Assessing potential impact of 2015 American Thyroid Association guidelines on community standard practice for I-131 treatment of low-risk differentiated thyroid cancer: case study of Jordan.

OBJECTIVES: The 2015 American Thyroid Association (ATA) guidelines called for significantly more selective 131I therapy in patients with low-risk differentiated thyroid cancer (DTC). We hypothesized that application of these guidelines would significantly reduce the 131I activity utilized by an academic tertiary hospital in Jordan. METHODS: All DTC patients managed at Jordan University Hospital (JUH) between 1/2009 and 6/2019 were classified according to the 2015 ATA risk category and 131I activity was assigned accordingly. The actual 131I activity administered was compared with that recommended by the 2015 ATA guidelines. RESULTS: In total, 135/182 DTC patients (74.2%) managed at JUH underwent 131I therapy. Of those, 58 (43%) had ATA low-, 58 (43%) intermediate-, and 19 (14%) high-risk disease. The low-, intermediate-, and high-risk DTC patients received an average (±SD) initial 131I activity of 3.53 ± 0.95, 4.40 ± 1.49, and 5.06 ± 2.52 GBq, respectively. Withholding 131I therapy altogether in the 2015 ATA low-risk patients would result in decreasing the 131I activity in the overall patient population by 37%. Withholding 131I therapy only in low-risk papillary thyroid microcarcinomas while administering 1.11 GBq of 131I to other low-risk patients would result in 28% reduction of 131I. CONCLUSION: This study demonstrates a significant reduction in 131I therapeutic activity that would be given to DTC patients in an academic tertiary setting in Jordan, following acceptance of the 2015 ATA recommendations. Institutions that adopted the 2015 ATA guidance should measure outcomes in comparison to their historical controls and report those findings, while long-term results of randomized controlled trials are forthcoming.

Development and validation of a scale to measure the gross anatomy preparedness of medical graduates / Desarrollo y validación de una escala para medir la preparación anatómica general de los graduados médicos

SUMMARY: Postgraduate refresher courses may address deficiencies in the gross anatomy preparedness of medical graduates. However, the literature does not offer a method to identify such deficiencies. Our aim is to develop and validate a scale to measure the gross anatomy preparedness of medical graduates. First, we defined gross anatomy preparedness (the construct) as "the benchmark of personal ability in gross anatomy against the standard required for clinical practice." Next, we conducted a literature search for extant items related to our definition. To develop our scale, we grouped the items under three headings: proficiency, preference, and pertinence. Finally, we constructed item-specific response anchors to "Likertize" the items. We recruited experts to validate the content and conducted cognitive interviews to validate the response process. To evaluate the internal structure and reliability of the scale, we invited a purposive sample of 120 surgery residents to complete the scale and explored the results of the pilot test using data reduction and reliability analysis. A total of 77 surgery residents completed the scale. Varimax-rotated principal components analysis revealed three components with eigenvalues greater than one, and the components explained 64 % of the total variance. The rotated solution was consistent with the original structure of the questionnaire. The components, which represented the proficiency, preference, and pertinence item sets, explained 25 %, 23 %, and 16 %, respectively, of the total variance. Cronbach's α coefficients for the item sets were 0.72, 0.71, and 0.61, respectively. We developed and validated a scale to measure the gross anatomy preparedness of medical graduates. In addition, we offer conceptual guidelines to help users interpret the results of the scale. Outcome data are required to substantiate the predictive validity of the scale.

