Thyroidectomy Outcomes in Obese Patients.

INTRODUCTION: Obese patients often have higher complication rates after elective general surgeries; however, few studies have examined the outcomes after thyroidectomy. This study examines whether increased body mass index (BMI) is associated with poor postoperative outcomes after thyroid surgery. METHODS: A retrospective review of patients who underwent thyroidectomy from 2015 to 2018 was performed. Demographics, comorbidities, pathology, and extent of resection (total versus hemithyroidectomy) were examined. Patients were classified into BMI groups according to the WHO definitions, and the incidence of surgical outcomes was determined in each group. Surgical outcomes of interest included readmission rates (RRs), length of stay, average operating room time, return to the operating room, hypocalcemia, postop infections, hematomas, and recurrent laryngeal nerve injury. Between-subjects statistics including independent samples t-test, ANOVA, and chi-square analyses were performed. RESULTS: There were n = 465 patients included with a mean BMI 32.35 (standard deviation = 8.55) and median BMI 30.78 (Q1 = 26.26, Q3 = 36.73). There were no differences between BMI groups in age, gender, smoking, heart disease. There was a positive association between increased BMI and postoperative infection (P < 0.001), pneumonia (P = 0.018), and surgical site infection (P = 0.04), which were highest for BMI > 40. Increased BMI was associated with a higher 30-d RR (P = 0.008), particularly for BMI >40 versus BMI <40 (6.2% versus 1.05%; P = 0.003). There were no significant differences between surgical outcomes for patients with increased BMI who underwent total thyroidectomy or hemithyroidectomy. CONCLUSIONS: Excellent postoperative outcomes were observed in all BMI categories. Higher postoperative infection and 30-d RRs were observed in the morbidly obese. Contrary to previous studies, operating room times were similar regardless of BMI.

A >50% Intraoperative Parathyroid Hormone Decrease Into Normal Reference Range Predicts Complete Excision of Malignancy in Patients With Parathyroid Carcinoma.

INTRODUCTION: The mainstay of successful treatment for parathyroid carcinoma remains complete surgical excision. Although intraoperative parathyroid hormone (ioPTH) monitoring is a useful adjunct during parathyroidectomy for benign primary hyperparathyroidism, its utility for parathyroid carcinoma remains unclear. METHODS: A retrospective review of 796 patients who underwent parathyroidectomy with ioPTH monitoring for primary hyperparathyroidism revealed 13 patients with parathyroid carcinoma on final pathology from two academic institutions. A systematic review yielded 5 additional parathyroid carcinoma patients. Complete excision of malignancy, or operative success (eucalcemia ≥6 mo. after parathyroidectomy); operative failure (persistent hypercalcemia <6 mo. after parathyroidectomy); and perioperative complications were evaluated. Comparison of the >50% ioPTH decrease alone to >50% ioPTH decrease into normal reference range was analyzed using Chi-squared, Kolmogorov-Smirnov, Kruskal-Wallis tests. RESULTS: All 18 parathyroid carcinoma patients achieved a >50% ioPTH decrease, and 14 patients also had a final ioPTH level decrease into normal reference range. 93% of patients who met normal parathyroid hormone reference range had operative success, whereas only two of the four (50%) patients with parathyroid carcinoma with a >50% ioPTH decrease alone demonstrated operative success. CONCLUSIONS: Parathyroidectomy guided by a >50% ioPTH decrease into normal reference range may better predict complete excision of malignant tissue in patients with parathyroid carcinoma compared to >50% ioPTH decrease alone. IoPTH monitoring should be used in conjunction with clinical judgment and complete en bloc resection for optimal treatment and success.

Operative success is achieved regardless of ioPTH criterion used during focused parathyroidectomy for sporadic primary hyperparathyroidism.

BACKGROUND: Focused parathyroidectomy (F-PTX) guided by intraoperative parathormone (ioPTH) monitoring may result in higher operative failure rates from missed multiglandular disease (MGD) in patients with sporadic primary hyperparathyroidism (spHPT) when ioPTH levels do not reach normal range. METHODS: A retrospective review included 690 patients with spHPT who underwent F-PTX and ioPTH monitoring were divided into 2 groups: >50% ioPTH decrease to normal range, and >50% ioPTH decrease to above normal range. Operative success, recurrence, bilateral/unilateral neck exploration (BNE/UNE), MGD were evaluated. RESULTS: 533 patients demonstrated >50% ioPTH decrease to normal range, and 157 patients >50% ioPTH decrease to above normal range. There were no differences in operative success 99% vs. 97%, recurrence 2.5% vs. 5%, BNE 12% vs. 11%, UNE 4% vs. 5%, or MGD 4% vs. 4%, (p > 0.05) with 46 months mean follow-up. CONCLUSIONS: There were no differences in operative success, failure, BNE, UNE or MGD regardless of ioPTH criterion used for F-PTX.

