Predicting nodal metastases in squamous cell carcinoma of the oral tongue using artificial intelligence.

OBJECTIVE: The presence of occult nodal metastases in patients with squamous cell carcinoma (SCC) of the oral tongue has implications for treatment. Upwards of 30% of patients will have occult nodal metastases, yet a significant number of patients undergo unnecessary neck dissection to confirm nodal status. This study sought to predict the presence of nodal metastases in patients with SCC of the oral tongue using a convolutional neural network (CNN) that analyzed visual histopathology from the primary tumor alone. METHODS: Cases of SCC of the oral tongue were identified from the records of a single institution. Only patients with complete pathology data were included in the study. The primary tumors were randomized into 2 groups for training and testing, which was performed at 2 different levels of supervision. Board-certified pathologists annotated each slide. HALO-AI convolutional neural network and image software was used to perform training and testing. Receiver operator characteristic (ROC) curves and the Youden J statistic were used for primary analysis. RESULTS: Eighty-nine cases of SCC of the oral tongue were included in the study. The best performing algorithm had a high level of supervision and a sensitivity of 65% and specificity of 86% when identifying nodal metastases. The area under the curve (AUC) of the ROC curve for this algorithm was 0.729. CONCLUSION: A CNN can produce an algorithm that is able to predict nodal metastases in patients with squamous cell carcinoma of the oral tongue by analyzing the visual histopathology of the primary tumor alone.

Unmasking of left heart dilation following treatment for precapillary pulmonary hypertension.

A 13-year-old spayed female dog was referred for a history of tachypnea and dyspnea. Severe pulmonary hypertension was diagnosed based on tricuspid regurgitation velocities and 2-dimensional echocardiography. Left atrial size was normal at the time of this diagnosis. However, following treatment with a selective phosphodiesterase inhibitor, echocardiography revealed unmasking of left heart dilation. Key clinical message: If phosphodiesterase inhibition therapy is deemed appropriate in patients with hemodynamically important myxomatous mitral valvular disease, using the lowest effective dosage and careful monitoring with echocardiography ± thoracic radiographs should be considered.

Découverte de dilatation cardiaque gauche après traitement d'hypertension pulmonaire précapillaire. Une chienne stérilisée de 13 ans a été référée pour une histoire de tachypnée et de dyspnée. Une hypertension pulmonaire sévère a été diagnostiquée sur la base des vitesses de régurgitation tricuspidienne et de l'échocardiographie bidimensionnelle. La taille de l'oreillette gauche était normale au moment de ce diagnostic. Cependant, après un traitement avec un inhibiteur sélectif de la phosphodiestérase, l'échocardiographie a révélé une dilatation du coeur gauche.Message clinique clé :Si un traitement par inhibition de la phosphodiestérase est jugé approprié chez les patients présentant une pathologie valvulaire mitrale myxomateuse évidente et hémodynamiquement significative, l'utilisation de la dose efficace la plus faible et une surveillance attentive par échocardiographie avec ou sans radiographies thoraciques doivent être envisagées.(Traduit par Dr Serge Messier).

Evaluation of Allyl Isothiocyanate as a Soil Fumigant for Tomato (Lycopersicon esculentum Mill.) Production.

Fusarium wilt (Fusarium oxysporum f. sp. lycopersici), root-knot nematodes (Meloidogyne spp.), and purple nutsedge (Cyperus rotundus L.) are among the most damaging soilborne pests for tomato (Lycopersicon esculentum Mill.) production in the southeastern United States. Allyl isothiocyanate (allyl ITC) was evaluated as a potential fumigant alternative for control of soilborne pathogens, nematodes, and weeds. Shank- or drip-injected allyl ITC at rates ranging from 221 to 367 kg ha-1 exhibited excellent performance, reducing the recovery of total F. oxysporum from treated soils. Shank- or drip-injected allyl ITC at 367 kg ha-1 provided equivalent control of C. rotundus compared with 1,3-dichloropropene + chloropicrin and metam potassium, respectively. Totally impermeable film (TIF) did not further reduce the recovery of F. oxysporum and various nematodes from soil treated with allyl ITC compared with virtually impermeable film (VIF). However, TIF mulch significantly improved C. rotundus control versus shank- or drip-injected allyl ITC treatments under VIF mulch. Overall, allyl ITC is an effective methyl bromide alternative against F. oxysporum, C. rotundus, and plant-parasitic nematodes Criconemella spp. and Hoplolaimus spp. in plasticulture tomato production.

