Influence of Adrenal Venous Sampling on Management in Patients with Primary Aldosteronism Independent of Lateralization on Cross-Sectional Imaging.

BACKGROUND: Patients with primary aldosteronism undergo imaging of the adrenal glands after confirmation of the disease. Adrenal venous sampling (AVS) is a useful adjunct to imaging, and advocates believe that AVS should be performed before surgical management. Others argue that patients with unilateral lesions on imaging do not require AVS. Although AVS accuracy has been established, few studies have evaluated how AVS alters management. Our study aimed to determine how AVS affected management of these patients. STUDY DESIGN: Patient data were collected retrospectively from the electronic medical records at a single institution. Patients aged 18 years or older who underwent AVS with successful adrenal vein cannulation from 2007 to 2016 were included. The laterality of AVS was compared with laterality of preprocedural imaging for each patient. The management plan before AVS was determined by laterality on preprocedural imaging. The primary outcomes were management of primary aldosteronism, change in management compared with the plan before AVS, and antihypertensive medication use after therapy. RESULTS: Seventy-four patients had successful adrenal venous cannulation. Thirty-three (44.6%) patients had AVS lateralization that was concordant with preprocedural imaging. Forty-one (55.4%) patients had AVS lateralization that was non-concordant with preprocedural imaging. There was a change in management in 29 (39.2%) patients. CONCLUSIONS: Adrenal venous sampling can delineate the source of aldosterone hypersecretion, and often this is not concordant with cross-sectional imaging. We found that many patients avoided a potentially non-curative operation due to AVS. Adrenal venous sampling frequently alters the management of aldosteronomas and should be highly considered in patients before surgical intervention.

Third-Year Medical Student Impressions of Resident Teaching in Simulated and Clinical Settings.

We sought to determine whether simulation-based medical education using Trauma Evaluation and Management® (TEAM®) training module contributes to a positive impression of resident and faculty teaching. Qualitative and quantitative data regarding medical students' experience of TEAM® training and their interaction with instructors were collected using anonymous surveys after the completion of the training module. A combination of yes or no responses, as well as classification of student confidence and perceptions on the utility of TEAM® training obtained using Likert-type scales, was evaluated. Qualitative data regarding student perceived strengths and weaknesses of this training and their perception of the quality of teaching were collected and analyzed. Most of the students felt the quality of teaching was better when compared with clinical settings, with 91 per cent of the respondents who provided additional feedback stating that residents were better teachers in the simulated setting. The application of TEAM® training in the surgical clerkship curriculum provides an environment to foster high-quality resident-led education.

Hispanic ethnicity and complication profile following laparoscopic and open cholecystectomy.

BACKGROUND: Hispanic ethnicity is associated with increased incidence of gallbladder disease. Additionally, ethnicity has been shown to be an outcome determinant in several conditions and procedures but has never been studied as a potential determinant of morbidity or mortality after laparoscopic or open cholecystectomy. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program database, patients who underwent cholecystectomy and related procedures were studied in Hispanic and non-Hispanic cohorts. Mortality and postoperative complication rates were calculated and adjusted for patient demographics and comorbidities through multivariate analysis. RESULTS: Hispanics had decreased morbidity following cholecystectomy as compared to non-Hispanics on univariate analysis in combined, laparoscopic, and open cohorts (RR 0.64, P value < 0.001; 0.68, <0.001; 0.77, <0.001, respectively). The reduction was not found to be statistically significant in multivariate analysis. A similar reduction was seen for mortality (RR 0.30, <0.001; 0.39, <0.001; 0.28, <0.001, respectively) which remained on multivariate analysis in both combined and open cohorts (RR 0.63, 0.008 and 0.48, 0.021, respectively). Additionally, the rates of several postoperative complications were found to be reduced in Hispanic patients. Though our study demonstrates a lower rate of established comorbidities for poor outcomes in Hispanics, after adjustment in multivariate analysis, the entirety of the reduced risk could not be accounted for. CONCLUSIONS: While the Hispanic cohort has an increased incidence in gallbladder disease as compared to non-Hispanics, the complication, morbidity, and mortality rates are lower in unadjusted analysis. With adjustment, morbidity was not statistically significant and mortality was only significant in combined and open cohorts. This suggests that increased incidence rates do not equate with worse outcomes, but Hispanic ethnicity may be associated with better outcomes.

Ethnic disparities in traumatic brain injury care referral in a Hispanic-majority population.