RESUMEN: Los cursos de actualización de posgrado pueden abordar las deficiencias en la preparación de la anatomía macroscópica de los graduados médicos. Sin embargo, la literatura no ofrece un método para identificar tales deficiencias. Nuestro objetivo fue desarrollar y validar una escala para medir la preparación anatómica general de los graduados médicos. Primero, definimos la preparación para la anatomía macroscópica (el constructo) como "el punto de referencia de la capacidad personal en anatomía macroscópica frente al estándar requerido para la práctica clínica". A continuación, realizamos una búsqueda bibliográfica de elementos existentes relacionados con nuestra definición. Para desarrollar nuestra escala, agrupamos los ítems bajo tres encabezados: competencia, preferencia y pertinencia. Finalmente, construimos anclas de respuesta específicas del ítem para "dar me gusta" a los ítems. Reclutamos expertos para validar el contenido y realizamos entrevistas cognitivas para validar el proceso de respuesta. Para evaluar la estructura interna y la confiabilidad de la escala, invitamos a una muestra intencional de 120 residentes de cirugía a completar la escala y exploramos los resultados de la prueba piloto utilizando la reducción de datos y el análisis de confiabilidad. Un total de 77 residentes de cirugía completaron la escala. El análisis de componentes principales rotados con Varimax reveló tres componentes con valores propios mayores que uno, y los componentes explicaron el 64 % de la varianza total. La solución rotada fue consistente con la estructura original del cuestionario. Los componentes, que representaban los conjuntos de ítems de competencia, preferencia y pertinencia, explicaban el 25 %, el 23 % y el 16 %, respectivamente, de la varianza total. Los coeficientes de Cronbach para los conjuntos de elementos fueron 0,72, 0,71 y 0,61, respectivamente. Desarrollamos y validamos una escala para medir la preparación anatómica general de los graduados médicos. Además, ofrecemos pautas conceptuales para ayudar a los usuarios a interpretar los resultados de la escala. Se requieren datos de resultados para corroborar la validez predictiva de la escala.

Contemporary considerations in adjuvant radioiodine treatment of adults with differentiated thyroid cancer.

Differentiated thyroid cancer (DTC) is the most common endocrine malignancy with a growing incidence worldwide. The initial conventional management is surgery, followed by consideration of 131 I treatment that includes three options. These are termed remnant ablation (targeting benign thyroid remnant), adjuvant (targeting presumed microscopic DTC) and known disease (targeting macroscopic DTC) treatments. Some experts mostly rely on clinicopathologic assessment for recurrence risk to select patients for the 131 I treatment. Others, in addition, apply radioiodine imaging to guide their treatment planning, termed theranostics (aka theragnostics or radiotheragnostics). In patients with low-risk DTC, remnant ablation rather than adjuvant treatment is generally recommended and, in this setting, the ATA recommends a low 131 I activity. 131 I adjuvant treatment is universally recommended in patients with high-risk DTC (a primary tumor of any size with gross extrathyroidal extension) and is generally recommended in intermediate-risk DTC (primary tumor >4 cm in diameter, locoregional metastases, microscopic extrathyroidal extension, aggressive histology or vascular invasion). The optimal amount of 131 I activity for adjuvant treatment is controversial, but experts reached a consensus that the 131 I activity should be greater than that for remnant ablation. The main obstacles to establishing timely evidence through randomized clinical trials for 131 I therapy include years-to-decades delay in recurrence and low disease-specific mortality. This mini-review is intended to update oncologists on the most recent clinical, pathologic, laboratory and imaging variables, as well as on the current 131 I therapy-related definitions and management paradigms, which should optimally equip them for individualized patient guidance and treatment.

Noninvasive follicular neoplasm with papillary-like nuclear features (NIFTP): a 13-year retrospective review at Jordan University Hospital.

OBJECTIVE: Noninvasive follicular neoplasm with papillary-like nuclear features (NIFTP) is the term to describe what was previously known as encapsulated follicular variant of papillary thyroid carcinoma. This new paradigm shift was agreed upon by experts in the field. The objective of this study is to evaluate cases previously diagnosed as follicular adenomas, follicular variant of papillary thyroid carcinoma and hyperplastic nodules to be reclassified as NIFTP according to the new criteria. Furthermore, the clinical follow-up of these NIFTP cases is evaluated. METHODS: This retrospective study reviewed potential NIFTP cases over the last 13 years, at Jordan University Hospital. RESULTS: A total of 811 thyroid surgery reports were identified and revised to identify the potential NIFTP cases. The review yielded 173 cases identified as potential NIFTP cases. Further pathological slide review resulted in a revised diagnosis of 32 cases of NIFTP according to the new criteria. The NIFTP cases comprised 4% of the total number of thyroidectomy cases and 16.1% of the total pool of previously diagnosed papillary thyroid carcinoma cases at our institution. While 111 cases retained their original diagnosis. Follow-up showed that all patients are alive and well with no evidence of disease. CONCLUSION: Patients with NIFTP are not uncommon and the diagnosis is made only after a thorough evaluation of excision. Therefore, initial conservative management of solitary thyroid nodules suspicious for NIFTP in the form of lobectomy is recommended to avoid unnecessary total thyroidectomies. Our follow-up of NIFTP cases is similar to all previous reports.

