Outcomes of Preoperative Medical Therapy for Thyroidectomy in Autoimmune Thyroid Disease.

INTRODUCTION: Thyroidectomy provides definitive treatment for autoimmune thyroid disease (AITD) often resulting in improved quality of life. Historically, patients with AITD undergoing thyroidectomy have increased rates of postoperative hypoparathyroidism and recurrent laryngeal nerve palsy. We investigated the outcomes of preoperative medications in patients with AITD undergoing thyroidectomy. METHODS: We performed a retrospective analysis of patients who underwent thyroidectomy for AITD at a single institution from 2015 to 2021. Surgical outcomes and perioperative laboratory values were analyzed by type of AITD and type of preoperative medical treatment: none, saturated solution of potassium iodide (SSKI), corticosteroids, or both SSKI and corticosteroids. RESULTS: A total of 123 patients underwent thyroidectomy for AITD and were included in analysis: 50 received no preoperative medications, 40 received SSKI, 20 received corticosteroids, and 13 received both. Seventy-six patients had Graves' disease and 47 had Hashimoto's thyroiditis. There were no significant differences in blood loss, operative time, wound complications, hematoma, or recurrent laryngeal nerve injury for patients treated with preoperative corticosteroids compared to those who were not. Patients who received corticosteroids and patients with Graves' disease more commonly had at least one instance of hypocalcemia postoperatively (P < 0.01, P = 0.01), although only on postoperative day 1 was mean calcium < 8.5 mg/dL. There was no difference in rate of transient or permanent hypoparathyroidism. CONCLUSIONS: Patients who received corticosteroids preoperatively had no increased risk of complications. They did have mildly lower calcium levels in the early postoperative period, although no difference in hypoparathyroidism. Further exploration is warranted to investigate the impact of preoperative corticosteroids on operative difficulty, quality of life, and autoantibody clearance.

Nontechnical Skills for Surgeons as a Framework to Evaluate Cardiopulmonary Bypass Management Skills of Resident Trainees.

BACKGROUND: Nontechnical skills are critical in cardiac surgery but currently there is no formal paradigm to teach these in residency training. We investigated the use of the Nontechnical skills for surgeons (NOTSS) system as a framework to assess and teach nontechnical skills related to cardiopulmonary bypass (CPB) management. METHODS: Single-center retrospective analysis of Integrated and Independent pathway thoracic surgery residents who participated in dedicated nontechnical skills evaluation and training. Two CPB management simulation scenarios were utilized. All residents received a lecture on CPB fundamentals and then individually participated in the first simulation ("Pre-NOTSS"). Immediately following this, nontechnical skills were rated by self-assessment and by a NOTSS trainer. All residents then underwent group NOTSS training followed by the second individual simulation ("Post-NOTSS"). Nontechnical skills were rated as before. NOTSS categories assessed included Situation Awareness, Decision Making, Communication and Teamwork, and Leadership. RESULTS: Nine residents were divided into 2 groups: Junior (n = 4, PGY1-4) and Senior (n = 5, PGY5-8). Pre-NOTSS resident self-ratings were higher for Senior than Junior in the categories of Decision Making, Communication and Teamwork, and Leadership while trainer ratings were similar between the groups. Post-NOTSS, resident self-ratings were higher for Senior than Junior in Situation Awareness and Decision Making while trainer scores were higher for both groups in Communication and Teamwork and Leadership. CONCLUSIONS: The NOTSS framework in conjunction with simulation scenarios provides a practical framework to evaluate and teach nontechnical skills related to CPB management. NOTSS training can lead to improvements in both subjective and objective ratings of nontechnical skills for all PGY levels.

Second Opinions in Breast Cancer Surgery: What Have We Learned?