Academic Global Surgery: Creating Opportunities, Equity, and Diversity.

A workforce trained in the development and delivery of equitable surgical care is critical in reducing the global burden of surgical disease. Academic global surgery aims to address the present inequities through collaborative partnerships that foster research, education, advocacy and training to support and increase the surgical capacity in settings with limited resources. Barriers include a deficiency of resources, personnel, equipment, and funding, a lack of communication, and geographical challenges. Multi-level partnerships remain fundamental; these types of partnerships include a wide range of trainees, professionals, institutions, and nations, yet care must be taken to avoid falling into the trap of surgical "voluntourism" and undermining the expertise and practice of long-standing frontline providers. Academic global surgery has the benefit of developing a community of surgeons who possess the tools needed to collaborate on individual, institutional, and international levels to address inequities in surgery that are spread variously across the globe. However, challenges for surgeons pursuing a career in global surgery include balancing clinical responsibilities while integrating global surgery as a career during training. This is due in part to the lack of mentorship, research time, grant funding, support to attend conferences, and a limitation of resources, all of which are significantly more pronounced for surgeons from low-resource countries.

Case Report: Metastatic renal cell carcinoma to the thyroid- A rare encounter.

Background: Renal cell carcinoma (RCC) accounts for approximately 4% of new adult cancers. By fine needle aspiration, identification of metastatic RCC to thyroid is challenging; therefore, surgical resection is indicated for definitive characterization. Our report surveys metastatic RCC to thyroid in our hospital. Methods: Twenty years retrospective review of electronic records in our institution identified five patients with metastatic renal cell carcinoma to the thyroid. We analyzed patient charts and pathology reports to evaluate clinical parameters and therapy. Results: In all cases, the original RCC was of clear cell type. Pathologic tumor stage ranged from pT1a to pT3a, Fuhrman nuclear grade varied from 2 to 4 and angiolymphatic invasion was noted in one case. In three patients, RCC in the thyroid occurred as an oligometastasis with no evidence of disease in the nephrectomy bed or other parts of the body. In two patients, concomitant recurrent RCC and metastases to liver, lung, brain and chest wall were documented. The thyroid metastases were found approximately 10 years after completion of nephrectomy with a range of 0-21 years. Three thyroid fine needle aspirations correctly identified the disease, one was negative, and one was classified as atypical cells present, suspicious for RCC. Conclusion: The thyroid gland is an uncommon location for RCC metastasis and can appear across a wide range of initial stages and grades of the disease. Thyroid metastases occurred as late as 21 years from the initial tumor resection. Increased awareness and a high index of suspicion are needed to detect metastasis, as they can be found in atypical locations and mimic primary disease.

We Aren't Just 'Slack'ing Off: Utilizing a Digital Tool to Connect Emerging Women Leaders in Global Health.

Background: Investing in women leaders in global health catalyzes growth and positive outcomes for individuals and their communities, yet large gender disparities persist in leadership within the field due to several barriers. The use of digital tools facilitates cross-institutional and international collaborations to allow individuals or groups to create or share information, ideas, career interests, and other forms of expression via virtual communities. Digital tools can dramatically expand access to and the quantity and quality of opportunities for networking, mentoring, and collaboration to support women in their professional development. Objectives: The objective of this paper is to document tangible examples of positive experiences, connections, or collaborations resulting from connecting with other participants in a Slack network. We aimed to evaluate this network to understand how to better build, model, and scale advantageous digital networks of women leaders in global health moving forward. Methods: Semi-structured interviews were conducted virtually with seven members of the Slack network from Africa and North America who volunteered to share their experiences. Transcripts of six of these interviews were analyzed for key points using thematic analysis to derive short vignettes from each interview. Findings: The findings of this study indicate that Slack is a highly beneficial tool for women in global health to use for facilitating job searches, mentoring opportunities, promoting project collaborations, and proposing programming and outreach ideas in a remote environment. We found distinct recommendations for utilizing this digital networking tool in a way that best supports and engages women in global health. It is important to spread awareness and ensure visibility of the network to recruit and maintain members, design the network in a way that inspires internal motivation, encourage consistent and meaningful engagement, send weekly emails, and maintain accessibility for a global membership base. Conclusions: The Slack network provides an engaging digital tool that facilitates communication, opportunities, and growth among women in global health. Digital tools such as Slack can help to increase opportunities for participants from low- and-middle-income countries to engage in the same networking and leadership opportunities as individuals from high-income countries. It remains critical to continue to build, advance, and scale advantageous networks like Slack to promote equity and accessibility among women leaders in the global north and south into the post-pandemic world.