Impact of repeated fumigant applications on soil properties, crop yield, and microbial communities in a plastic-mulched tomato production system.

Pre-plant soil fumigation is widely applied to control nematodes, soil-borne fungal pathogens, and weeds in vegetable crops. However, most of the research evaluating the effect of fumigants on crop yield and soil microbial communities has been done on single compounds despite growers mainly applying fumigant combinations. We studied the effect of different fumigant combinations (chloropicrin, 1,3-dichloropropene, and metam potassium) on soil properties, crop yield, and the soil bacterial and fungal microbiome for two consecutive years in a plastic-mulched tomato production system in Florida (United States). While combinations of fumigants did not improve plant productivity more than the individual application of these products, application of fumigants with >60 % chloropicrin did significantly increase yield. Fumigant combinations had no significant effect on bacterial diversity, but fumigants with >35 % chloropicrin reduced soil fungal diversity and induced temporary changes in the soil bacterial and fungal community composition. These changes included short-term increases in the relative abundance of Firmicutes and Ascomycota, as well as decreases in other bacterial and fungal taxa. Repeated fumigation reduced network complexity and the relative abundance of several predicted bacterial functions and fungal guilds, particularly after fumigation and at end of harvest (3-months post fumigation). A structural equation model (SEM) showed fumigants not only directly impact crop yield, but they can also indirectly determine variations in plant productivity through effects on the soil microbiome. Overall, this study increases our understanding of the environmental and agricultural impacts of fumigants in a plastic-mulched tomato production system.

Frailty as a Predictor of Post-Surgical Outcomes in Patients With Cutaneous Malignancies of the Scalp and Neck Requiring Flap Reconstruction.

BACKGROUND: Investigate the ability of frailty status to predict post-surgical outcomes in patients with cutaneous malignancies of the scalp and neck undergoing flap reconstruction. METHODS: National Surgical Quality Improvement Program database was used to isolate patients with cutaneous malignancies of the scalp and neck who underwent surgical resection between 2015 to 2019. Univariate and multivariate analyses were performed to determine if frailty score correlated with negative post-operative outcomes. Receiver operating characteristic (ROC) curves allowed testing of the discriminative performance of age versus frailty. RESULTS: This study demonstrated an independent correlation between frailty and major complications as well as non-home discharge. In ROC curve analysis, frailty demonstrated superior discrimination compared to age for predicting major complications. CONCLUSION: Our study demonstrated an association between increasing frailty and major complications as well as the likelihood of a non-home discharge. When compared to age, frailty was also shown to be a better predictor of major complications.

Spatial and temporal distribution of Scirtothrips dorsalis (Thysanoptera: Thripidae) and their natural enemies in Florida strawberry fields.