Introduction Second-opinion consultations (SOCs) provide many benefits. However, duplicate office visits and the logistics of transferring medical records may be concerning for delaying treatment. There is currently no clear understanding regarding the characteristics of patients with breast cancer who desire second surgical opinions or if this contributes to delays in care. Methods A review of our institutional database from July 1, 2019, to December 31, 2019, identified breast cancer patients who were documented to be SOCs or primary consultations (PC). Neoadjuvant chemotherapy patients were excluded. Comparisons of patient characteristics, tumor characteristics, and surgery factors were performed using chi-square analysis. All analyses were two-tailed and statistical significance was assigned at p <0.05. This study was deemed IRB-exempt. Results In our review, 158 breast cancer patients were identified, 21 (13.3%) SOCs and 137 (86.7%) PCs. Of the SOCs, 90% (19/21) underwent surgery at our institution. The study revealed an increased incidence of SOCs in those patients who ultimately underwent mastectomy (p=0.039) as well as those with lower pathologic T stage (p=0.021). There were no other differences in demographics, surgery, or tumor characteristics. No delay was seen in time for treatment. Conclusions Patients who sought second opinions were more likely to undergo mastectomy and had lower pathologic tumor size. The time from biopsy to surgery appointment was longer in patients who sought second opinions but there were no differences in the time from biopsy or surgery appointment. It is encouraging that those who sought second opinions did not face any delay in care once established.

Demographics and medical school exposures to rural health influence future practice.

BACKGROUND: One-fifth of the US population lives in rural areas. A record number of rural hospitals have closed, creating increased burdens on regional centers and delays in care. This study aimed to assess medical student perceptions of rural surgery and health care, and to elucidate influential factors for future practice. METHODS: We administered a survey to medical schools throughout Indiana, Illinois, and Michigan. The survey was designed and evaluated by a survey content expert and piloted among a group of students. Student and faculty liaisons disseminated the survey between February and May 2021. Descriptive analysis of data was completed using Stata v.16.1 (StataCorp, LLC, College Station, TX). RESULTS: The respondents included 700 medical students; 59.5% were female, with an equal distribution across medical school classes. More than 98% of students believe we "lack" or "are in great need of" rural health care providers, as well as rural surgeons; however, more than half of the students did not agree that the rural workforce is declining. Only 15.7% of students reported an interest in "pursuing a future career in a rural setting." Students with exposure to rural health care, coming from a rural hometown, or having a dependent had a positive association with interest in pursuing rural practice. CONCLUSION: Although students are aware of the lack of rural surgeons and health care providers, there remains an educational deficit. Expanding exposure to rural health care and surgery while in medical school may increase the number of students interested in pursuing a career in a rural setting, potentially shrinking the rural workforce gap.

Phage-Related Ribosomal Proteases (Prps): Discovery, Bioinformatics, and Structural Analysis.

Many new antimicrobials are analogs of existing drugs, sharing the same targets and mechanisms of action. New antibiotic targets are critically needed to combat the growing threat of antimicrobial-resistant bacteria. Phage-related ribosomal proteases (Prps) are a recently structurally characterized antibiotic target found in pathogens such as Staphylococcus aureus, Clostridioides difficile, and Streptococcus pneumoniae. These bacteria encode an N-terminal extension on their ribosomal protein L27 that is not present in other bacteria. The cleavage of this N-terminal extension from L27 by Prp is necessary to create a functional ribosome. Thus, Prp inhibition may serve as an alternative to direct binding and inhibition of the ribosome. This bioinformatic and structural analysis covers the discovery, function, and structural characteristics of known Prps. This information will be helpful in future endeavors to design selective therapeutics targeting the Prps of important pathogens.

Uncovering the Overlap of Global and Domestic Rural Surgery for Medical Trainees.