Prognostic factors and survival analysis of Hurthle cell carcinoma: A population-based study.

BACKGROUND: Hurthle cell carcinoma is a rare type of differentiated thyroid cancer and historically associated with a worse prognosis. The aim of this study was to define the demographic and socioeconomic factors, tumor characteristics, and surgical treatment status associated with Hurthle cell carcinoma survival using the most recent population-level data. METHODS: The Surveillance, Epidemiology, and End Results database was queried for adult patients (>18 years of age) diagnosed with Hurthle cell carcinoma from 2000 to 2018. The demographic factors, socioeconomic factors, tumor characteristics, and extent of surgery data were collected as potential predictors. The outcomes of interest were 10-year overall and disease-specific survival, which were estimated using the Kaplan-Maier method. The associations between the potential predictors and survival were evaluated using the Cox proportional hazard model. RESULTS: In total, 4,643 patients with Hurthle cell carcinoma were identified using the Surveillance, Epidemiology, and End Results database. The cohort was predominately White, had a mean age of 57.7 (±15.6), 69% female sex, and median follow-up was 90 months. The 10-year overall survival and Hurthle cell carcinoma-specific survival were 78.1% (95% confidence interval: 76.7%-79.5%) and 91.8% (95% confidence interval: 90.9%-92.9%), respectively. Younger age <55 years, female sex, White race, Hispanic ethnicity, higher household income, and lower tumor grade and stage were significantly associated with increased survival (P < .01). In the multivariate Cox proportional hazard model, all variables except race and ethnicity remained significantly associated with overall survival. Although patients who underwent thyroid surgery had improved survival compared to no surgery, the extent of surgery did not have any effect on their overall or disease-specific survival. CONCLUSION: This study highlighted the aggressive nature of Hurthle cell carcinoma and the effect of socioeconomic factors, such as household income, which may play a role in Hurthle cell carcinoma survivorship. Research is needed to understand the interplay of these factors and their role in predicting patient outcomes.

Strategies to Improve Women's Leadership Preparation for Early Career Global Health Professionals: Suggestions from Two Working Groups.

Background: Despite advances in gender equality, women still experience inequitable gaps in global health leadership, and barriers to women's advancement as leaders in global health have been well described in the literature. In 2021, the Johns Hopkins Center for Global Health conducted two virtual working groups for emerging women leaders to share challenges and suggest solutions to advance women's leadership in global health. In this paper, we present emerging themes from the working groups, provide a framework for the results, and discuss strategies for advancing women's leadership in global health. Objectives: The objective of this paper is to synthesize and share the themes of the two working group sessions to provide strategies for improving women's leadership training and opportunities in the field of global health. Methods: Approximately 182 women in the global health field participated in two virtual working group sessions hosted by the Johns Hopkins Center for Global Health using the Zoom platform. Participants were divided into virtual breakout rooms and discussed pre-assigned topics related to women's leadership in global health. The participants then returned to share their ideas in a plenary session. Notes from the breakout rooms and transcripts from the plenary session were analyzed through a participatory and iterative thematic analysis approach. Findings: We found that the working group participants identified two overarching themes that were critical for emerging women leaders to find success in global health leadership. First, the acquisition of individual essential skills is necessary to advance in their careers. Second, the institutional environments should be setup to encourage and enable women to enter and succeed in leadership roles. The participants also shared suggestions for improving women's leadership opportunities such as including the use of virtual technologies to increase training and networking opportunities, intersectionality in mentorship and sponsorship, combatting impostor syndrome, and the importance of work-life balance. Conclusions: Investing in women and their leadership potential has the promise to improve health and wealth at the individual, institutional, and community levels. This manuscript offers lessons and proposes solutions for increasing women's leadership through improving individual level essential skills and fostering environments in which women leaders can emerge and thrive.

