Patterns in the Reporting of Aggressive Histologic Subtypes in Papillary Thyroid Cancer.

INTRODUCTION: The tall cell, columnar, and diffuse sclerosing subtypes are aggressive histologic subtypes of papillary thyroid cancer (PTC) with increasing incidence, yet there is a wide variation in reporting. We aimed to identify and compare factors associated with the reporting of these aggressive subtypes (aPTC) to classic PTC (cPTC) and secondarily identify differences in outcomes. METHODS: The National Cancer Database was utilized to identify cPTC and aPTC from 2004 to 2017. Patient and facility demographics and clinicopathologic variables were analyzed. Independent predictors of aPTC reporting were identified and a survival analysis was performed. RESULTS: The majority of aPTC (67%) were reported by academic facilities. Compared to academic facilities, all other facility types were 1.4-2.0 times less likely to report aPTC (P < 0.05). Regional variation in reporting was noted, with more cases reported in the Middle Atlantic, despite there being more total facilities in the South Atlantic and East North Central regions. Compared to the Middle Atlantic, all other regions were 1.4-5 times less likely to report aPTC (P < 0.001). Patient characteristics including race and income were not associated with aPTC reporting. Compared to cPTC, aPTC had higher rates of aggressive features and worse 5-y overall survival (90.5% versus 94.5%, log rank P < 0.001). CONCLUSIONS: Aggressive subtypes of PTC are associated with worse outcomes. Academic and other facilities in the Middle Atlantic were more likely to report aPTC. This suggests the need for further evaluation of environmental or geographic factors versus a need for increased awareness and more accurate diagnosis of these subtypes.

Low Mitotic Activity in Papillary Thyroid Cancer: A Marker for Aggressive Features and Recurrence.

CONTEXT: The significance of low mitotic activity in papillary thyroid cancer (PTC) is largely undefined. OBJECTIVE: We aimed to determine the behavioral landscape of PTC with low mitotic activity compared to that of no- and high-mitotic activity. METHODS: A single-institution consecutive series of PTC patients from 2018-2022 was reviewed. Mitotic activity was defined as no mitoses, low (1-2 mitoses/2 mm2) or high (≥3 mitoses/2 mm2) per the World Health Organization. The 2015 American Thyroid Association risk stratification was applied to the cohort, and clinicopathologic features were compared between groups. For patients with ≥6 months follow-up, Cox regression analyses for recurrence were performed. RESULTS: 640 PTCs were included - 515 (80.5%) no mitotic activity, 110 (17.2%) low mitotic activity, and 15 (2.3%) high mitotic activity. Overall, low mitotic activity exhibited rates of clinicopathologic features including vascular invasion, gross extrathyroidal extension, and lymph node metastases in between those of no- and high-mitotic activity. PTCs with low mitotic activity had higher rates of intermediate- and high-risk ATA risk stratification compared to those with no mitotic activity (p < 0.001). Low mitotic activity PTCs also had higher recurrence rates (15.5% vs. 4.5%, p < 0.001). Low mitotic activity was associated with recurrence, independent of the ATA risk stratification (HR 2.96; 95% CI 1.28-6.87, p = 0.01). CONCLUSIONS: Low mitotic activity is relatively common in PTC and its behavior lies within a spectrum between no- and high-mitotic activity. Given its association with aggressive clinicopathologic features and recurrence, low mitotic activity should be considered when risk stratifying PTC patients for recurrence.

Ablation techniques or active surveillance compared to surgical resection in patients with low-risk papillary thyroid cancer: a systematic review and meta-analysis.