BACKGROUND: Functional outcomes after traumatic brain injury (TBI) can be significantly improved by discharge to posthospitalization care facilities. Many variables influence the discharge disposition of the TBI patient, including insurance status, patient condition, and patient prognosis. The literature has demonstrated an ethnic disparity in posthospitalization care referral, with Hispanics being discharged to rehabilitation and nursing facilities less often than non-Hispanics. However, this relationship has not been studied in a Hispanic-majority population, and thus, this study seeks to determine if differences in neurorehabilitation referrals exist among ethnic groups in a predominately Hispanic region. METHODS: This study is a retrospective cohort that includes 1128 TBI patients who presented to University Medical Center El Paso, Texas, between the years 2005 and 2015. The patients' age, sex, race, residence, admission Glasgow Coma Scale (GCS), GCS motor, Injury Severity Score (ISS), hospital and intensive care unit length of stay (LOS), mechanism of injury, and discharge disposition were analyzed in univariate and multivariate models. RESULTS: Our study population had an insurance rate of 55.5%. Insurance status and markers of injury severity (hospital LOS, intensive care unit LOS, ISS, GCS, and GCS motor) were predictive of discharge disposition to rehabilitation facilities. The study population was 70% Hispanic, yet Hispanics were discharged to rehabilitation facilities (relative risk: 0.56, P: 0.001) and to long-term acute care/nursing facilities (relative risk: 0.35, P < 0.0001) less than non-Hispanics even after LOS, ISS, ethnicity, insurance status, and residence were adjusted for in multivariate analysis. CONCLUSIONS: This study suggests that patients of different ethnicities but comparable traumatic severity and insurance status receive different discharge dispositions post-TBI even in regions in which Hispanics are the demographic majority.

American Thyroid Association Scientific Statement on the Use of Potassium Iodide Ingestion in a Nuclear Emergency.

This document serves to summarize the issues and the American Thyroid Association (ATA) position regarding the use of potassium iodide as a thyroid blocking agent in the event of a nuclear accident. The purpose is to provide a review and updated position statement regarding the advanced distribution, stockpiling, and availability of potassium iodide in the event of nuclear radiation emergencies in the United States.

Calcitonin-Negative Neuroendocrine Tumor of the Thyroid.

Neuroendocrine tumors (NETs) of the thyroid are rare; the most common type is medullary thyroid carcinoma (MTC). They are derived from parafollicular cells (C-cells) that usually express calcitonin, chromogranin, and carcinoembryonic antigen. Calcitonin-negative NETs of the thyroid are extremely rare, and the origin of these tumors is unclear. Whereas some believe that these tumors are from follicular cells, recent reports have shown expression of calcitonin gene-related peptide in these tumors, indicating parafollicular C-cell origin. Here, we report a case of calcitonin-negative NET of the thyroid in a 74-year-old woman, with review of the literature.

Management of microcarcinomas (papillary and medullary) of the thyroid.

PURPOSE OF REVIEW: Microcarcinomas of the thyroid gland are defined by the size criteria as tumors measuring less than 1 cm in greatest dimension. The clinical significance of papillary thyroid microcarcinoma (PTMC) and medullary thyroid microcarcinoma (MTMC) is debatable. Variation in practice patterns exist in the United States with regard to diagnosis, treatment, and long-term management. We review the most recent guidelines on the management of these controversial malignancies. RECENT FINDINGS: PTMC has recently been shown to be the most common thyroid malignancy in patients older than 45 years in the United States. The management of patients with PTMC is not well defined, although recent studies have indicated that total or near-total thyroidectomy decreases overall recurrence rate. BRAF mutation testing plays an increasingly important role in perioperative management and has potential for targeted molecular therapies.Prophylactic thyroidectomy is indicated early in life for RET mutation carriers at risk for medullary thyroid cancer. New evidence suggests that timing may be personalized based on specific exon mutations and serum calcitonin levels. The biological significance and surgical management of MTMC have been debated, but the most recent studies indicate a relatively high incidence of lymph node metastases, distant metastases, and persistently elevated postoperative calcitonin; and argue for the aggressive management of even the smallest MTMCs. SUMMARY: Total or near-total thyroidectomy is the treatment of choice in patients with PTMC in order to eradicate multifocal disease and decrease overall recurrence rate. If there are palpable, biopsy-proven, or grossly apparent metastases at the time of operation, central lymphadenectomy should be performed. Prophylactic thyroidectomy in hereditary cases of MTMC may be guided by knowledge of specific exon mutations and calcitonin levels. The extent of operation for both hereditary and sporadic MTMC is nonstandardized, and further studies are needed to clarify this issue.

Neuroendocrine tumors of the pancreas.

PURPOSE OF REVIEW: Pancreatic neuroendocrine tumors (PNETs) are rare tumors, with an incidence of one per 100, 000 individuals per year, and they account for 1-2% of all pancreatic neoplasms. PNETs are a heterogeneous group with varying clinical presentation, tumor biology and prognosis. This article reviews the current diagnostic strategy and treatment armamentarium for PNETs. Special attention is paid to recent and ongoing developments in treatment, particularly with regards to multimodality treatment and newer systemic therapies for unresectable disease. RECENT FINDINGS: There has been significant progress in the genetic understanding of hereditary syndromes in regards to PNETs, as well as in the diagnosis and treatment of resectable and nonresectable PNETs. Whereas surgical therapy remains the most advisable therapy for resectable neuroendocrine tumors of the pancreas, there have been significant recent advances in systemic therapy for those with unresectable disease. Results from recent clinical trials examining mammalian target of rapamycin inhibitors and tyrosine kinase inhibitors for unresectable disease are promising in expanding treatment options for metastatic PNETs. SUMMARY: Neuroendocrine tumors of the pancreas are a heterogeneous group of tumors with varying clinical presentation, tumor biology and prognosis. Clinicians must be aware of the variety of manifestations of this disease, as well as the role of systemic chemotherapy in treatment of unresectable disease.