Prevalence of Occult Central Lymph Node Metastasis by Tumor Size in Papillary Thyroid Carcinoma: A Systematic Review and Meta-Analysis.

BACKGROUND: While papillary thyroid carcinoma (PTC) is associated with high occult central neck metastasis (CNM) rates, prophylactic central neck dissection (pCND) is controversial. This meta-analysis aims to look at the occult CNM rate according to tumor size. METHODS: A literature search was conducted in PubMed from inception to April 2023. Inclusion criteria were primary studies that determined occult CNM rates in cN0 PTC by tumor size. Heterogeneity, influential case diagnostics, and proportion data were evaluated with Cochran's Q-test, Baujat plots and Forest plots, respectively. RESULTS: Fifty-two studies were included in this meta-analysis. The findings demonstrated an occult CNM rate of 30.3% for tumors ≤ 5 mm, 32.7% for tumors ≤ 1 cm, 46.0% for tumors between 1 and 2 cm, 43.1% for tumors between 2 and 4 cm, and 61.2% for tumors > 4 cm. The heterogeneity of each study group was high, though no publication bias was noted. While there was a trend towards increased occult CNM rates with larger tumors, comparisons between different size cutoffs varied in significance. CONCLUSION: This comprehensive review affirms that occult CNM is high and that an ipsilateral pCND can be justified in all PTC patients for accurate differentiation between Stage I and Stage II disease and its clinical implications.

The Use of Tenofovir Disoproxil Fumarate and Tenofovir Alafenamide for Preventing Vertical Transmission of Hepatitis B.

BACKGROUND: Mother-to-child transmission (MTCT) of hepatitis B virus may occur in highly viremic mothers despite the infants receiving appropriate immunoprophylaxis. We aimed to review tenofovir disoproxil fumarate (TDF) and tenofovir alafenamide (TAF) data for preventing MTCT. METHODS AND DATA SELECTION: We performed a systematic review between January 1, 2015 and December 31, 2021 on PUBMED, EMBASE, Cochrane, CNKI, and Wanfang databases. Data was extracted from randomized controlled trials or cohort studies in English or Chinese. The outcomes of interest included the efficacy and safety of TDF versus TAF or TDF/TAF versus placebo for preventing MTCT (PROSPERO registration: CRD42021256656). RESULTS: Data from forty-three studies (13 randomized controlled trials, 30 nonrandomized studies) were included in the review. All infants in the studies received appropriate immunoprophylaxis. Among 3656 highly viremic mothers treated with TDF, hepatitis B virus DNA suppression to the levels <200,000 IU/mL at delivery was achieved in 34% to 100% of mothers. MTCT rates were 0 to 5% and 2 to 83% in mothers treated with TDF and in those who received no treatment, respectively. Congenital malformation rates were 0 to 2.1% in the TDF groups, which did not differ from the nontreated groups. Similar findings were reported in 4 studies that enrolled 326 mothers for maternal TAF therapy, resulting in 0% of MTCT and 0% infant malformation. All studies observed that TDF or TAF maternal therapy reduced MTCT rates significantly without safety concerns when compared with untreated groups, except for 1 RCT that failed the therapeutic endpoint. CONCLUSIONS: TDF is well established for preventing MTCT in highly viremic mothers, whereas TAF may become an option as data emerges.

Incidence of Dysphonia and Dysphagia Exceeds Recurrent Laryngeal Nerve Injury During Thyroid Surgery.

OBJECTIVES: To determine the prevalence of separate and combined voice and swallowing impairments before and after total thyroidectomy and to delineate risk factors for these symptoms. METHODS: Retrospective review of 592 consecutive patients who underwent total thyroidectomy from July 2003 to August 2015. RESULTS: Combined voice and swallowing problems occurred preoperatively in 4.7% (11/234), 3.3% (3/92), and 6.0% (16/266) of patients with malignancy, hyperthyroidism, and benign euthyroid disease, respectively. Postoperatively, prevalence was 5.1%, 2.2%, and 1.9%, respectively. Benign euthyroid disease (20.7%) had the greatest risk of preoperative dysphagia (P = 0.003) and the largest glands (P < 0.001). Comparing before and after surgery, the cancer and benign euthyroid groups had decreased dysphagia (cancer: 11.5% vs. 6.0%, P = 0.034; benign: 20.7% vs. 3.8%, P < 0.001) but increased dysphonia (cancer: 19.2% vs. 28.6%, P = 0.017; benign: 15.8% vs. 27.1%, P = 0.002). Overall, 23/592 (3.9%) developed new dysphagia and 122/592 (20.6%) developed new dysphonia after surgery. Intraoperative recurrent laryngeal nerve transection occurred in 12 cases (2.0%). CONCLUSIONS: Total thyroidectomy resolved dysphagia but increased dysphonia in benign and malignant euthyroid patients. Voice and swallowing problems following thyroidectomy occurred more frequently than intraoperative recurrent laryngeal nerve transection, confirming symptoms often occur in the absence of suspected nerve injury.