Parotid gland metastasis as an initial presentation of renal cell carcinoma: A case report.

This report is to describe a rare case of parotid metastasis from renal cell carcinoma (RCC) in a50- year- old male presenting with unilateral facial symptoms. Following investigations, the patient was diagnosed to have metastatic renal cell carcinoma. He was planned for radio-chemotherapy, and got deceased 1 year afterward.

Wound infiltration with bupivacaine 0.5% with or without adrenaline does not decrease pain after thyroidectomy. A randomized controlled study.

OBJECTIVES: To study the effect of local wound infiltration with and without adrenaline on pain perception after thyroidectomy using the visual analog score (VAS).  Methods: A prospective randomized controlled double-blinded study was conducted between May 2015 and June 2016 at The University of Jordan Hospital, Amman, Jordan. Eighty-nine patients undergoing planned thyroidectomy were included in the study. Patients were divided randomly into 3 groups: Group A, local wound infiltration with bupivacaine 0.5% was administered; Group B, bupivacaine 0.5% with adrenaline was administered; Group C (control), no infiltration was performed. Standardized thyroidectomies were performed in the 3 groups. Pain perception was measured using VAS at 2, 4, 6, 12, and 24 hours after surgery. A comparison between the 3 groups was carried out. Results: No significant differences among the 3 groups were observed at all time points (p=0.246). Visual analog scores were significantly lower at 12 and 24 hours after operations.  Conclusion: Local wound infiltration with bupivacaine 0.5% does not decrease pain perception after thyroidectomy performed under general anesthesia, and adding adrenaline does not enhance its effect.

Reasons for operation cancellations at a teaching hospital: prioritizing areas of improvement.

PURPOSE: To report rates of and reasons for operation cancellation, and to prioritize areas of improvement. METHODS: Retrospective data were extracted from the monthly reports of cancelled listed operations. Data on 14 theatres were collected by the office of quality assurance at Jordan University Hospital from August 2012 to April 2016. Rates and reasons for operation cancellation were investigated. A Pareto chart was constructed to identify the reasons of highest priority. RESULTS: During the period of study, 6,431 cases (9.31%) were cancelled out of 69,066 listed cases. Patient no-shows accounted for 62.52% of cancellations. A Pareto analysis showed that around 80% of the known reasons for cancellation after admission were due to a lack of surgical theatre time (30%), incomplete preoperative assessment (21%), upper respiratory tract infection (19%), and high blood pressure (13%). CONCLUSION: This study identified the most common reasons for operation cancellation at a teaching hospital. Potential avoidable root causes and recommended interventions were suggested accordingly. Future research, available resources, hospital policies, and strategic measures directed to tackle these reasons should take priority.

A rare case of extracranial meningioma in parapharyngeal space presented as a neck mass.

BACKGROUND: Meningiomas are the most common intracranial tumor, but rarely, they can develop extracranially, usually in the neck. There are very few cases of parapharyngeal meningioma reported in literature and little is known about their biological behavior and operative management. We present a patient with a primary parapharyngeal meningioma that presented as an anterior neck mass. CASE PRESENTATION: The patient is a 55-year-old female who presented with neck mass. A CT scan and MRI revealed a large, well defined, mildly enhancing soft tissue mass located in the right carotid sheath extended from the level of the thyroid gland into the skull base jugular foramen superiorly. Cervical exploration with partial excision of the mass was performed. Histological examination revealed meningiothelial cells with intranuclear inclusions, arranged in a syncytial pattern. Mutiple psamoma bodies these findings are consistent with the diagnosis of meningioma. CONCLUSION: Extracranial meningiomas are quite rare. The diagnosis of these types of tumors is challenging due to the non specific nature of the symptoms. The anatomic complexity of the region of parapharyngeal space also makes their detection difficult. Imaging modalities can aid in the diagnosis, but pathological examinations are essential in confirming a definite diagnosis.

