A Comprehensive Study on the Diagnosis and Management of Noninvasive Follicular Thyroid Neoplasm with Papillary-Like Nuclear Features.

Background: Since the noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTPs) was introduced in 2016, most retrospective studies have included cases diagnosed as encapsulated follicular variant of papillary thyroid carcinoma. We investigate a cohort diagnosed with NIFTP at resection. Methods: Retrospective institutional cohort of NIFTP from 2016 to 2022, including clinical, cytological, and molecular data for 319 cases (6.6% of thyroid surgeries, 183 cases as NIFTP-only). Results: The patient cohort had unifocal or multifocal thyroid nodules. Female:male ratio was 2.7:1, mean age was 52 years and median NIFTP size was 2.1 cm. NIFTP was associated with multiple nodules in 23% patients (n = 73) and 12% of NIFTP were multifocal (n = 39). Fine needle aspiration (FNA) of NIFTP (n = 255) were designated as nondiagnostic = 5%, benign = 13%, atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) = 49%, follicular neoplasm/suspicious for follicular neoplasm (FN/SFN) = 17%, suspicious for malignancy = 12%, or malignant = 4%. Molecular alterations were identified in 93% (n = 114), RAS or RAS-like. Thyroid Imaging Reporting and Data System (TI-RADS) score 4 was recorded in 50% of NIFTP, followed by scores 3 and 5 (26% and 20%, respectively). We also investigated the factors associated with extent of surgery. In our NIFTP-only group (n = 183), 66% were identified after hemithyroidectomy (HT) and 34% after total thyroidectomy (TT). On univariate analysis, TT patients demonstrated higher Bethesda category by FNA, more often had aberrant preoperative thyroid function, and/or underwent an FNA of additional nodule(s). With multivariable regression, Bethesda V NIFTP, in the presence of other nodules being evaluated by FNA and aberrant preoperative thyroid function, independently predicts TT. Bethesda II NIFTP correlated significantly with HT. Fifty-two patients (28%) with NIFTP-only had at least one postoperative surveillance ultrasound. In the NIFTP-only cohort, no HT patients had completion thyroidectomy or received postoperative radioactive iodine. No recurrence or metastases were recorded with median follow-up of 35 months (6-76 months; n = 120). Conclusions: Given this large cohort of NIFTP, including a large subset of isolated NIFTP-only, some with >6 years of follow-up and no tumor recurrences, consensus practical guidelines are needed for adequate postoperative management. Given the American Thyroid Association (ATA) provides guidelines for management of low-risk malignancies, guidance regarding that for borderline/biologically uncertain tumors, including NIFTP, is a reasonable next step.

Development and Implementation of a Practical Onboarding Curriculum for Physician Quality and Safety Leaders.

Physicians are increasingly asked to assume quality and safety (Q&S) leadership roles; prior experience varies, and onboarding training is limited. Semistructured interviews were completed with physician Q&S leaders; interview responses were analyzed using 2-step rapid analysis. Interview learnings informed development of a 2-day onboarding training and complementary digital resource repository. Attendees were surveyed to evaluate the training. Thirteen semistructured interviews with physician leaders from 6 academic medical centers demonstrated 61.5% had no formal Q&S training before assuming their role. Respondents identified a range of knowledge gaps. A 2-day virtual onboarding training and complementary digital repository were created. Attendee surveys demonstrated 96% (73/76) believed the training would be "extremely" or "moderately" helpful to others. Subject-matter familiarity across all content areas improved after the training. Using front-line stakeholder input, a pilot onboarding curriculum for Q&S leaders was created. Future work includes ongoing implementation and iterative improvement.

Limited disease progression in endocrine surgery patients with treatment delays due to COVID-19.