INTRODUCTION: Medical trainees who participate in global rotations demonstrate improved cultural sensitivity, increased involvement in humanitarian efforts, and ability to adapt to limited resources. The global coronavirus pandemic halted global rotations for medical trainees. Domestic rural surgery (DRS) may offer a unique alternative. We aimed to understand medical students' perceptions of the similarities and differences between global surgery and DRS and how students' priorities impact career choices. METHODS: An electronic survey was administered at eleven medical training institutions in Indiana, Illinois, and Michigan in spring 2021. Mixed methods analysis was performed for students who reported an interest in global surgery. Quantitative analysis was completed using Stata 16.1. RESULTS: Of the 697 medical student respondents, 202 were interested in global surgery. Of those, only 18.3% were also interested in DRS. Students interested in DRS had more rural exposures. Rural exposures associated with DRS interest were pre-clinical courses (P = 0.002), clinical rotations (P = 0.045), and rural health interest groups (P < 0.001). Students interested in DRS and those unsure were less likely to prioritize careers involving teaching or research, program prestige, perceived career advancement, and well-equipped facilities. The students who were unsure were willing to utilize DRS exposures. CONCLUSIONS: Students interested in global surgery express a desire to practice in low-resource settings. Increased DRS exposures may help students to understand the overlap between global surgery and DRS when it comes to working with limited resources, achieving work-life balance and practice location.

Biomarker Risk Score Algorithm and Preoperative Stratification of Patients with Pancreatic Cystic Lesions.

BACKGROUND: Pancreatic cysts are incidentally detected in up to 13% of patients undergoing radiographic imaging. Of the most frequently encountered types, mucin-producing (mucinous) pancreatic cystic lesions may develop into pancreatic cancer, while nonmucinous ones have little or no malignant potential. Accurate preoperative diagnosis is critical for optimal management, but has been difficult to achieve, resulting in unnecessary major surgery. Here, we aim to develop an algorithm based on biomarker risk scores to improve risk stratification. STUDY DESIGN: Patients undergoing surgery and/or surveillance for a pancreatic cystic lesion, with diagnostic imaging and banked pancreatic cyst fluid, were enrolled in the study after informed consent (n = 163 surgical, 67 surveillance). Cyst fluid biomarkers with high specificity for distinguishing nonmucinous from mucinous pancreatic cysts (vascular endothelial growth factor [VEGF], glucose, carcinoembryonic antigen [CEA], amylase, cytology, and DNA mutation) were selected. Biomarker risk scores were used to design an algorithm to predict preoperative diagnosis. Performance was tested using surgical (retrospective) and surveillance (prospective) cohorts. RESULTS: In the surgical cohort, the biomarker algorithm outperformed the preoperative clinical diagnosis in correctly predicting the final pathologic diagnosis (91% vs 73%; p < 0.000001). Specifically, nonmucinous serous cystic neoplasms (SCN) and mucinous cystic neoplasms (MCN) were correctly classified more frequently by the algorithm than clinical diagnosis (96% vs 30%; p < 0.000008 and 92% vs 69%; p = 0.04, respectively). In the surveillance cohort, the algorithm predicted a preoperative diagnosis with high confidence based on a high biomarker score and/or consistency with imaging from ≥1 follow-up visits. CONCLUSIONS: A biomarker risk score-based algorithm was able to correctly classify pancreatic cysts preoperatively. Importantly, this tool may improve initial and dynamic risk stratification, reducing overdiagnosis and underdiagnosis.

Mobile MUTE specifies subsidiary cells to build physiologically improved grass stomata.

Plants optimize carbon assimilation while limiting water loss by adjusting stomatal aperture. In grasses, a developmental innovation-the addition of subsidiary cells (SCs) flanking two dumbbell-shaped guard cells (GCs)-is linked to improved stomatal physiology. Here, we identify a transcription factor necessary and sufficient for SC formation in the wheat relative Brachypodium distachyon. Unexpectedly, the transcription factor is an ortholog of the stomatal regulator AtMUTE, which defines GC precursor fate in Arabidopsis The novel role of BdMUTE in specifying lateral SCs appears linked to its acquisition of cell-to-cell mobility in Brachypodium Physiological analyses on SC-less plants experimentally support classic hypotheses that SCs permit greater stomatal responsiveness and larger range of pore apertures. Manipulation of SC formation and function in crops, therefore, may be an effective approach to enhance plant performance.