Outcomes of Early Versus Delayed Completion Thyroidectomy for Malignancy.

PURPOSE: To determine whether time interval between hemi-thyroidectomy and subsequent completion thyroidectomy impacts outcomes. METHODS: Retrospective review of 68 patients having completion thyroidectomy from August 2012 to December 2019. Patients were separated into two groups based on the time interval between surgeries: early (≤10 days) or delayed (≥90 days). RESULTS: Patients who underwent delayed completion thyroidectomy (n = 17) had significantly higher rates of hypocalcemia and/or hypoparathyroidism (P = .03) and higher rates of requiring postoperative hospitalization (P=.07) compared to those who underwent early completion thyroidectomy (n = 51). Delayed completion had significantly lower risk of developing one or more of dysphonia, dysphagia, or vocal cord paresis postoperatively (P=.02). No patients developed hematoma or wound infection. CONCLUSIONS: Delayed completion thyroidectomy is associated with increased rates of hypocalcemia, but lower rates of dysphonia and dysphagia. Given the low risk of long-term complications in both groups, it may be beneficial to perform completion thyroidectomy early in order to expedite cancer treatment.

Intrahepatic microbes govern liver immunity by programming NKT cells.

The gut microbiome shapes local and systemic immunity. The liver is presumed to be a protected sterile site. As such, a hepatic microbiome has not been examined. Here, we showed a liver microbiome in mice and humans that is distinct from that of the gut and is enriched in Proteobacteria. It undergoes dynamic alterations with age and is influenced by the environment and host physiology. Fecal microbial transfer experiments revealed that the liver microbiome is populated from the gut in a highly selective manner. Hepatic immunity is dependent on the microbiome, specifically the bacteroidetes species. Targeting bacteroidetes with oral antibiotics reduced hepatic immune cells by approximately 90%, prevented antigen-presenting cell (APC) maturation, and mitigated adaptive immunity. Mechanistically, our findings are consistent with presentation of bacteroidetes-derived glycosphingolipids to NKT cells promoting CCL5 signaling, which drives hepatic leukocyte expansion and activation, among other possible host-microbe interactions. Collectively, we reveal a microbial/glycosphingolipid/NKT/CCL5 axis that underlies hepatic immunity.

Use of fibrin adhesive for preventing pharyngocutaneous fistula in total laryngectomy.

BACKGROUND: Minimizing pharyngocutaneous fistula after total laryngectomy is a perpetual focus for head and neck surgeons. Multiple intrinsic and extrinsic factors have been implicated in the wound healing process. Activated fibrin glue uniquely promotes healing as a tissue adhesive as well as a biochemical growth factor. METHODS: We present a pilot case series of total laryngectomy with simple pharyngeal closure with a single surgeon. Fibrin tissue adhesive was incorporated in all patients along with standardized pre-operative, operative, and post-operative care. Outcomes measured included pharyngocutaneous fistula rate, perioperative complications, and other wound complications as well as long term swallowing function and voice rehab outcomes. We also present a review of the literature for the theoretical basis of using fibrin glue as well as other similar applications. RESULTS: Fibrin tissue adhesive was successfully used in 18 consecutive patients undergoing total laryngectomy and pharyngoplasty. Despite the presence of a variety of wound healing risk factors including prior radiation and tobacco use, there were no pharyngocutaneous fistulas or other significant wound problems. No locoregional or free tissue overlay flap was done. CONCLUSION: Fibrin tissue glue is a readily available, easily applied, and cost-effective adjunct that may reduce pharyngocutaneous fistula.

A Randomized Single-Blinded Trial of Ibuprofen- versus Opioid-Based Primary Analgesic Therapy in Outpatient Otolaryngology Surgery.

OBJECTIVE: To compare the efficacy of pain control and opioid consumption between patients who receive opioid as primary analgesic therapy and those who receive ibuprofen. STUDY DESIGN: Prospective randomized trial. SETTING: Tertiary care academic hospital. SUBJECT AND METHODS: Adult patients undergoing outpatient otolaryngology surgery were assigned to take hydrocodone/acetaminophen or ibuprofen for postoperative analgesia. Patient-recorded pain scores and analgesic consumption were analyzed. RESULTS: Out of 185 recruits, 108 (58%) completed responses. Fifty-six patients (52%) received opioid medication for primary analgesic treatment versus 52 (48%) who received ibuprofen. There was no difference in reported pain scores between the treatment groups. Those who received ibuprofen as primary therapy reported a significantly lower consumption of opioid medication at 2.04 tablets/pills (95% CI, 0.9-3.1) versus 4.86 (3.6-6.1; P = .001). Based on multivariate analysis, male sex and older age exhibited lower reported pain scores, while older age and use of ibuprofen as primary therapy exhibited lower opioid requirements. CONCLUSION: For postoperative pain management in outpatient otolaryngology procedures, ibuprofen as primary therapy can provide equally effective pain control as compared with hydrocodone/acetaminophen while decreasing overall opioid requirement. Prescription pill counts are further described to help guide physician practices in the era of an opioid epidemic.