BACKGROUND: The COVID-19 pandemic profoundly impacted the delivery of care and timing of elective surgical procedures. Most endocrine-related operations were considered elective and safe to postpone, providing a unique opportunity to assess clinical outcomes under protracted treatment plans. METHODS: American Association of Endocrine Surgeon members were surveyed for participation. A Research Electronic Data Capture survey was developed and distributed to 27 institutions to assess the impact of COVID-19-related delays. The information collected included patient demographics, primary diagnosis, resumption of care, and assessment of disease progression by the surgeon. RESULTS: Twelve out of 27 institutions completed the survey (44.4%). Of 850 patients, 74.8% (636) were female; median age was 56 (interquartile range, 44-66) years. Forty percent (34) of patients had not been seen since their original surgical appointment was delayed; 86.2% (733) of patients had a delay in care with women more likely to have a delay (87.6% vs 82.2% of men, χ2 = 3.84, P = .05). Median duration of delay was 70 (interquartile range, 42-118) days. Among patients with a delay in care, primary disease site included thyroid (54.2%), parathyroid (37.2%), adrenal (6.5%), and pancreatic/gastrointestinal neuroendocrine tumors (1.3%). In addition, 4.0% (26) of patients experienced disease progression and 4.1% (24) had a change from the initial operative plan. The duration of delay was not associated with disease progression (P = .96) or a change in operative plan (P = .66). CONCLUSION: Although some patients experienced disease progression during COVID-19 delays to endocrine disease-related care, most patients with follow-up did not. Our analysis indicated that temporary delay may be an acceptable course of action in extreme circumstances for most endocrine-related surgical disease.

Mesenteric Ischemia in Patients with Coronavirus 2019: A Scoping Review.

Background: Coronavirus 2019 (COVID-19) is a systemic disease associated with severe gastrointestinal complications including life-threatening mesenteric ischemia. We sought to review and summarize the currently available literature on the presentation, management, and outcomes of mesenteric ischemia in patients with COVID-19. Patients and Methods: The PubMed database was searched to identify studies published between January 2020 and January 2021 that reported one or more adult (≥18 years) patients with COVID-19 who developed mesenteric ischemia during hospitalization. The demographic characteristics, clinical and imaging findings, management, and outcomes of patients from each study were extracted and summarized. Results: A total of 35 articles reporting on 61 patients with COVID-19 with mesenteric ischemia met the eligibility and were included in our study. The mean age was 60 (±15.9) years, and 53% of patients were male. Imaging findings of these patients included mesenteric arterial or venous thromboembolism, followed by signs of mesenteric ischemia. Sixty-seven percent of patients were taken to the operating room for an exploratory laparotomy and bowel resection and 21% were managed conservatively. The terminal ileum was the most commonly involved area of necrosis (26%). The mortality rate of patients with COVID-19 with mesenteric ischemia was 33%, and the most common cause of death was multiorgan failure or refractory septic shock. Twenty-seven percent of patients managed operatively died during the post-operative period. Conclusions: Mesenteric ischemia in patients with COVID-19 is a devastating complication associated with a high rate of morbidity and mortality. Further efforts should focus on developing strategies for early recognition and management.

The glass podium: Gender representation within the American Association of Endocrine Surgeons (AAES) from 2010 to 2019.

BACKGROUND: Despite increasing numbers of women in surgery, female underrepresentation in surgical societies remains an ongoing issue. We sought to determine the gender composition of presenters at the American Association of Endocrine Surgery annual meetings. METHODS: Utilizing previous meeting data, we collected gender information for presenters from 2010 to 2019, including first/senior author combinations. Awards winners and invited lecturers were also reviewed. We performed binomial testing to analyze proportions of male to female presenters, with significance set at P < .05. Temporal trends were analyzed via linear regression. RESULTS: Fifty-six percent of American Association of Endocrine Surgery fellows and 36% of members are female. Of 354 podium and 477 poster presentations, women were listed less often as first (42.7%, P = .007) and senior (30.6%, P < .0001) podium authors and less often as first (42.8%, P = .002) and senior (29.8%, P < .0001) poster authors. The most common combination of first/senior authors was male-male (43.1%), followed by female-male (26.8%), female-female (16.1%), and male-female (14.0%). Less than 15% of invited lecturers were women, and women represented a minority in nearly all award categories. We observed a positive trend in female first authorship over time (slope = 0.766, 95% confidence interval, 0.70%-2.23%, P = .26) but no change in female senior authorship over time (slope = 0.03348, 95% confidence interval, 1.086%-1.153%, P = .95). CONCLUSION: Women are underrepresented as American Association of Endocrine Surgery presenters and less likely to receive awards or deliver invited lectures. Although female first authorship increased over time, women continued to lag behind men as senior authors and mentors to trainees and junior faculty. Opportunities to improve speaker and awardee representation should be explored.

