Noise level and surgeon stress during thyroidectomy in an endocrine surgery operating room.

INTRODUCTION: Noise in the operating room is an ongoing problem that impacts the outcome of any surgery. Noise as a stressor can produce a startling reaction and activate the fight or flight response of the autonomic and endocrine systems. The psychobiology of stress as assessed by salivary cortisol level is a sensitive measure of allostatic load. This study aims to correlate, both subjectively and objectively, the salivary cortisol levels of the surgeon with noise level measurement in an endocrine surgery operating room (OR). MATERIALS AND METHODS: A prospective observational study was conducted in the Endocrine surgery OR of a tertiary care center. We recorded the noise from the shifting in of patients in the OR to shifting out using a digital sound level meter. The operating surgeon (S) provided two salivary cortisol samples (normal salivary cortisol <5 nmol/L), one baseline and another after the procedure. The questionnaire for the assessment of distraction during thyroidectomy was filled in by the S at the end of the procedure. Salivary cortisol levels were analyzed using SLV-4635 (formerly SLV-2930) DRG Instruments GmbH German using the ELISA technique. Statistical analysis was performed using SPSS 22.0. RESULTS: A total of 37 procedures with 74 salivary cortisol samples and 259 questionnaire responses from S were analyzed. All patients with only benign FNAC were operated upon (64.9% colloid). Mean TSH levels were 3.5 ± 6.7 mIU/L. The majority had a solitary thyroid nodule (STN) (25/37, 67.6%). Nineteen patients (51.3%) underwent open hemithyroidectomy, 10 patients total thyroidectomy, and eight patients endoscopic hemithyroidectomy. The mean noise level in the OR was 70 db. The maximum and minimum noise level in the OR was 90.06 and 51.81 dB, respectively. A total of 74 salivary cortisol samples from the S were collected (baseline and post-noise exposure) and mean cortisol levels were recorded. The surgeon was more significantly affected by surrounding noise, especially during critical phases 3 of surgery, mainly, RLN dissection and parathyroid dissection as recorded by their responses in the questionnaire (p = 0.003). The maximum value of post-operative salivary cortisol of surgeon was recorded as 23. 48 ng/mL and the minimum value recorded was 0.49 ng/mL. The difference in baseline cortisol and post-noise exposure cortisol levels of surgeon was found to be significant (p < 0.001). Maximum and mean noise levels were significantly associated with post-noise exposure salivary cortisol elevation in the surgeon (p = 0.032 and 0.014, respectively). The noise levels during RLN dissection were borderline significant with the post-noise exposure salivary cortisol of the surgeon (p = 0.055). CONCLUSION: Our research is the first such study which has been done to assess noise levels and their effect on thyroidectomy using objective salivary cortisol measurement. It challenges the misconstrued notion that visceral surgeries requiring lesser instruments are not associated with noise-related stress. Noise is a major distraction and the effect of long-term effect on the entire surgical team needs to be studied.

Mammography and Digital Breast Tomosynthesis in Granulomatous and Nongranulomatous Mastitis.

INTRODUCTION: Digital Mammography (DM) is extensively used for breast imaging however, lesion visibility is often limited by overlapping tissues, which affects lesion characterization. Digital breast tomosynthesis (DBT) reduces the effect of overlapping tissues and helps in revealing obscured findings. We aimed to describe the mammographic findings in granulomatous and non-granulomatous mastitis and assess the utility of adjunctive DBT in lesion characterization. MATERIALS AND METHODS: DM and DBT images of histo-pathologically diagnosed cases of granulomatous (GM) and non-granulomatous mastitis (NGM) were reviewed according to the BI-RADS lexicon. Presence of contiguous/ interconnected lesions, tubular densities, interspersed hypodensities/fat densities within the involved areas were also assessed. The perceived utility of adjunct DBT was scored from 0-2. RESULTS: Of 33 reviewed patients (24 GM, 9 NGM; median age 39 years, range 24-78); 13/33 (39.4%) were under 35 years of age. DBT detected masses in 24/33 (72.7%), whereas only 15/33 (45.4%) were visible on DM alone. Contiguous or inter-connected lesions were found in 10/33 (30.3%) cases. Tubular extensions were seen in 14 cases and interspersed hypodensities in 15. None of the enlarged lymph nodes had irregular shape or indistinct margins or loss of fatty hilum. DBT was able to categorize more lesions as BIRADS 4a or below, as compared to DM alone. CONCLUSIONS: Mammographic presence of multiple contiguous iso-dense masses, reniform contour of axillary lymph nodes with preserved fatty hilum despite a large area of breast involvement favour a benign etiology; especially if DBT reveals tubular extensions or lesions with inhomogenous low density areas within.