Given the recent invasion of Scirtothrips dorsalis Hood in North America, there is limited information regarding their distribution and population dynamics in cultivated small fruit crops. Therefore, we investigated the spatial and temporal distribution of S. dorsalis and their natural enemies in commercially produced strawberry fields in Florida. During 2 consecutive strawberry production seasons, 4 and 6 geographically separated strawberry fields were sampled and were divided into grids with 30-40 sampling points per field. At each sampling point, 4-5 leaf and flower samples were collected, and sticky traps were deployed. We quantified the occurrence of S. dorsalis as well as potential natural enemies, including Orius spp., Geocoris spp., and other predators such as long-legged flies. During both years, most of the S. dorsalis and natural enemies were found on field borders, and counts progressively diminished further into the interiors of plots and away from field edges. Cluster and outlier analysis revealed that S. dorsalis formed statistically significant clusters and that these "hot spots" remained in the same general locations throughout the season. There was a strong relationship between the occurrence of natural enemies and the presence of S. dorsalis, but the number of natural enemies was generally low compared to S. dorsalis. Our results indicate that targeting field borders for chemical control or planting strawberries away from natural areas containing potential alternative hosts for thrips may be an effective strategy for reducing agricultural inputs; however, future field assessments are needed to determine if these methods could replace the treatment of entire fields.

Thyroid Cancer Incidence and Tumor Size in New Mexico American Indians, Hispanics, and Non-Hispanic Whites, 1992 to 2019.

BACKGROUND: The incidence of thyroid cancer in the United States has risen dramatically since the 1970s, driven by an increase in the diagnosis of small tumors. There is a paucity of published New Mexico (NM) specific data regarding thyroid cancer. We hypothesized that due to New Mexico's unique geographic and cultural makeup, the incidence of thyroid cancer and tumor size at diagnosis in this state would differ from that demonstrated on a national level. METHODS: The New Mexico Tumor Registry (NMTR) was queried to include all NM residents diagnosed with thyroid cancer between 1992 and 2019. For 2010 to 2019, age-adjusted incidence rates were calculated via direct method using the 2000 United States population as the adjustment standard. Differences in incidence rate and tumor size by race/ethnicity and residence (metropolitan vs non-metropolitan) were assessed with rate ratios between groups. For 1992 to 2019, temporal trends in age-adjusted incidence rates for major race/ethnic groups in NM [Non-Hispanic White (NHW), Hispanic, and American Indian (AI)] were assessed by joinpoint regression using National Cancer Institute software. RESULTS: Our study included 3,161 patients for the time period 2010 to 2019, including NHW (1518), Hispanic (1425), and AI (218) cases. The overall incidence rates for NM AIs were lower than those for Hispanics and NHWs because of a decreased incidence of very small tumors (<1.1 cm). The incidence rates for large tumors (>5.1 cm) was equivalent among groups. In the early 2000s, Hispanics also had lower rates of small tumors when compared to NHWs but this trend disappeared over time. CONCLUSION: AIs in New Mexico have been left out of the nationwide increase in incidental diagnosis of small thyroid tumors. This same pattern was noted for Hispanics in the early 2000s but changed over time to mirror incidence rates for NHWs. These data are illustrative of the health care disparities that exist among New Mexico's population and how these disparities have changed over time.

Depletion of JunB increases adipocyte thermogenic capacity and ameliorates diet-induced insulin resistance.

The coexistence of brown adipocytes with low and high thermogenic activity is a fundamental feature of brown adipose tissue heterogeneity and plasticity. However, the mechanisms that govern thermogenic adipocyte heterogeneity and its significance in obesity and metabolic disease remain poorly understood. Here we show that in male mice, a population of transcription factor jun-B (JunB)-enriched (JunB+) adipocytes within the brown adipose tissue exhibits lower thermogenic capacity compared to high-thermogenic adipocytes. The JunB+ adipocyte population expands in obesity. Depletion of JunB in adipocytes increases the fraction of adipocytes exhibiting high thermogenic capacity, leading to enhanced basal and cold-induced energy expenditure and protection against diet-induced obesity and insulin resistance. Mechanistically, JunB antagonizes the stimulatory effects of PPARγ coactivator-1α on high-thermogenic adipocyte formation by directly binding to the promoter of oestrogen-related receptor alpha, a PPARγ coactivator-1α downstream effector. Taken together, our study uncovers that JunB shapes thermogenic adipocyte heterogeneity, serving a critical role in maintaining systemic metabolic health.

Outcomes of Carotid Body Tumor Management with Active Surveillance.