BACKGROUND: The global prevalence of thyroid cancer is on the rise. About one-third of newly diagnosed thyroid cancer cases comprise low-risk papillary thyroid cancer (1.5 cm or more minor). While surgical removal remains the prevailing approach for managing low-risk papillary thyroid cancer (LPTC) in patients, other options such as active surveillance (AS), radiofrequency ablation (RFA), microwave ablation (MWA), and laser ablation (LA) are also being considered as viable alternatives. This study evaluated and compared surgical thyroid resection (TSR) versus non-surgical (NS) methods for treating patients with LPTC. METHODS: The study encompassed an analysis of comparisons between surgical thyroid resection (TSR) and alternative approaches, including active surveillance (AS), radiofrequency ablation (RFA), microwave ablation (MWA), or laser ablation (LA). The focus was on patients with biopsy-confirmed low-risk papillary thyroid cancer (LPTC) of less than 1.5 cm without preoperative indications of local or distant metastasis. The primary outcomes assessed were recurrence rates, disease-specific mortality, and quality of life (QoL). Data were collected from prominent databases, including Cochrane Database, Embase, MEDLINE, and Scopus, from inception to June 3rd, 2020. The CLARITY tool was utilized to evaluate bias risk. The analysis involved odds ratios (OR) with 95% confidence intervals (CI) for dichotomous outcomes, as well as mean differences (MD) and standardized mean differences (SMD) for continuous outcomes. The study is registered on PROSPERO under the identifier CRD42021235657. RESULTS: The study incorporated 13 retrospective cohort studies involving 4034 patients. Surgical thyroid resection (TSR), active surveillance (AS), and minimally invasive techniques like radiofrequency ablation (RFA), microwave ablation (MWA), and laser ablation (LA) were performed in varying proportions of cases. The analysis indicated that specific disease mortality rates were comparable among AS, MWA, and TSR groups. The risk of recurrence, evaluated over different follow-up periods, showed no significant differences when comparing AS, RFA, MWA, or LA against TSR. Patients undergoing AS demonstrated better physical health-related quality of life (QoL) than those undergoing TSR. However, no substantial differences were observed in the overall mental health domain of QoL when comparing AS or RFA with TSR. The risk of bias was moderate in nine studies and high in four. CONCLUSION: Low-quality evidence indicates comparable recurrence and disease-specific mortality risks among patients with LPTC who underwent ablation techniques or active surveillance (AS) compared to surgery. Nevertheless, individuals who opted for AS exhibited enhanced physical quality of life (QoL). Subsequent investigations are warranted to validate these findings.

Active antiracism through surgical education.

INTRODUCTION: Disparities in surgical outcomes are well documented. Racial/ethnic minorities are also disproportionately underrepresentated in surgery; however, most surgeons do not acknowledge the existence of disparities. Diversity, equity, and inclusion (DEI) education in surgery is needed, yet DEI education is often confined to designated diversity lectures, limiting depth of content. Underrepresented minorities (URMs) are also more likely to be tasked with leading DEI initiatives, perpetuating the minority tax and limiting non-URM engagement. METHODS: A DEI curriculum was implemented in a general surgery department, inclusive of programming at morbidity and mortality (M&M) and grand rounds (GR). RESULTS/LESSONS LEARNED: After implementing a DEI curriculum there was a significant increase in DEI topics at M&M (0% versus 27.3%; p < 0.01) and GR (0% versus 18.4%; p < 0.001). The majority of DEI M&Ms were presented by non-URMs (88.89%). Most DEI GR were presented by URMs (55%). CONCLUSIONS: Structured integration of DEI initiatives into surgery department conferences may serve as a practical approach to increasing departmental awareness of disparities, expanding DEI engagement, and increasing academic recognition for DEI initiatives.

Race, Gender, and International Medical Graduates: Leadership Trends in Academic Surgical Societies.