Indian endocrine surgery websites are they comparable?

INTRODUCTION: In modern day surgical practice, patients and their relatives garner more knowledge through websites rather than direct interaction with the consultant physician. We aimed to assess whether Indian endocrine surgery websites matched with their counterparts abroad. MATERIALS & METHODS: We identified 60 endocrine surgery websites worldwide and 12 endocrine surgery websites maintained by trained endocrine surgeons from India. The website parameters, demographic data of the websites, rank, and other parameters were assessed using a professional website (www.Alexa.com). An endocrine surgeon along with a technical website advisor rated the content, presentation, and likes from a scale of 1-5 (1 minimum score and 5 maximum score). RESULTS: A total of 72 individual endocrine surgery websites, out of which 60 were from abroad and 12 were from India, were analyzed. A majority of foreign websites were ranked (43/60), whereas 2/12 Indian websites were ranked (P < 0.0001). Foreign websites had a better landscape profile. Except for pancreatic facts, which were significantly different (P = 0.006) between Indian and foreign websites, there was no significant difference in thyroid facts, parathyroid facts, adrenal facts, photographs, videos, postop advice, contact information, publications, and complications. CONCLUSION: Most parameters were comparable in both groups. Postoperative advice and complications were present in only a few websites. A well-designed endocrine surgery website can aid both the patient and the treating physician.

Patient, thyroid, and surgeon related factors that make thyroidectomy difficult-cohort study.

INTRODUCTION: When thyroidectomy is performed under optimal conditions within a milieu of sound anatomical and physiological knowledge combined with meticulous surgical skills, complications are minimal. However, thyroidectomy can be difficult, and its complications can be life-threatening. The factors that predict difficult thyroidectomy can be patient-, thyroid-, or surgeon-related, and we aimed to study these three factors. . MATERIALS AND METHODS: This prospective study was performed in a tertiary care center between September 2016 and March 2017. We developed and validated modified thyroidectomy difficulty scale (TDS), with 11 items. Preoperatively, height, weight, neck length, and other parameters were recorded. Postoperatively, the modified TDS form was filled out by the surgeon and assistant, blinded to each other's responses. The minimum score was 19 and maximum was 54. The surgeon's baseline pulse rate was monitored throughout the procedure using a pulse oximeter probe that was On-The-Go (OTG) compatible. The probe was placed over the ear lobule/pinna of the surgeon and connected to an Android phone that was comfortably placed in the surgeon's pocket inside the gown. An application USB SPO2, was used in recording the pulse rate. RESULTS: A total of 52 patients undergoing hemi- or total thyroidectomy were included in this study. All had benign cytology on fine needle aspiration cytology (colloid, 71.42%). A total of 104 modified TDS questionnaires filled by the operating surgeon and assistant were analyzed. The pulse rate of the operating surgeon, as measured by the novel pulse oximeter, was recorded in 52 surgeries. The minimum score was 20, maximum score was 35.50, and mean score was 26.85 ± 2.80. There was an interobserver agreement in most domains of the modified TDS except mobility. The surgeon was found to have the maximum heart rate when performing recurrent laryngeal nerve (RLN) dissection in 38 patients (73.07%). DISCUSSION: We found that majority of the trainees found thyroidectomy to be a vigorously intense activity. Thyroidectomy is a demanding surgery, which requires meticulous identification and dissection of the RLN and parathyroid glands for optimum outcome.

Selection of appropriate statistical methods for data analysis.

In biostatistics, for each of the specific situation, statistical methods are available for analysis and interpretation of the data. To select the appropriate statistical method, one need to know the assumption and conditions of the statistical methods, so that proper statistical method can be selected for data analysis. Two main statistical methods are used in data analysis: descriptive statistics, which summarizes data using indexes such as mean and median and another is inferential statistics, which draw conclusions from data using statistical tests such as student's t-test. Selection of appropriate statistical method depends on the following three things: Aim and objective of the study, Type and distribution of the data used, and Nature of the observations (paired/unpaired). All type of statistical methods that are used to compare the means are called parametric while statistical methods used to compare other than means (ex-median/mean ranks/proportions) are called nonparametric methods. In the present article, we have discussed the parametric and non-parametric methods, their assumptions, and how to select appropriate statistical methods for analysis and interpretation of the biomedical data.

