Sonographic Appearance Is Useful in Predicting the Extent of Initial Operative Therapy for Thyroid Nodules Classified as "Suspicious for Malignancy".

The "suspicious for malignancy" (SFM) category of the Bethesda system for reporting thyroid cytopathology predicts an incidence of malignancy from 60 to 75 per cent. Recommended treatment is via either lobectomy or total/near total thyroidectomy. Identification of predictors of malignancy in this category would be useful in selecting the extent of operative therapy in these patients. Published literature has suggested that suspicious ultrasound (US) findings are useful in predicting malignancy in both the "benign," "atypia of uncertain significance/follicular lesion of uncertain significance," and "suspicious for follicular neoplasm" categories. We hypothesized that US would be similarly useful in patients with nodules classified as SFM. We performed a retrospective analysis of patients with fine needle aspiration biopsy (FNAB) classified as SFM who underwent thyroidectomy from October 2007 to October 2012. Data collected included symptoms, suspicious imaging findings, FNAB results, and histopathology results-all obtained via chart review. Findings were compared between patients with/without a diagnosis of thyroid malignancy. Significance was set at P < 0.05. Of 3839 FNAB, 53 were classified as SFM. Of these, 36 were available for review. Twenty-four (66.7%) carcinomas were identified-19 papillary, 3 follicular variant of papillary, 1 follicular, and 1 medullary. No symptoms/signs reached significance as a predictor of malignancy. A suspicious US appearance, however, was significantly associated with an underlying carcinoma (P = 0.002). Patients with a Bethesda system for reporting thyroid cytopathology report of SFM and suspicious US findings are statistically more likely to harbor an underlying malignancy. This information is useful in selecting which patients are most likely to benefit from total/near total thyroidectomy as opposed to lobectomy as the initial operative strategy.

Pilot Randomized Controlled Trial of Laparoscopic Cholecystectomy vs Active Nonoperative Therapy for the Treatment of Biliary Dyskinesia.

BACKGROUND: Despite widespread adoption by the surgical community, high-quality prospective data supporting the practice of laparoscopic cholecystectomy (LC) for the treatment of biliary dyskinesia (BD) are lacking. STUDY DESIGN: Adult patients meeting criteria for diagnosis of BD (Rome III symptoms, normal ultrasound, gallbladder ejection fraction < 38%) were randomized to either LC or a trial of nonoperative (NO) therapy with a low-dose neuromodulator (amitriptyline 25 mg/day). Patients in the NO arm were allowed to cross over to the surgical arm and remain in the study for any reason. Besides collection of basic demographics and medical/surgical history, patients were administered a standardized quality of life (QOL) assessment (Short Form-8) and a symptom-specific questionnaire (Rome III criteria) at enrollment and monthly through the study to assess the effect of treatment on biliary symptoms and overall QOL. RESULTS: Thirty patients were enrolled over 12 months (15 LC, 15 NO). In the LC group, 13 underwent LC, 1 refused surgery, 1 withdrew. In the NO group, 14 crossed over to the LC group (13 of whom had LC), yielding 26 patients who underwent LC. The SF-8 physical scores (PCS-8) were significantly improved at both the first and last follow-up visits (p < 0.0001, p = 0.0003, respectively). The SF-8 mental scores (MCS-8) were also significantly improved at both the first and last follow-up visits (p = 0.0187, p = 0.0017, respectively). With median follow-up of 12 months (range 3 to 14 months), all 26 reported relief of pain. CONCLUSIONS: This pilot study raises doubts regarding the feasibility of a randomized trial, presumably due to both clinician and patient bias toward LC and the lack of "gold-standard" nonoperative treatments. However, these prospective data indicate that, with careful patient selection (standardized symptom criteria/imaging methodology), LC results in pain relief and significant improvement in QOL in BD patients. Further prospective study of these findings is warranted.

The Integration of Adult Acute Care Surgeons into Pediatric Surgical Care Models Supplements the Workforce without Compromising Quality of Care.

Acute care of children remains a challenge due to a shortage of pediatric surgeons, particularly in rural areas. In our institutional norm, all cases in patients age six and older are managed by dedicated general surgeons. The provision of care to these children by these surgeons alleviates the impact of such shortages. We conducted a five-year retrospective analysis of all acute care pediatric surgical cases performed in patients aged 6 to 17 years by a dedicated group of adult general surgeons in a rural tertiary care hospital. Demographics, procedure, complications, outcomes, length of stay, and time of consultation/operation were obtained via chart review. Elective, trauma related, or procedures performed by a pediatric surgeon were excluded. Descriptive statistics are reported. A total of 397 cases were performed by six dedicated general surgeons during the study period. Mean age was 11.5 ± 3.1 years. In all, 100 (25.2%) were transferred from outlying facilities and 52.6 per cent of consultations/operations occurred at night (7P-7A), of which 33.2 per cent occurred during late night hours (11P-7A). On weekends, 34.0 per cent occurred. Appendectomy was the most commonly performed operation (n = 357,89.9%), of which 311 were laparoscopic (87.1%). Others included incision/drainage (4.5%), laparoscopic cholecystectomy (2.0%), bowel resection (1.5%), incarcerated hernia (0.5%), small bowel obstruction (0.5%), intra-abdominal abscess drainage (0.3%), resection of intussusception (0.3%), Graham patch (0.3%), and resection omental torsion (0.3%). Median length of stay was two days. Complications occurred in 23 patients (5.8%), of which 22(5.5%) were the result of the disease process. These results parallel those published by pediatric surgeons in this age group and for the diagnoses treated. Models integrating dedicated general surgeons into pediatric call rotations can be designed such that quality of pediatric care is maintained while providing relief to an overburdened pediatric surgical workforce.

Quantification of saxitoxin and neosaxitoxin in human urine utilizing isotope dilution tandem mass spectrometry.

Saxitoxin and neosaxitoxin are potent neurotoxins that can cause paralytic shellfish poisoning when consumed. A new assay is presented here to quantify saxitoxin (STX) and neosaxitoxin (NEO) in human urine samples. Sample preparation of 500-microL samples included the use of weak-cation-exchange solid-phase extraction in a multiplexed 96-well format. Extracts were preconcentrated and analyzed via 10-min hydrophilic interaction liquid chromatography followed by electrospray ionization. Protonated molecular ions were quantified via multiple reaction monitoring mode in a Qtrap mass spectrometer. The method uses novel 15N7-isotopically enriched STX and NEO internal standards. Method validation included the characterization of two enriched urine pools. The lowest reportable limits for STX and NEO were 4.80 and 10.1 ng/mL, respectively, using both quantification and confirmation ions. These two toxins were not detected in a reference range of humans who consumed seafood in the preceding 72 h, suggesting that few false positives would occur when trying to identify people exposed to STX or NEO.