Effect of Intraoperative Neuromonitoring on the Risks of Recurrent Laryngeal Nerve Injury During Thyroidectomy: A Doubly Robust Approach.

OBJECTIVE: To evaluate the relationship between the use intraoperative neuromonitoring (IONM) during thyroidectomy and the risk of recurrent laryngeal nerve (RLN) injury. BACKGROUND: The role of IONM in reducing RLN injury during thyroidectomy remains controversial. Several studies on this topic apply conventional multivariable regression to adjust for confounding. However, estimates from this method may be biased due to model misspecification, especially with a rare outcome such as RLN injury. METHODS: We used a pooled dataset created by linking the 2016-2019 National Surgical Quality Improvement Project General Participant User File with the corresponding Targeted-Thyroidectomy file. The primary outcome was RLN injury rates, and the secondary outcomes were operating time and postoperative length of stay. A doubly robust (DR) estimator, in the form of an inverse-probability-weighted regression adjustment model, was used to estimate the effect of the use of IONM on the risk of RLN injury. Sensitivity analyses was performed. RESULTS: Twenty-four thousand three hundred seventy patients were evaluated, out of which 15,836 (70%) patients had IONM during thyroidectomy, and RLN injury occurred in 1498 (6.2%) cases. Rates of RLN injury increase with increasing age and BMI and are higher in patients with a cancer diagnosis, previous neck operation, total thyroidectomy, and node dissection. Doubly robust model suggests that the use of IONM was associated with a significant reduction in overall rate of RLN injury [risk ratio 0.77, confidence interval (CI), 0.68-0.87, P <0.001], and postoperative length of stay [-2.5 hours (CI, -4.18 to -0.81 h), P =0.004]. However, IONM use was associated with an increase in operating time [15.41 minutes (CI, 13.29-17.54 minutes), P <0.0001]. Sensitivity analyses revealed that our estimates are largely robust to confounding. CONCLUSION: In a balanced cohort of patients undergoing thyroidectomy from multiple sites and surgeons participating in National Surgical Quality Improvement Project, the use of IONM during thyroidectomy was associated with reduction in RLN injury.

Total Thyroidectomy vs Thyroid Lobectomy for Localized Papillary Thyroid Cancer in Children: A Propensity-Matched Survival Analysis.

BACKGROUND: Current guidelines recommend total thyroidectomy (TT) and radioablation for most papillary thyroid cancer (PTC) in children. These guidelines have been criticized as aggressive, especially for early-stage PTC, as it likely does not influence patient survival and results in life-long thyroid hormone replacement. We sought to study whether the extent of thyroidectomy (TT vs thyroid lobectomy [TL]) influences overall and disease-specific survival in children with localized PTC. METHODS: The National Cancer Database and the Surveillance, Epidemiology, and End Results registries were queried. Patients 18 years or younger with low-risk PTC between 2004 and 2016 were included. Using a 1:1 propensity score matching, patients who underwent TT were matched for age, sex, race, year of diagnosis, and tumor size with a similar cohort of patients who underwent TL. Primary end points were overall survival and disease-specific survival. RESULTS: There were 3,500 patients identified as surgically treated for PTC, of which 1,325 patients met inclusion criteria for matching. Three hundred and twenty-six patients were matched. One hundred and sixty-three patients had TT; 140 were female and mean age was 16 years (interquartile range [IQR] 13 to 17 years). One hundred and sixty-three patients had TL; 140 were female and mean age was 16 years (IQR 14 to 17 years). Median follow-up was 5.0 years (IQR 2.8 to 8 years) and 8.3 years (IQR 3.6 to 14.4 years) in the National Cancer Database and Surveillance, Epidemiology, and End Results cohorts, respectively. There was no statistically significant difference in overall survival or disease-specific survival in patients with PTC < 4 cm, regardless of whether patients underwent TT or TL (p = 0.32 for National Cancer Database registry and p = 0.67 for Surveillance, Epidemiology, and End Results registry). CONCLUSIONS: This study suggests that the extent of thyroidectomy does not influence survival for pediatric patients with early-stage PTC and that TL might be adequate in this patient population.

Response rates in metastatic neuroendocrine tumors receiving peptide receptor radionuclide therapy and implications for future treatment strategies.