The Magnitude of Antral Resection in Laparoscopic Sleeve Gastrectomy and its Relationship to Excess Weight Loss.

BACKGROUND: The objective of this study was to evaluate the effect of antral resection on weight loss and complications after laparoscopic sleeve gastrectomy (LSG). METHODS: This was a retrospective study of the prospectively collected data of patients who underwent LSG at Jordan University Hospital from February 2011 to February 2012. Patients were divided into two groups based on antral resection: group A underwent a 6-cm antral resection, and group B underwent a 2-cm antral resection. The percentage of excess weight loss (%EWL) was calculated at 3, 6, 12, and 24 months postoperatively. RESULTS: One hundred and ten patients were included in the study, all of whom completed at least 24 months of follow-up (mean follow-up, 33 months). Their mean body mass index was 46.1 ± 7.9 kg/m(2). In group A, the mean %EWL was 38.1 ± 14.1, 54.9 ± 19.9, 65.6 ± 22.8, and 66.8 ± 28.4% at 3, 6, 12, and 24 months, respectively. However, in group B, the mean %EWL was 42.1 ± 13.4, 63.8 ± 19.8, 80.0 ± 22.1, and 81.5 ± 22.9% at 3, 6, 12, and 24 months, respectively. Patients in group B experienced statistically significant greater weight loss than patients in group A. Statistically significant greater weight regain was seen in group A. Group A had a higher incidence of reflux symptoms (six patients; 11%) than group B (four patients; 7.1%). CONCLUSIONS: Radical antral resection in association with LSG safely potentiates the restrictive effect achieved and may result in greater and better maintained weight loss.

Comparison of ilioinguinal/iliohypogastric nerve blocks and intravenous morphine for control of post-orchidopexy pain in pediatric ambulatory surgery.

BACKGROUND: The present study is a prospective randomized double-blinded study that designed to evaluate and compare the effectiveness of postoperative pain control and incidence of complications between ilioinguinal/iliohypogastric nerve block and intravenous morphine in paediatric patients undergoing unilateral orchidopexy in day surgery unit. METHODS: Seventy patients aged 2-12 years were randomly allocated to two groups of thirty five. One group received intravenous morphine 100 microgram/kg before skin incision and the other group had ilioinguinal/iliohypogastric nerve block with 0.25 ml/kg bupivacaine 0.5% also before skin incision. All patients have received standardized anaesthesia. Postoperative pain was assessed using 0 - 10 scale at 0, 1, 2, 3 and 4 postoperative hours, also the intraoperative fentanyl requirements, time to first postoperative analgesia, the total number of paracetamol doses and any extra analgesic requirements were recorded, side effects like respiratory depression, vomiting, itching, inguinal hematoma and lower limb weakness were assessed during the first 24 hours. RESULTS: Pain scores were significantly lower in the morphine group compared to the block group on admission and one hour after admission to the postanaesthesia care unit, no significant difference in pain score on 2nd, 3rd and 4th postoperative hours. The total number of intraoperative fentanyl doses was significantly higher in the block group compared to morphine group, there was no significant difference in the duration of analgesia, number of total paracetamol doses, need for extra analgesics in both groups over the 24 postoperative hours. None of the seventy patients experienced postoperative respiratory depression, inguinal hematoma or lower limb weakness, but significantly more patients in morphine group experienced vomiting and itching compared to the block group. CONCLUSION: Ilioinguinal/iliohypogastric nerve block and intravenous morphine administered following general anaesthesia for unilateral orchidopexy in day surgery unit are safe and effective in controlling postoperative pain, morphine analgesia had a higher incidence of postoperative vomiting and itching.

Performance of chloride/phosphate test in patients with primary hyperparathyroidism. Is it related to calcium level?