OBJECTIVES: To assess outcomes of carotid body tumors (CBTs) managed with active surveillance. METHODS: Retrospective chart review of CBTs managed with active surveillance from 2001 to 2019. RESULTS: A total of 115 cases were identified during chart review. Sixty-five of these patients were managed with active surveillance, and 11 patients had bilateral tumors for a total of 76 tumors. Follow-up records with symptomatic outcomes were available for 51 patients, and 47 tumors had follow-up imaging. Thirty-one (66%) actively surveilled CBTs remained stable or decreased in size while 16 (34%) increased in size. Patients undergoing active surveillance developed symptoms in 12 cases, 6 of these patients underwent surgical intervention. Nine CBTs managed with active surveillance (18%) were ultimately resected. The majority of patients who did not undergo surgical intervention never developed symptoms (36/42, 86%). CONCLUSIONS: Active surveillance may be a reasonable approach for a subset of CBTs.

Lymph Node Metastases in Papillary Thyroid Carcinoma can be Predicted by a Convolutional Neural Network: a Multi-Institution Study.

OBJECTIVES: The presence of nodal metastases in patients with papillary thyroid carcinoma (PTC) has both staging and treatment implications. However, lymph nodes are often not removed during thyroidectomy. Prior work has demonstrated the capability of artificial intelligence (AI) to predict the presence of nodal metastases in PTC based on the primary tumor histopathology alone. This study aimed to replicate these results with multi-institutional data. METHODS: Cases of conventional PTC were identified from the records of 2 large academic institutions. Only patients with complete pathology data, including at least 3 sampled lymph nodes, were included in the study. Tumors were designated "positive" if they had at least 5 positive lymph node metastases. First, algorithms were trained separately on each institution's data and tested independently on the other institution's data. Then, the data sets were combined and new algorithms were developed and tested. The primary tumors were randomized into 2 groups, one to train the algorithm and another to test it. A low level of supervision was used to train the algorithm. Board-certified pathologists annotated the slides. HALO-AI convolutional neural network and image software was used to perform training and testing. Receiver operator characteristic curves and the Youden J statistic were used for primary analysis. RESULTS: There were 420 cases used in analyses, 45% of which were negative. The best performing single institution algorithm had an area under the curve (AUC) of 0.64 with a sensitivity and specificity of 65% and 61% respectively, when tested on the other institution's data. The best performing combined institution algorithm had an AUC of 0.84 with a sensitivity and specificity of 68% and 91% respectively. CONCLUSION: A convolutional neural network can produce an accurate and robust algorithm that is capable of predicting nodal metastases from primary PTC histopathology alone even in the setting of multi-institutional data.

Impact of fumigants on non-target soil microorganisms: a review.

Fumigants have been used for decades to control soil-borne pathogens of high-value crops, and increasing evidence indicates they can affect non-target soil microbial communities. Understanding the impacts of these products on soil microorganisms is of critical importance not only for evaluating their environmental safety, but also because soil microbial communities have a central role in soil quality and nutrient cycling, plant growth, and crop production. Thus, we conducted a systematic review and metanalysis study of fumigant impacts on non-target soil microorganisms. In general, we found that fumigation decreases the bacterial diversity and abundance of total bacteria and nitrogen-cycling genes by approximately 10-50% during the first four weeks after application compared to non-treated soils. These decreases appear transient and tend to diminish or disappear after four weeks. Increases in bacterial diversity and abundance can occur after fumigation but are less common. Fumigant application can also alter bacterial community composition during the first six weeks after treatment by significantly increasing and/or decreasing the relative abundance of bacterial taxa involved in key soil functions such as N-cycling and plant-growth promotion. Knowledge gaps and areas where future research efforts should be prioritized to improve our understanding of the impact of organic fumigants on non-target soil microorganisms are discussed.

Epithelioid Hemangioendothelioma with WWTR1-CAMTA1 Fusion in the Parotid Gland Presenting as Bell's Palsy.