BACKGROUND: Peptide receptor radionuclide therapy is a targeted therapy used to treat unresectable somatostatin receptor-positive neuroendocrine tumors. The objective of this study was to evaluate response rates among neuroendocrine tumors of different primaries and identify factors relevant to future treatment strategies. METHODS: We retrospectively reviewed patients who received peptide receptor radionuclide therapy for neuroendocrine tumors from 2018 to 2019 at our institution. Patients were assessed with computed tomography/magnetic resonance imaging and 68Ga-DOTATATE-positron emission tomography before and after 2 or 4 cycles of peptide receptor radionuclide therapy. Tumor response was evaluated by RECIST 1.1. Statistics included multinomial logistic regression models and Fisher exact test. RESULTS: Twenty-seven patients underwent 92 cycles of peptide receptor radionuclide therapy: pancreas (n = 11), small bowel (n = 7), and other (n = 9) neuroendocrine tumors. Overall, 30% (8 of 27) had partial response, 59% (16 of 27) stable disease, and 11% (3 of 27) progressed. Pancreatic neuroendocrine tumors responded differently from small bowel neuroendocrine tumors regardless of cycle number (P = .01). The majority of pancreatic neuroendocrine tumors (6 of 11) had partial response to peptide receptor radionuclide therapy, while all small bowel neuroendocrine tumors had stable disease. Pancreatic neuroendocrine tumors stable after 2 cycles were more likely to respond to additional cycles versus other neuroendocrine tumors (probability: 60% vs 11%). CONCLUSION: Patients with unresectable advanced or metastatic pancreatic neuroendocrine tumors may benefit from a full course of peptide receptor radionuclide therapy, whereas other neuroendocrine tumors appear less likely to respond. Large prospective studies are needed to confirm these findings.

Thyroidectomy for euthyroid patients with Hashimoto thyroiditis and persisting symptoms: A cost-effectiveness analysis.

BACKGROUND: Despite thyroid hormone replacement, some euthyroid patients with Hashimoto thyroiditis will continue to experience persistent symptoms that reduce their quality of life. Recent studies indicate that total thyroidectomy is superior to medical therapy alone in improving these symptoms. However, there is a high complication rate after total thyroidectomy in patients with Hashimoto thyroiditis. This study evaluates the cost-effectiveness of total thyroidectomy for euthyroid patients who have Hashimoto thyroiditis with persistent symptoms. METHODS: We utilized a Markov model to compare total thyroidectomy and medical therapy alone over the lifetime of the cohort. Costs, probabilities, and utility parameters were derived from literature and Medicare cost data. A willingness-to-pay threshold of $100,000/quality-adjusted life years was used. We performed sensitivity analyses to ascertain model uncertainty. RESULTS: On average, medical therapy alone costs $12,845, produced 16.9 quality-adjusted life years, and was dominated. Total thyroidectomy costs $1,490 less and produced 1.4 more quality-adjusted life years. Probabilistic sensitivity analysis confirmed total thyroidectomy as the optimal strategy in 89% of cases. Medical therapy alone will become cost-effective if the cost of uncomplicated thyroidectomy increases by 25%, if the probability of permanent complication after total thyroidectomy increases 12-fold, or if there is no gain in quality of life after thyroidectomy. CONCLUSION: Total thyroidectomy is more cost-effective than medical therapy alone for the management of euthyroid patients who have Hashimoto thyroiditis with persistent symptoms.

Surgical Management of Pancreatic Neuroendocrine Tumors.

Surgical management of pancreatic neuroendocrine tumors (PNETS) is steadily evolving and is influenced by multiple factors. Sporadic PNETs are generally managed more aggressively than those occurring in the background of hereditary syndromes, and functioning PNETs are almost always resected if they are not metastatic. Localized nonfunctioning PNETs less than 2 cm can often be observed. Surgical resection for localized PNET greater than 2 cm comprises parenchymal sparing pancreas resections, such as enucleations, or formal anatomic resection, such as distal pancreatectomy or pancreaticoduodenectomy. PNETs commonly metastasize to the liver, and several systemic and liver-directed options to treat hepatic metastases are available.

Postoperative Outcomes in Graves' Disease Patients: Results from the Nationwide Inpatient Sample Database.