OBJECTIVE: To examine the sensitivity of the chloride/phosphate (Cl/PO4) ratio with a cut-off point of >33 as a diagnostic test for primary hyperparathyroidism (pHPT) in surgically proven patients, and its performance at different calcium levels. METHODS: This is a retrospective medical records based study. Data of 120 patients diagnosed with pHPT, already operated in the Department of Surgery, Cisanello Hospital, Pisa, Italy between March 2010 and June 2011 were reviewed. They were divided into 4 subgroups according to their calcium levels. The Cl/PO4 ratio was measured for each patient, with a cut-off point of 33, sensitivity of Cl/PO4 test was measured. Test sensitivity was calculated for each subgroup, and a correlation with the parathyroid hormone (PTH) level was investigated. Performance of the equation was tested for the normocalcemic patients with a suitable control group. RESULTS: The sensitivity of Cl/PO4 ratio for the whole group was 0.883 (0.809-0.932). The sensitivity was 0.9340 (0.857-0.973) for patients with serum calcium above normal levels. A similar result of 0.933 (0.830-0.978) was demonstrated for the subgroup with hypercalcemia <1 (mg/dL) above normal level. Normocalcemic patients constituted 24%; for this subgroup, the sensitivity test was 0.724 (0.562-0.887), specificity was 0.763 (0.628-0.898), positive predictive value was 0.700 (0.536-0.864), and negative predictive value was 0.784 (0.651-0.916). No correlation was identified between the performance of formula and serum PTH level. CONCLUSION: The Cl/PO4 test seems to be a good tool to anticipate pHPT and showed a fair performance in normocalcemic patients.

Underlay mesh repair for spontaneous lumbar hernia.

INTRODUCTION: Lumbar hernia is a rare condition with fewer than 300 cases reported in the literature. It arises through posterolateral abdominal wall defects, named the inferior triangle (Petit) and superior triangle (Grynfelt). It can be congenital or acquired, primary or secondary, peritoneal or extraperitoneal, reducible or complicated. PRESENTATION OF CASE: We report a 63 year old female patient who presented to our hospital with a reducible right superior lumbar hernia. She underwent repair with underlay mesh after inversion of the sac and had a smooth postoperative course. DISCUSSION: In contrast to the classical procedure the underlay mesh modification saved us from enlarging the defect, and was quick and associated with minimal tissue injury. CONCLUSION: Underlay mesh repair for spontaneous lumbar hernia is feasible when the defect is small.

Recurrent right sublingual ranula, concomitant with ipsilateral submandibular salivary gland aplasia.

INTRODUCTION: Oral ranula is a retention cyst that arises from the salivary gland with recurrence rate of up to 25% after complete excision of ranula and up to 2% in case of complete excision of ranula and sublingual gland. Major salivary gland aplasia is a rare finding that is usually associated with other developmental anomalies. PRESENTATION OF CASE: We report a 15-year-old female patient presented with recurrent intraoral cystic swelling that was documented to be sublingual ranula. CT scan revealed also the absence of right submandibular salivary gland with persistence of its Whartons duct. This combination has never been reported previously. DISCUSSION: The combination of recurrent sublingual ranula associated with aplasia of ipsilateral submandibular salivary gland and persistence of Whartons duct has never been reported before in the literature, a finding that may provide the base for future research. CONCLUSION: Further research may prove similar associations between oral ranula and salivary gland aplasia, which may have clinical implications on diagnostic and management plan decisions.

Isolated multiple bilateral thyroid metastases from prostatic adenocarcinoma: case report and literature review.

Solitary metastasis from prostate adenocarcinoma to thyroid gland is very rare and usually associated with other distal metastasis. This report describes for the first time isolated multiple bilateral thyroid metastasis from prostatic adenocarcinoma. A 67-year-old man who is known as a case of prostatic adenocarcinoma was admitted to a hospital as a case of a multinodular goiter on the basis of clinical and CT scan findings. Total thyroidectomy was performed and histopathology result showed adenomatous goiter containing bilateral metastatic prostatic adenocarcinoma. This is the first report of isolated multiple bilateral thyroid gland metastasis from prostatic adenocarcinoma without other distal metastasis. Such lesions are very rare and can be misdiagnosed, so high index of suspicion for thyroid metastasis should be always maintained in all oncology patients with isolated thyroid mass because early resection and thyroidectomy will change the prognosis for patient.