Epithelioid hemangioendothelioma is a rare tumor of endothelial differentiation most commonly arising in soft tissue, liver, and lung, following a variable clinical course. Most cases are characterized by a t(1;3)(p36;q23-25) resulting in WWTR1-CAMTA1 fusion. Only five epithelioid hemangioendothelioma have been previously reported arising in the salivary glands. None have presented as Bell's palsy. In the current case, a 37-year-old female presented with a longstanding complaint of pain and fullness in the right preauricular region and progressive episodes of Bell's palsy and facial nerve weakness. Surgical resection showed a tumor comprised of atypical cells with occasional intracytoplasmic vacuoles in a fibromyxoid stroma. Immunohistochemical stains demonstrated the neoplastic cells expressed ERG, CD31, and CD34, confirming vascular differentiation. Fluorescence in situ hybridization revealed a t(1;3)(p36;q25), confirming a diagnosis of epithelioid hemangioendothelioma. At 12-month follow-up, the patient has no evidence of disease.

Sorghum cover crop and repeated soil fumigation for purple nutsedge management in tomato production.

BACKGROUND: Purple nutsedge (Cyperus rotundus L.) is one of the most common and troublesome weeds. Field research trials were conducted in Florida to evaluate the effects of repeated fumigation and a sorghum sudangrass [Sorghum bicolor S. bicolor var. sudanense (Piper) Stapf.] cover crop on purple nutsedge (Cyperus rotundus L.) populations over time in tomato (Solanum lycopersicum L.) production. RESULTS: Among the soil fumigants, DMDS + metam potassium was consistently the most effective treatment in terms of in-crop purple nutsedge control. Plots with a sorghum cover crop during the fallow period exhibited higher purple nutsedge density during the tomato growing season as well as higher purple nutsedge shoot and tuber densities during the fallow period compared to the chemical fallow. CONCLUSION: DMDS + metam potassium was the most effective fumigant for purple nutsedge control. Unexpectedly, a sorghum cover crop during the fallow period was less effective than chemical fallow for purple nutsedge management, and therefore we do not recommend the use of sorghum cover crops for weed management in fields where purple nutsedge is the major weed species.

Long-term effect of fumigation and a sorghum cover crop on broadleaf and grass weeds in plastic-mulched tomato.

BACKGROUND: Broadleaf and grass weeds can adversely affect growth and productivity of plastic-mulched tomato (Solanum lycopersicum L.). Two, four-year research trials were conducted in Florida to evaluate the effect of repeated fumigation and chemical fallow versus a sorghum [Sorghum bicolor S. bicolor var. sudanense (Piper) Stapf.] cover crop on broadleaf and grass weeds in tomato plasticulture. RESULTS: 1,3-Dichloropropene (1,3-D) + chloropicrin (Pic), dimethyl disulfide (DMDS) + Pic, and DMDS + metam potassium effectively controlled broadleaf weeds in-crop and reduced densities by 79-98% compared to the non-fumigated control but provided inconsistent control of grass weeds. DMDS + metam potassium was generally the most effective fumigant. During the fallow period, a sorghum cover crop effectively reduced broadleaf weed density than the chemical fallow, while chemical fallow effectively reduced grass weed density than the cover crop. The fallow program did not affect in-crop densities of broadleaf and grass weeds. In some measurements, the evaluated fumigants resulted in taller tomato plants and higher yield compared to the non-fumigated control. CONCLUSION: We conclude that the evaluated soil fumigants effectively control broadleaf and grass weeds. Planting a sorghum cover crop effectively suppresses broadleaf weeds but not grasses during the fallow period. However, this suppression does not result in reduced weed density in-crop despite the fact that similar weed species were observed in both time periods. © 2020 Society of Chemical Industry.

Fallow management input strategies for weed management in Florida cabbage production.