The technique of story-telling in thyroid diseases including surgery; useful or not.

INTRODUCTION: In the modern day busy clinical practice, the communication between patient/relative and caregiver is at a minimal level. The patients and relatives feel apprehensive when advised about surgical/interventional treatment. Storytelling is such a technique of health communication made in common man language and can operate in a virtual environment. This study aims to unveil the efficacy of storytelling technique on patients undergoing Hemithyroidectomy for benign cytology. MATERIALS & METHODS: A story of a lady (cartoon version), aged 25 years, with a benign solitary thyroid nodule (STN), who underwent uneventful hemithyroidectomy was depicted in this movie including the history, clinical examination, investigations, counseling, and the operative procedure, and the running time of the animation movie is 4 min. For developing this movie, high-end graphic work station and various multimedia authoring tools like Adobe Flash, Photoshop, Captivate, Maya and Final Cut Pro, were used. The story was shown to patients with clinical STN who were provisional candidates for surgery. The patients filled in the evaluation of multimedia animation questionnaire at the time of discharge. RESULTS: 60 patients participated in the study. One form was disqualified due to incomplete filling. Mean age was 35.45 ±â€¯12.8 years.55 (91.6%) were females. All patients were euthyroid. The mean weight of thyroid nodule was 40.80 ±â€¯20.79 g. The final histopathology was colloid in the majority. All participants found the movie useful. In the questionnaire, the mean score for improved understanding of the disease was 73.9 ±â€¯14.7, better organization of treatment was 78.6 ±â€¯13.1 stimulated interest in the relatives was 70.8 ±â€¯15.8 and saved unnecessary discussion with the consultant was 55.5 ±â€¯7.8. CONCLUSION: Story telling is a useful tool in health communication. With the widespread availability of high-speed internet and affordable mobile computing devices, story telling can be a useful tool to patients and relatives in decision making and in addition, saves valuable time of the treating consultant.

Natural ear rings.

Ear lobe keloids are common following ear piercing and these lesions are conspicuous and cosmetically unappealing. Multiple methods including surgery, radiotherapy, anti mitotic agents, silicone sheet, pressure clips, and cryotherapy have been used. The Challenge is to have a good cosmetic outcome with minimal recurrence.

Cross-cultural validity of the thyroid-specific quality-of-life patient-reported outcome measure, ThyPRO.

BACKGROUND AND PURPOSE: Thyroid diseases are common and often affect quality of life (QoL). No cross-culturally validated patient-reported outcome measuring thyroid-related QoL is available. The purpose of the present study was to test the cross-cultural validity of the newly developed thyroid-related patient-reported outcome ThyPRO, using tests for differential item functioning (DIF) according to language version. METHODS: The ThyPRO consists of 85 items summarized in 13 multi-item scales and one single item. Scales cover physical and mental symptoms, well-being and function as well as social and daily function and cosmetic concerns. Translation applied standard forward-backward methodology with subsequent cognitive interviews and reviews. Responses (N = 1,810) to the ThyPRO were collected in seven countries: UK (n = 166), The Netherlands (n = 147), Serbia (n = 150), Italy (n = 110), India (n = 148), Denmark (n = 902) and Sweden (n = 187). Translated versions were compared pairwise to the English version by examining uniform and nonuniform DIF, i.e., whether patients from different countries respond differently to a particular item, although they have identical level of the concept measured by the item. Analyses were controlled for thyroid diagnosis. DIF was investigated by ordinal logistic regression, testing for both statistical significance and magnitude (ΔR (2) > 0.02). Scale level was estimated by the sum score, after purification. RESULTS: For twelve of the 84 tested items, DIF was identified in more than one language. Eight of these were small, but four were indicative of possible low translatability. Twenty-one instances of DIF in single languages were identified, indicating potential problems with the particular translation. However, only seven were of a magnitude which could affect scale scores, most of which could be explained by sample differences not controlled for. CONCLUSION: The ThyPRO has good cross-cultural validity with only minor cross-cultural invariance and is recommended for use in international multicenter studies.

Itch itch with not a wink of sleep.