BACKGROUND: Current surgical indications for Graves' disease include intractability to medical and/or radioablative therapy, compressive symptoms, and worsening ophthalmopathy. Total thyroidectomy for Graves' disease may be technically challenging and lead to untoward perioperative outcomes. This study examines outcomes in patients with Graves' disease who underwent total thyroidectomy and assesses its safety for this patient population. METHODS: A retrospective cross-sectional analysis was performed using the Nationwide Inpatient Sample database from 2006 to 2011. Total thyroidectomy performed in patients with Graves' disease, benign multinodular goiter (MNG), and thyroid cancer was identified. Demographic factors, comorbidities, and postoperative complications were evaluated. Chi-square, one-way analysis of variance, and risk-adjusted multivariable logistic regression were performed. RESULTS: Of 215,068 patients who underwent total thyroidectomy during the study period, 11,205 (5.2%) had Graves' disease, 110,124 (51.2%) MNG, and 93,739 (43.6%) thyroid malignancy. Patients with Graves' disease were younger than MNG and thyroid cancer patients (Mage = 42.8 years vs. 55.5 and 51.0 years; p < 0.01). The Graves' disease group included a higher proportion of women (p < 0.01) and nonwhites (p < 0.01). Postoperatively, Graves' patients had significantly higher rates of hypocalcemia (12.4% vs. 7.3% and 10.3%; p < 0.01), hematomas requiring reoperation (0.7% vs. 0.4% and 0.4%; p < 0.01), and longer mean hospital stay (2.7 days vs. 2.4 and 2.2 days; p < 0.01) compared to MNG and thyroid cancer patients, respectively. On risk-adjusted multivariate logistic regression, Graves' disease was independently associated with a higher risk of vocal-cord paralysis (odds ratio [OR] = 1.36 [confidence interval (CI) 1.08-1.69]), tracheostomy (OR = 1.35 [CI 1.1-1.67]), postoperative hypocalcemia (OR = 1.65 [CI 1.54-1.77]), and hematoma requiring reoperation (OR = 2.79 [CI 2.16-3.62]) compared to MNG patients. High-volume centers for total thyroidectomy were independently associated with lower risk of postoperative complications, including in patients with Graves' disease. CONCLUSIONS: Despite low overall morbidity following total thyroidectomy, Graves' disease patients are at increased risk of postoperative complications, including bleeding, vocal-cord paralysis, tracheostomy, and hypocalcemia. These risks appear to be lower when performed at high-volume centers, and thus referral to these centers should be considered. Total thyroidectomy may therefore be a safe treatment option for appropriately selected patients with Graves' disease when performed by experienced surgeons.

Location of abnormal parathyroid glands: lessons from 810 parathyroidectomies.

BACKGROUND: Primary hyperparathyroidism (pHPT) is commonly treated with targeted parathyroidectomy (PTX) guided by preoperative imaging and intraoperative parathormone monitoring. Despite advanced imaging techniques, failure of parathyroid localization still occurs. This study determines the anatomical distribution of single abnormal parathyroid glands, which may help direct the surgeon in PTX when preoperative localization is unsuccessful. METHODS: A retrospective review of prospectively collected data of 810 patients with pHPT who underwent initial PTX at a tertiary medical center was performed. All patients had biochemically confirmed pHPT and single-gland disease. Abnormal parathyroid gland localization was determined at time of operation, correlated with operative and pathology reports, and confirmed by operative success defined as eucalcemia for ≥6 mo after PTX. Patients with multiple endocrine neoplasia, secondary, tertiary, or familial hyperparathyroidism, multiglandular disease, parathyroid cancer, and ectopic glands were excluded. Data were analyzed by chi-square and Z-test analyses. RESULTS: Among 810 patients who underwent PTX for pHPT, single abnormal parathyroid glands were unequally distributed among the four eutopic locations (left superior, 15.7%; left inferior, 31.3%; right superior, 15.8%; right inferior, 37.2%; P < 0.01). Abnormal inferior parathyroid glands (68.5%) were significantly more common than abnormal superior glands (31.5%), respectively (P < 0.01). In men, the most common location for single abnormal parathyroid glands was the right inferior position (43.4%, P < 0.01). Overall, there was no significant difference in laterality. CONCLUSIONS: This large series of patients suggests that single eutopic abnormal parathyroid glands are more likely to be inferior. In men, moreover, if an abnormal parathyroid gland is not localized preoperatively, the right inferior location should be explored first. Nevertheless, successful PTX remains predicated on knowledge of parathyroid anatomy, experience, and judgment of the surgeon.