BACKGROUND: Fallow period weed management is an important Florida production consideration due to its duration and impact on the cash crop. Cover cropping is a valuable summer fallow period option for weed suppression. Sorghum-sudangrass is a commonly used, competitive, and allelopathic Florida summer cover crop. The effect of increased seeding rate, a herbicide application, and added fertilizer inputs during the fallow period on the cover crop, weed populations, and cabbage yield was explored and compared to nontreated and chemical fallow controls. RESULTS: Increased sorghum-sudangrass seeding rates had no effect on the resultant stand density or biomass compared to the standard seeding rate. Cover cropping did not consistently suppress purple nutsedge, Florida pusley, or wild radish and added fertilizer inputs produced variable results. S-metolachlor enhanced purple nutsedge suppression at low densities but did not improve grass, wild radish, and Florida pusley suppression. CONCLUSIONS: Increased fallow management inputs did not consistently enhance weed suppression or provide benefit to the cash crop. Sorghum-sudangrass suppressed Poaceae densities during the fallow period but did not adequately suppress nutsedge, wild radish, or Florida pusley densities over time. We conclude that weed management inputs should be focused on the cash crop and that enhanced management during the fallow period has limited benefit. © 2021 Society of Chemical Industry.

Efficacy of metam potassium on Fusarium oxysporum, Macrophomina phaseolina, Meloidogyne javanica, and seven weed species in microcosm experiments.

BACKGROUND: Metam potassium (metam-K) is a soil fumigant widely used to control plant pathogens, nematodes, and weeds in Florida plasticulture production. The objective of the study was to determine the efficacy of metam-K against Fusarium oxysporum, Macrophomina phaseolina, Meloidogyne javanica, and seven important weed species under controlled conditions. The optimal rates generated in this study provide insight into the efficacy of metam-K for field application. RESULTS: F. oxysporum and M. phaseolina were similarly sensitive toward metam-K with a 90% effective concentration (EC90 ) of 478 and 493 µmol kg-1 soil, respectively. Meloidogyne javanica was the most sensitive pest with an EC90 of 25 µmol kg-1 which is similar to previous studies. Chenopodium album was the most sensitive weed seed with an EC90 of 260 µmol kg-1 . Geranium carolinianum and Medicago lupulina were the least sensitive weed species with EC90 values of 786 and 567 µmol kg-1 , respectively. CONCLUSION: It is apparent from these results that metam-K can effectively control important pests in Florida plasticulture production systems with the correct application rate and adequate exposure of pest to the fumigant.

Terrain-Perception-Free Quadrupedal Spinning Locomotion on Versatile Terrains: Modeling, Analysis, and Experimental Validation.

Dynamic quadrupedal locomotion over rough terrains reveals remarkable progress over the last few decades. Small-scale quadruped robots are adequately flexible and adaptable to traverse uneven terrains along the sagittal direction, such as slopes and stairs. To accomplish autonomous locomotion navigation in complex environments, spinning is a fundamental yet indispensable functionality for legged robots. However, spinning behaviors of quadruped robots on uneven terrain often exhibit position drifts. Motivated by this problem, this study presents an algorithmic method to enable accurate spinning motions over uneven terrain and constrain the spinning radius of the center of mass (CoM) to be bounded within a small range to minimize the drift risks. A modified spherical foot kinematics representation is proposed to improve the foot kinematic model and rolling dynamics of the quadruped during locomotion. A CoM planner is proposed to generate a stable spinning motion based on projected stability margins. Accurate motion tracking is accomplished with linear quadratic regulator (LQR) to bind the position drift during the spinning movement. Experiments are conducted on a small-scale quadruped robot and the effectiveness of the proposed method is verified on versatile terrains including flat ground, stairs, and slopes.

The effect of preoperative embolization on surgical outcomes for carotid body tumor resection.