New trends in the clinicopathological features of differentiated thyroid cancer in Central Jordan.

OBJECTIVE: To investigate the current trends in presentation and distribution of differentiated thyroid cancer (DTC) at the largest referral hospital for endocrine cancers in Central Jordan. METHODS: We analyzed the clinical features, management and outcome of 110 patients diagnosed with thyroid carcinoma at Jordan University Hospital, Amman, between 1996 and 2001. RESULTS: Papillary carcinoma was diagnosed in 87 patients (80%), follicular carcinoma in 3 patients (2.7%), Hurthle cell carcinoma in 8 patients (7.3%), medullary carcinoma in 5 (4.5%), and anaplastic carcinoma in 4 patients (3.6%), metastatic cancer in 2 patients and lymphoma in one patient. Time course analysis showed an increasing trend in surgery for thyroid cancer from 28 cases in 1986-1991 to 48 in 1996-2001. As time advanced, the incidence of locally invasive disease and lymph node involvement markedly increased over the last 5 years of the study (from 28-62%). All patients with follicular carcinoma were diagnosed in the period 1986-1994. After thyroidectomy and a follow up period of 2-15 years, 10 patients died of their disease, 4 of these died within one year from anaplastic thyroid carcinoma. CONCLUSION: The dramatic decline in the incidence of follicular thyroid carcinoma combined with the increase in the advanced forms of thyroid cancer in Central Jordan may suggest a possible environmental factor in thyroid carcinogenesis in this region. We suggest a larger scale studies and steps to investigate the etiologic factors for thyroid carcinogenesis in Central Jordan.

Neck dissection of level IIb: is it really necessary?

OBJECTIVES: To determine whether resection of level IIb is necessary in elective or therapeutic neck dissections. STUDY DESIGN: Prospective case series. METHODS: Level IIb nodes were analyzed for micrometastases as separate specimens in 160 neck dissections on 148 patients with squamous cell carcinoma of the head and neck. RESULTS: In 106 elective neck dissections (N0 necks) from upper aerodigestive tract (UADT) and skin/parotid squamous carcinoma primaries, level IIb was involved in 4.5% and 33%, respectively. In 54 therapeutic neck dissections (N+ necks) from UADT and skin/parotid squamous carcinoma primaries, level IIb was involved in 25% and 71%, respectively. Apart from skin/parotid squamous carcinoma primaries, level IIb was never involved unless level IIa was also involved. CONCLUSIONS: Level IIb nodes can be left in situ in UADT primary carcinomas in nontonsillar N0 necks without significantly compromising regional clearance of micrometastases.

Salvage vertical partial laryngectomy for radiation failure in early glottic carcinoma.

BACKGROUND: Partial laryngectomy after failure of radiotherapy for early glottic cancer is an accepted surgical salvage procedure. However, there have been only a few studies on recurrent disease or long-term survival. METHODS: Twenty-one patients who were treated with salvage partial vertical laryngectomy (PVL) following failure of primary radiotherapy were prospectively studied. Median follow up was 69 months (range 24-204 months). Patients were seen at two- monthly intervals for the first 24 months and then 3-4 monthly for 5 years after their partial surgery or until death. RESULTS: Local control was 71.4% (15/21). Among the six patients who recurred within the larynx, two patients developed a second primary; one on the ipsilateral false cord at 24 months and the other on the contra-lateral vocal cord at 10 years. The no evidence of disease rate following salvage PVL was 95%, 85% and 73% at 12,24 and 36 months, respectively, with a mean disease free interval of 34.9 months (range 7-120). Survival was 90%, 85% and 80% at 12, 24 and 36 months,respectively, with a median survival of 152 months for the group. Three patients died of their disease and four from other causes. Four local recurrences occurred within 32 months. Two developed neck metastases and died of their disease. Four patients were treated successfully with completion laryngectomy. Only one of these died, but this was due to a second primary squamous cell carcinoma in the lung. Three of the four patients with local recurrence shad an extended procedure. CONCLUSION: Partial vertical laryngectomy is an excellent alternative to total laryngectomy for salvage following failure of -radiation. Although local recurrence occurred more frequently in those patients having an extended partial procedure, this was not statistically different.