Bowel Ischemia in COVID-19 Infection: One-Year Surgical Experience.

BACKGROUND: COVID-19 is a deadly multisystemic disease, and bowel ischemia, the most consequential gastrointestinal manifestation, remains poorly described. Our goal is to describe our institution's surgical experience with management of bowel ischemia due to COVID-19 infection over a one-year period. METHODS: All patients admitted to our institution between March 2020 and March 2021 for treatment of COVID-19 infection and who underwent exploratory laparotomy with intra-operative confirmation of bowel ischemia were included. Data from the medical records were analyzed. RESULTS: Twenty patients were included. Eighty percent had a new or increasing vasopressor requirement, 70% had abdominal distension, and 50% had increased gastric residuals. Intra-operatively, ischemia affected the large bowel in 80% of cases, the small bowel in 60%, and both in 40%. Sixty five percent had an initial damage control laparotomy. Most of the resected bowel specimens had a characteristic appearance at the time of surgery, with a yellow discoloration, small areas of antimesenteric necrosis, and very sharp borders. Histologically, the bowel specimens frequently have fibrin thrombi in the small submucosal and mucosal blood vessels in areas of mucosal necrosis. Overall mortality in this cohort was 33%. Forty percent of patients had a thromboembolic complication overall with 88% of these developing a thromboembolic phenomenon despite being on prophylactic pre-operative anticoagulation. CONCLUSION: Bowel ischemia is a potentially lethal complication of COVID-19 infection with typical gross and histologic characteristics. Suspicious clinical features that should trigger surgical evaluation include a new or increasing vasopressor requirement, abdominal distension, and intolerance of gastric feeds.

Diabetes mellitus and hyperglycemia are associated with inferior oncologic outcomes in adrenocortical carcinoma.

PURPOSE: Prior literature suggests that cancer patients with hyperglycemia and type 2 diabetes mellitus (DM) exhibit worse oncologic and overall outcomes. Tumor metabolism and anabolism pathophysiology may explain this association, although this has not been adequately studied in adrenocortical carcinoma (ACC). We hypothesized that DM would be associated with worse oncological outcomes in ACC, and we utilized data from a national database and institutional sources for multimodal analysis. METHODS: Both a multi-institutional database (the Collaborative Endocrine Surgery Quality Improvement Program or CESQIP) and a single-center longitudinal cohort (Dana Farber Cancer Institute or DFCI) were queried as unique retrospective cohorts to identify patients with ACC. Patient demographics, tumor characteristics, DM-specific variables, and oncologic outcome data were assessed. Results were analyzed via univariate analysis and multivariable linear regression analysis. Statistical significance was defined as p < 0.05. RESULTS: Forty-eight CESQIP patients met inclusion criteria; 16 (33.0%) had DM. DM patients had a higher frequency of recurrence on longitudinal follow-up (12.5% v 0.0%, p = 0.04). Persistent disease was observed in 68.8% of DM patients and 40.6% of non-DM patients (p = 0.06). Patients in the DFCI cohort with lower average glucose values (< 110 mg/dL) had a significant survival benefit (p < .0001). A mean serum glucose > 110 mg/dL had increased risk (HR 36.3, 95% confidence interval 1.6, 831.3) for all-cause mortality. CONCLUSIONS: This multi-institutional, multimodal analysis suggests that patients with DM have worse oncologic and overall outcomes for ACC. While further study is warranted, consideration should be given among clinicians to optimize glycemic control as part of their ACC management.

Impact of staff turnover during cardiac surgical procedures.