OBJECTIVE: Compare the effects of preoperative embolization for carotid body tumor resection on surgical outcomes to carotid body tumor resections without preoperative embolization. METHODS: Single-center retrospective review of all consecutive patients who underwent carotid body tumor resection from 2001 to 2019. Surgical outcomes with emphasis on operative time (estimated blood loss and cranial nerve injury) of patients undergoing carotid body tumor resection following preoperative embolization were compared to those undergoing resection alone using unpaired Student's t-test and Fisher's exact test. RESULTS: Forty-six patients (15% male, mean age 50 ± 15 years) underwent resection of 49 carotid body tumors. Patients undergoing preoperative embolization (n = 20 (40%)) had larger mean tumor size (4.0 ± 0.7 vs 3.2 ± 1 cm, p = 0.006), increased Shamblin II/III tumor classification (18 (90%) vs 22 (76%), p < 0.001), operative time (337 ± 195 vs 199 ± 100 min, p = 0.004), and cranial nerve injuries overall (8 (40%) vs 2 (10%), p = 0.01) compared to patients undergoing resection without preoperative embolization (n = 29 (60%)). In subgroup analysis of Shamblin II/III classification tumors (n = 40), preoperative embolization (n = 18) was associated with increased tumor size (4.1 ± 0.6 vs 3.5 ± 0.9 cm, p = 0.01), operative time (351 ± 191 vs 244 ± 105 min, p = 0.02), and cranial nerve injury overall (8 (44%) vs 2 (9%), p = 0.03) compared to resections alone (n = 19). In further subgroup analysis of large (⩾ 3 cm) tumors (n = 37), preoperative embolization (n = 18) was associated with increased operative time (350 ± 191 vs 198 ± 99 min, p = 0.006) and cranial nerve injury overall (8 (44%) vs 2 (11%), p = 0.03) compared to resections alone (n = 19). There were no significant differences in estimated blood loss, transfusion requirement, or hematoma formation between any of the embolization and non-embolization subgroups. CONCLUSION: After controlling for tumor Shamblin classification and size, carotid body tumor resections following preoperative embolization were associated with increased operative time and inferior surgical outcomes compared to those tumors undergoing resection alone. Nonetheless, such results remain susceptible to the confounding effects of individual tumor characteristics often used in the decision to perform preoperative embolization, underscoring the need for prospective studies evaluating the utility of preoperative embolization for carotid body tumors.

Airway Management in Substernal Goiter Surgery.

OBJECTIVE(S): To review the experience of 3 hospitals with airway management during surgery for substernal goiter and identify preoperative factors that predict the need for advanced airway management techniques. METHODS: A retrospective chart review between 2009 and 2017 of patients with substernal goiter treated surgically at 1 of 3 hospitals was performed. RESULTS: Of the 179 patients included in the study, 114 (63.7%) were female, the mean age was 55.1 years (range 20-87). Direct laryngoscopy or videolaryngoscopy was successful in 162 patients (90.5%), with fiberoptic intubation used for the remaining 17 patients. Thirty-one patients (17.4%) required >1 intubation attempt; these patients had larger thyroids (201.3 g, 95% CI 155.3-247.2 g) than those intubated with 1 attempt (144.7 g, 95% CI 127.4-161.9 g, P = .009). Those who required >1 attempt had higher BMI (38.3, 95% CI 34.0-42.6 vs. 32.9, 95% CI 31.5-34.3, P = .02). Mallampati score was found to be a predictor of >1 attempt, though tracheal compression and tracheal shift were not found to be predictors of >1 attempt, nor was the lowest thyroid extent. BMI was the only independent factor on multivariable logistic regression of needing >1 attempt (odds ratio 1.056, 95% CI 1.011-1.103, P = .015). CONCLUSIONS: The majority of patients undergoing surgery for substernal goiter can be intubated routinely without the need for fiberoptic intubation. Thyroid-specific factors such as lowest thyroid extent and mass effect of the gland on the trachea do not appear to be associated with difficult intubation, whereas classic patient factors associated with difficulty intubation are. LEVEL OF EVIDENCE: VI.