (confirmation). Statistical analysis was done with Wilcoxon rank sum test and χ2 analysis. RESULTS: There were 300 patients in the near-infrared autofluorescence and 750 patients in the non-near-infrared autofluorescence group. The rate of incidental parathyroid tissue detection on final pathology was 13.3% (n = 40) in the near-infrared autofluorescence and 23.2% (n = 174) in the non-near-infrared autofluorescence group (P < .001). The rate of incidental parathyroid tissue detected on pathology with near-infrared autofluorescence decreased when used for identification and confirmation of parathyroid tissue (30.0% to 13.4%, P < .001), but not when used for confirmation only (19.6% to 18.5%, P = .89). Impact of near-infra red autofluorescence in decreasing the rate of incidental parathyroid tissue was more profound for early (38.5% to 17.1%) versus mid-late career surgeons (20% to 13%). CONCLUSION: Our results suggest that the use of near-infrared autofluorescence may help decrease the rate of incidental parathyroid tissue detected on final pathology if used for both identification and confirmation of parathyroid glands during thyroidectomy.

The utility of fluorescence imaging in detecting primary and metastatic small bowel carcinoid tumors.

BACKGROUND: Our aim was to investigate utility of indocyanine green (ICG) and autofluorescence (AF) imaging in detection of small bowel primary and metastatic carcinoids. METHODS: Using Institutional Review Board approval, ICG and AF imaging of small bowel carcinoids was performed. Imaging findings were prospectively recorded in operating room and compared with conventional imaging, surgical exploration and pathologic findings. RESULTS: There were 16 patients with 23 primary small bowel tumors, 27 mesenteric lymph nodes, 36 liver metastases and 2 peritoneal nodules. Carcinoid tumors exhibited brighter AF signals compared to background. AF imaging was superior to both DOTATATE PET and surgeon inspection/palpation in demonstrating small bowel primaries. Utility for metastatic lymph nodes and peritoneal metastases was limited. Superficial liver metastases exhibited brighter fluorescence compared to background on both ICG and AF imaging. CONCLUSIONS: This is the largest study assessing utility of near-infrared fluorescence imaging in detection of small bowel carcinoids. Our results show promise in the utilization fluorescence imaging to detect occult primary tumors and superficial liver metastases.

Parental Burnout Around the Globe: a 42-Country Study.

High levels of stress in the parenting domain can lead to parental burnout, a condition that has severe consequences for both parents and children. It is not yet clear, however, whether parental burnout varies by culture, and if so, why it might do so. In this study, we examined the prevalence of parental burnout in 42 countries (17,409 parents; 71% mothers; Mage = 39.20) and showed that the prevalence of parental burnout varies dramatically across countries. Analyses of cultural values revealed that individualistic cultures, in particular, displayed a noticeably higher prevalence and mean level of parental burnout. Indeed, individualism plays a larger role in parental burnout than either economic inequalities across countries, or any other individual and family characteristic examined so far, including the number and age of children and the number of hours spent with them. These results suggest that cultural values in Western countries may put parents under heightened levels of stress. Supplementary Information: The online version contains supplementary material available at 10.1007/s42761-020-00028-4.

Validation of the Turkish version of the Parental Burnout Assessment (PBA).

Parental Burnout (PB) is an exhaustion syndrome resulting from exposure to overwhelming parenting stress. The current gold-standard instrument, namely, Parental Burnout Assessment (PBA) was used in the International Investigation of Parental Burnout (IIPB), a 40-country study of the prevalence of PB around the world. The IIPB study has stimulated worldwide interest, but efforts are still needed to validate the PBA in different cultures. This study is the first on PB in a collectivist, predominantly Islamic country. It aims to examine the psychometric properties of the Turkish translation of the PBA. The PBA-Turkish was administered to 452 Turkish parents (60% mothers). The results showed that the PBA is a relevant construct in Turkish culture. We replicated the original four-factor structure of the PBA and tested a second-order factor structure through confirmatory factor analyses. The first- and second-order factor models fit the data well. The Emotional Distancing subscale, however, demonstrated lower reliability than the other subscales. We then attained measurement invariance across genders in a set of nested models with gradually increasing parameter constraints. Finally, non-working and single parents reported higher PB, pointing to the possible role of relationships and support as protective factors for Turkish parents.