OBJECTIVE: The impact of staff turnover during cardiac procedures is unknown. Accurate inventory of sharps (needles/blades) requires attention by surgical teams, and sharp count errors result in delays, can lead to retained foreign objects, and may signify communication breakdown. We hypothesized that increased team turnover raises the likelihood of sharp count errors and may negatively affect patient outcomes. METHODS: All cardiac operations performed at our institution from May 2011 to March 2016 were reviewed for sharp count errors from a prospectively maintained database. Univariate and multivariable analyses were performed. RESULTS: Among 7264 consecutive cardiac operations, sharp count errors occurred in 723 cases (10%). There were no retained sharps detected by x-ray in our series. Sharp count errors were lower on first start cases (7.7% vs 10.7%, P < .001). Cases with sharp count errors were longer than those without (7 vs 5.7 hours, P < .001). In multivariable analysis, factors associated with an increase in sharp count errors were non-first start cases (odds ratio [OR], 1.3; P = .006), weekend cases (OR, 1.6; P < .004), more than 2 scrub personnel (3 scrubs: OR, 1.3; P = .032; 4 scrubs: OR, 2; P < .001; 5 scrubs: OR, 2.4; P = .004), and more than 1 circulating nurse (2 nurses: OR, 1.9; P < .001; 3 nurses: OR, 2; P < .001; 4 nurses: OR, 2.4; P < .001; 5 nurses: OR, 3.1; P < .001). Sharp count errors were associated with higher rates of in-hospital mortality (OR, 1.9; P = .038). CONCLUSIONS: Sharp count errors are more prevalent with increased team turnover and during non-first start cases or weekends. Sharp count errors may be a surrogate marker for other errors and thus increased mortality. Reducing intraoperative team turnover or optimizing hand-offs may reduce sharp count errors.

Body of Evidence: Do Autopsy Findings Impact Medical Malpractice Claim Outcomes?

OBJECTIVE: Clinicians may hesitate to advocate for autopsies out of concern for increased malpractice risk if the pathological findings at time of death differ from the clinical findings. We aimed to understand the impact of autopsy findings on malpractice claim outcomes. METHODS: Closed malpractice claims with loss dates between 1995 and 2015 involving death related to inpatient care at 3 Harvard Medical School hospitals were extracted from a captive malpractice insurer's database. These claims were linked to patients' electronic health records and their autopsy reports. Using the Goldman classification system, 2 physician reviewers blinded to claim outcome determined whether there was major, minor, or no discordance between the final clinical diagnoses and pathologic diagnoses. Claims were compared depending on whether an autopsy was performed and whether there was major versus minor/no clinical-pathologic discordance. Primary outcomes included percentage of claims paid through settlement or plaintiff verdict and the amount of indemnity paid, inflation adjusted. RESULTS: Of 293 malpractice claims related to an inpatient death that could be linked to patients' electronic health records, 89 claims (30%) had an autopsy performed by either the hospital or medical examiner. The most common claim allegation was an issue with clinician diagnosis, which was statistically less common in the autopsy group (18% versus 38%, P = 0.001). There was no difference in percentage of claims paid whether an autopsy was performed or not (42% versus 41%, P = 0.90) and no difference in median indemnity of paid claims after adjusting for number of defendants ($1,180,537 versus $906,518, P = 0.15). Thirty-one percent of claims with hospital autopsies performed demonstrated major discordance between autopsy and clinical findings. Claims with major clinical-pathologic discordance also did not have a statistically significant difference in percentage paid (44% versus 41%, P > 0.99) or amount paid ($895,954 versus $1,494,120, P = 0.10) compared with claims with minor or no discordance. CONCLUSIONS: Although multiple factors determine malpractice claim outcome, in this cohort, claims in which an autopsy was performed did not result in more paid outcomes, even when there was major discordance between clinical and pathologic diagnoses.

Safety of outpatient adrenalectomy across 3 minimally invasive approaches at 2 academic medical centers.