Anti-Xa-guided enoxaparin thromboprophylaxis reduces rate of deep venous thromboembolism in high-risk trauma patients.

BACKGROUND: Appropriate prophylaxis against venous thromboembolism (VTE) remains undefined. This study evaluated an anti-Xa-guided enoxaparin thromboprophylaxis (TPX) protocol on the incidence of VTE in high-risk trauma patients based on Greenfield's Risk Assessment Profile (RAP) score. METHODS: This is a retrospective observational study of patients admitted to a trauma intensive care unit over a 12-month period. Patients were included if they received anti-Xa-guided enoxaparin TPX. Dosage was adjusted to a prophylactic peak anti-Xa level of 0.2 to 0.4 IU/mL. Subgroup analysis was performed on high-risk patients (RAP score ≥10) who received lower-extremity duplex ultrasound surveillance for deep vein thrombosis (DVT). Data are expressed as mean ± SD. Significance was assessed at p < 0.05. RESULTS: One hundred thirty-one patients received anti-Xa-guided enoxaparin TPX. Four patients were excluded for age or acute VTE on admission. Fifty-six patients with RAP score of ≥10 and surveillance duplex evaluations were included in the subgroup analysis with mean age 43 ± 20 years, Injury Severity Score of 25 ± 10, and RAP score of 16 ± 4. Prophylactic anti-Xa levels were initially achieved in 34.6% of patients. An additional 25.2% required 40 to 60 mg twice daily to reach prophylactic levels; 39.4% never reached prophylactic levels. Weight, body mass index, ISS, and RAP score were significantly higher with subprophylactic anti-Xa levels. One patient developed bleeding complications (0.8%). No patient developed intracerebral bleeding or heparin-induced thrombocytopenia.Nine VTE events occurred in the high-risk subgroup, including four DVT (7.1%), all asymptomatic, and five pulmonary emboli (8.9%). The historical rate of DVT in similar patients (ISS 31 ± 12 and RAP score 16 ± 5) was 20.5%, a significant decrease (p = 0.031). Mean chest Abbreviated Injury Scale scores were significantly higher for patients developing pulmonary emboli than DVT, 3.0 ± 1.1 vs. 0.0 (p < 0.001). CONCLUSIONS: Mean chest Abbreviated Injury Scale score was higher in patients developing pulmonary embolism. Increased weight, body mass index, ISS, and RAP score are associated with subprophylactic anti-Xa levels. Anti-Xa-guided enoxaparin dosing reduced the rate of DVT from 20.5% to 7.1% in high-risk trauma patients. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Mycobacterium abscessus infection in a burn intensive care unit patient.

BACKGROUND: Infection is the leading cause of death in burn patients. Historically, this was due to burn wound sepsis but pneumonia has now emerged as the most common source. In light of the increasing incidence of multi-drug-resistant organisms, the description of rare infections is paramount in continuing the fight against deadly pathogens. We aim to describe the second case of non-tuberculous mycobacterium (NTM) reported in a burn patient. Difficulties in diagnosis and management will also be highlighted. METHODS: A 70-y-old Caucasian female, with a past medical history for type 2 diabetes mellitus, was transferred to our facility after a house fire. She had sustained a 28% total body surface area (TBSA) flame burn to her neck, torso, and all four extremities. She underwent excision and grafting on hospital day five with multiple subsequent attempts at excision and grafting due to graft loss. On hospital day 14, a tracheostomy was performed. Her hospital course was complicated by ongoing respiratory failure, renal injury, and sepsis. RESULTS: Mycobacterium abscessus was found on blood cultures from central venous catheters and arterial line catheters as well as on tracheal aspirate and bronchoalveolar lavage (BAL) on hospital day 86. Imaging then revealed multiple pulmonary nodular densities with patchy ground-glass opacities. After multiple adjustments to the antibiotic regimen, tigecycline, clarithromycin, and cefoxitin therapy was started. She remained on this regimen for almost 4 wks. Her other infections included Acinetobacter baumanii treated with tobramycin and colistin, as well as Candida albicans for which she received fluconazole. Ultimately, her clinical state worsened leading to withdrawal of care. CONCLUSIONS: Sepsis NTM is rare in burn patients with only one other case described in the English-language literature. Both cases reflect differences in diagnosis and management. This highlights the need to discuss rare infections in an attempt to broaden the clinician's awareness of such pathogens, as well as to collaborate to form a consensus about their management.