BACKGROUND: Non-White and female surgeons are underrepresented in academic surgery faculty. We hypothesized that the leadership of major U.S. regional and national general surgery societies reflects these same racial and gender disparities. We suspected that attending a medical school or residency program with academic prestige would be more common for surgeons from underrepresented backgrounds. MATERIALS AND METHODS: Race/ethnicity and gender of the 2020-21 executive council members and 2012-21 society presidents of 25 major general surgery societies (7 regional, 18 national) was assessed. Academic prestige was determined by reputational top 25 programs, identified using U.S. News and World Report and Doximity rankings for medical school and residency, respectively. RESULTS: Surgical society executive council members (n = 204) were predominantly White (75.5%) and male (67.2%). The 50 non-White council members were Asian (n = 37), Black (n = 7), and Latinx (n = 6). 14 (6.9%) were international medical graduates (IMGs). 56.4% attended a school or program ranked in the Top 25 (n = 115). Surgical society presidents 2012-21 (n = 242) have been mostly White (87.6%) and male (83.4%). Non-White, male surgical society presidents were Asian (n = 13), Black (n = 9), and Latino (n = 6). Of the 41 female surgery society presidents, 92.7% were White, 7.3% (n = 3) Asian, and none Black or Latina. 13 were IMGs (5.3%). 55.0% of society presidents attended Top 25 (n = 133) schools or programs. The three non-White, female presidents all attended Top 25 schools/programs (100%). Of the 15 unique individuals who were male, non-White presidents, 12 attended top 25 schools or programs (80%). CONCLUSION: Women, non-White surgeons, and IMGs are underrepresented in U.S. surgical society leadership. Increasing racial diversity in U.S. surgical society leadership may require intentionality in mentorship and sponsorship, particularly for surgeons who did not attend prestigious schools or programs.

Appropriate selection of candidates for outpatient thyroidectomy.

PURPOSE OF REVIEW: Although traditionally an inpatient procedure, outpatient thyroidectomy has gained traction as a viable and well tolerated alternative for selected patients, with an added benefit of cost savings. RECENT FINDINGS: Research on outpatient thyroidectomy has focused on establishing its noninferiority in outcomes compared to the standard inpatient or overnight observation. Numerous studies have found comparable low rates of postoperative complications and no increase in readmission. Selection criteria have been well established by professional societies and research studies support the selection bias benefitting appropriately selected patients. The primary benefit of outpatient thyroidectomy reported is a decrease in cost, though additional theoretical benefits such as decreased exposure to nosocomial infections. SUMMARY: Outpatient thyroidectomy is a well tolerated approach in appropriately selected candidates, with cost reduction benefits. Adherence to societal guidelines for patient selection is paramount.

Comparison of Dosing Schemes for Thyroid Hormone Replacement Therapy After Thyroidectomy.

BACKGROUND: Current thyroid hormone replacement therapy (THRT) is built on weight-based standard calculation of dose. A novel Poisson regression model, which accounts for seven clinical variables, was recently proposed to improve accuracy of THRT. We aimed to compare the accuracy of estimated THRT dose to reach euthyroid and the difference in predicted dose between the Poisson (scheme A) and the weight-based standard (scheme B) in patients following total thyroidectomy for benign disease. METHODS: We retrospectively reviewed medical record of patients who underwent total or completion thyroidectomy for benign disease at a single institution between 2011 and 2019. The THRT dose was calculated using both schemes. We compared the difference between calculated THRT and prediction rates for optimal THRT dosing needed to achieve a euthyroid state between dosing schemes. Patients were evaluated for achieving euthyroid state, defined as TSH 0.45-4.5 mIU/L. We also compared dosing error rates (> 25 mcg over- and underdosing) between schemes. Prediction rates were compared by BMI tertiles to account for the effect of BMI extremes in achieving euthyroid state. The difference in predicted dose between schemes was calculated in both the total sample size and patients that met euthyroid. A measure of agreement, Kappa, was used to estimate agreement between dosing schemes. RESULTS: A total of 406 patients underwent total thyroidectomy for benign disease, with 184 having sufficient follow up data confirming euthyroid state. Of the 184 patients, 85.9% (n = 158) were women, 81% (n = 149) were Hispanic, and 56.5% (n = 104) were obese with a median BMI of 30.8 kg/m2. Scheme A resulted in a higher, but not statistically significant, accuracy rate (A: 60.3%, n = 111 versus B: 53.8%, n = 99; P = 0.21). Overdosing errors were lower with Scheme A (A:17.9% versus B: 32.1%; P = 0.0025) and less extreme > 25 µg (A: 17.9% versus B: 26.1%; P = 0.08). A trend in improved accuracy in patients with a BMI > 35 kg/m2 was noted (A: 46.9% versus B: 34.4%; P = 0.20). Scheme A also resulted in less overdosing errors in obese patients compared to Scheme B (A: 19.2% versus 45.2%; P = 0.0006). The average difference in predicted dose between schemes was an entire dose difference, mean of 16.0 µg and 15.8 µg for the total and euthyroid samples respectively. Furthermore, for the majority of patients the predicted dose did not match between the two dosing schemes for total and euthyroid samples, 76% (n = 311) and 76% (n = 141) respectively. In patients that achieved euthyroid, agreement between dosing schemes was low to moderate (Kappa = 0.360). CONCLUSIONS: Lower rates of overdosing were found for scheme A, particularly with obese patients. No statistically significant differences in predicted THRT dose was observed between schemes. The difference in predicted dose between schemes was on average 15 ug, correlating with an entire dose. The consideration of clinical variables other than weight (scheme A) when determining optimal THRT dosing may be of importance to prevent overdoses, with particular clinical relevance in patients with higher BMIs.