KEY CLINICAL MESSAGE: A 55-year-old man of dark complexion presented with multiple extensive swellings over the chest, right upper arm, and left shoulder for 10 years. Swellings were hyperpigmented, firm, and intensely pruritic especially over the chest region. The swellings progressed in size, extended, and developed satellite lesions over its 10 years history.

Quality of life (QoL) in patients with benign thyroid goiters (pre- and post-thyroidectomy): a prospective study.

BACKGROUND: Preservation of quality of life (QoL) seems an important therapeutic goal in patients with benign thyroid diseases. The aim of the present study was to investigate the impact of thyroidectomy on QoL in patients with benign goiters and to assess the significance of various factors affecting the outcome. METHODS: A prospective study consisting of 100 patients with benign goiters was conducted between November 2009 and March 2011. Patients completed a disease-specific ThyPRO questionnaire to assess QoL before and 6 months after thyroidectomy. Preoperative and postoperative scores were compared; and univariate and multivariate analyses were performed. RESULTS: Mean age of the patients was 40.5 years (M:F = 1:4.3); 82 % of the patients had nodular goiters, and the remaining 18 % had diffuse disease. None of the patients had overt thyroid dysfunction at the time they completed the questionnaire. Operative treatment for 54 % of the patients involved total thyroidectomy, whereas 46 % underwent hemithyroidectomy. None of these patients developed any permanent morbidity following surgery. Mean scores of QoL in the 12 domains examined were low and improved significantly (p < 0.001) after surgery: symptoms, 19.4 versus 0.7; fatigue, 29.5 versus 1.5; vitality, 44.4 versus 3.0; memory and concentration, 25.7 versus 1.5; nervousness, 29.6 versus 1.8; psychological well-being, 33.9 versus 1.3; mood swings, 34.9 versus 0.8; relationship, 15.4 versus 1.4; daily activity, 18.7 versus 1.3; sex life, 20.9 versus 1.7; appearance, 14.7 versus 1.0; and overall, 27 versus 5.5. On univariate analysis, weight of goiter was found to be significantly associated with improvement in the scores of the memory and concentration domain (p = 0.03). On multivariate analysis, factors significantly associated with improvement in different domains were young age (nervousness, p = 0.009), female gender (fatigue, p = 0.02), and weight of goiter (symptoms, p = <0.001; vitality, p = <0.001; and memory and concentration, p = <0.001). CONCLUSIONS: Patients with benign goiters experience significant improvement in QoL after thyroidectomy.

Assessment of swallowing function impairment in patients with benign goiters and impact of thyroidectomy: a case control study.

BACKGROUND: Swallowing-related quality of life (QoL) in patients with benign thyroid goiters is not much studied. The aim of this study was to assess swallowing function impairment in patients with benign goiters, compare it to a control population, and also find the impact of thyroidectomy and various factors on the outcome of swallowing function. METHODS: We performed a prospective case-control study from September 2009 to September 2011 which consisted of 124 patients who were to undergo primary thyroid surgery and 100 age- and sex-matched controls. A translated and validated modified swallowing quality-of-life (SWAL-QOL) questionnaire was used to assess patients' perception of dysphagia. Presurgery scores of patients and controls and pre- and postsurgery scores (>6 months after surgery) of patients were compared. RESULTS: The mean age of males and females in the control and patient groups were 37.7 vs. 39.5 years and 37.4 vs. 39.8 years, respectively. Twelve patients (9.7%) complained of dysphasia at presentation. Sixty-three patients (50.8%) underwent total thyroidectomy and 61 (49.2%) had hemithyroidectomy at the time of initial evaluation, 75, 23.4, and 1.6% of patients were euthyroid, hyperthyroid, and hypothyroid, respectively. Presurgery scores of patients in all of the 11 domains of the SWAL-QOL were lower compared to those of controls. Comparing separately with the matched controls, females had significant differences in nine domains (except for sleep and fatigue) of the SWAL-QOL questionnaire but males did not. Postoperatively, both male and female patients showed significant improvement in the scores of all the domains. Female gender, hyperthyroidism, thyroid nodularity, retrosternal extension, procedure, and weight of the resected specimen were the factors associated with significant improvement in various domains. CONCLUSION: Dysphagia seems to be an underestimated problem in patients with benign goiters. Uncomplicated thyroidectomy results in significant improvement in swallowing-related QoL irrespective of patient profile and extent of thyroidectomy.