BACKGROUND: Outpatient adrenalectomy has the potential to decrease costs, improve inpatient capacity, and decrease patient exposure to hospital-acquired conditions. Still, the practice has yet to be widely adopted and current studies demonstrating the safety of outpatient adrenalectomy are limited by sample size, extensive exclusion criteria, and no comparison to inpatient cases. We aimed to study the characteristics and safety of outpatient adrenalectomy using the largest such sample to date across 2 academic medical centers and 3 minimally invasive approaches. METHODS: All minimally invasive adrenalectomies were identified, starting from the time outpatient adrenalectomy was initiated at each institution. Cases involving removal of other organs, bilateral adrenalectomies, and cases in which a patient was admitted to the hospital before the day of surgery were excluded. Patient, tumor, and case characteristics were compared between outpatient and inpatient cases, and multivariable regression analysis was used to assess odds of 30-day readmission and/or complication. RESULTS: Of 203 patients undergoing minimally invasive adrenalectomy, 49% (n = 99) were performed on an outpatient basis. Outpatient disposition was more likely in the setting of lower estimated blood loss, case completion before 3 pm, and for surgery performed in the setting of nodule/mass and primary hyperaldosteronism versus Cushing's syndrome, pheochromocytoma, and metastasis (P < .05). There were no significant differences in patient age, body mass index, American Society of Anesthesiologists class, procedure performed, or total time under anesthesia between inpatient and outpatient cases. On adjusted analysis, outpatient adrenalectomy was not associated with increased 30-day readmission rate (odds ratio 0.23 [confidence interval 0.04-1.26] P = .09) or 30-day complication rate (odds ratio 0.21 [confidence interval 0.06-0.81] P = .02). CONCLUSION: Outpatient adrenalectomy can be performed safely without increased risk of 30-day complications or readmission in appropriately selected candidates.

An Examination of Medical Malpractice Claims Involving Physician Trainees.

PURPOSE: To identify patient-, provider-, and claim-related factors of medical malpractice claims in which physician trainees were directly involved in the harm events. METHOD: The authors performed a case-control study using medical malpractice claims closed between 2012-2016 and contributed to the Comparative Benchmarking System database by teaching hospitals. Using the service extender flag, they classified claims as cases if physician trainees were directly involved in the harm events. They classified claims as controls if they were from the same facilities, but trainees were not directly involved in the harm events. They performed multivariable regression with predictor variables being patient and provider characteristics. The outcome was physician trainee involvement in harm events. RESULTS: From the original pool of 30,973 claims, there were 581 cases and 2,610 controls. The majority of cases involved residents (471, 81%). Cases had a statistically significant higher rate of having a trainee named as defendants than controls (184, 32% vs 233, 9%; P < .001). The most common final diagnosis for cases was puncture or laceration during surgery (62, 11%). Inadequate supervision was a contributing factor in 140 (24%) cases overall, with the majority (104, 74%) of these claims being procedure related. Multivariable regression analysis revealed that trainees were most likely to be involved in harm events in specialties such as oral surgery/dentistry and obstetrics-gynecology (OR = 7.99, 95% CI 2.93, 21.83 and OR = 1.85, 95% CI 1.24, 2.66, respectively), when performing procedures (OR = 1.58, 95% CI 1.27, 1.96), or when delivering care in the emergency room (OR = 1.65, 95% CI 1.43, 1.91). CONCLUSIONS: Among claims involving physician trainees, procedures were common and often associated with inadequate supervision. Training directors of surgical specialties can use this information to improve resident supervision policies. The goal is to reduce the likelihood of future harm events.

A Long, Unnerving Road: Malpractice Claims Involving the Surgical Management of Thyroid and Parathyroid Disease.

BACKGROUND: Given their profound emotional, physical, and financial toll on patients and surgeons, we studied the characteristics, costs, and contributing factors of thyroid and parathyroid surgical malpractice claims. METHODS: Using the Controlled Risk Insurance Company Strategies' Comparative Benchmarking System database, representing ~30% of all US paid and unpaid malpractice claims, 5384 claims filed against general surgeons and otolaryngologists from 1995-2015 were reviewed to isolate claims involving the surgical management of thyroid and parathyroid disease. These claims were studied, and multivariable regression analysis was performed to identify factors associated with plaintiff payout. RESULTS: One hundred twenty-eight thyroid and parathyroid surgical malpractice claims were isolated. The median time from alleged harm event to closure of a malpractice case was 39 months. The most common associated complications were bilateral recurrent laryngeal nerve (RLN) injury (n = 23) and hematoma (n = 18). Complications led to death in 18 cases. Patient payout occurred in 33% of claims (n = 42), and the median cost per claim was $277,913 (IQR $87,343-$783,663). On multivariable analysis, bilateral RLN injury was predictive of patient payout (OR 3.58, p = 0.03), while procedure, death, and surgeon specialty were not. CONCLUSION: Though rare, malpractice claims related to thyroid and parathyroid surgery are costly, time-consuming, and reveal opportunities for early surgeon-patient resolution after poor outcomes.