Differences in outcomes after emergency general surgery between Hispanic subgroups in the New Jersey State Inpatient Database (2009-2014): The Hispanic population is not monolithic.

BACKGROUND: Our aim was to examine differences in clinical outcomes between Hispanic subgroups who underwent emergency general surgery (EGS). METHODS: Retrospective cohort study of the HCUP State Inpatient Database from New Jersey (2009-2014), including Hispanic and non-Hispanic White (NHW) adult patients who underwent EGS. Multivariable analyses were performed on outcomes including 7-day readmission and length of stay (LOS). RESULTS: 125,874 patients underwent EGS operations. 22,971 were Hispanic (15,488 with subgroup defined: 7,331 - Central/South American; 4,254 - Puerto Rican; 3,170 - Mexican; 733 - Cuban). On multivariable analysis, patients in the Central/South American subgroup were more likely to be readmitted compared to the Mexican subgroup (OR 2.02; p < 0.001, respectively). Puerto Rican and Central/South American subgroups had significantly shorter LOS than Mexican patients (Puerto Rico -0.58 days; p < 0.001; Central/South American -0.30 days; p = 0.016). CONCLUSIONS: There are significant differences in EGS outcomes between Hispanic subgroups. These differences could be missed when data are aggregated at Hispanic ethnicity.

Multimodal analgesia after thyroid or parathyroid surgery: A randomized controlled trial.

BACKGROUND: The opioid epidemic prompted reevaluation of surgeons' opioid prescribing practices. This study aimed to demonstrate noninferiority of a staged analgesic regimen after endocrine surgery. METHODS: We conducted a randomized controlled trial comparing analgesic regimens after thyroidectomy and/or parathyroidectomy. Adult patients (≥18 years) were randomized to study arm (A) as-needed acetaminophen + codeine or (B) scheduled acetaminophen/as-needed tramadol. Patients recorded pain scores and analgesics consumed in a study log. Clinical variables were collected from the medical record. RESULTS: Target enrollment was achieved (n = 126), and randomization was even (A: 44.5%, B: 55.6%). There was no difference between enrolled patients and those who returned the study log (52.4%) by sex (P = .667), age (P = .513), final pathology (P = .137), procedure (P = .667), or randomization arm (P = .795). Most patients (50.8%) reported moderate pain scores (4-6) with no difference between study arms (P = .451). There was no difference in average consumption by morphine milligram equivalents (A: 11.5 ± 12.1 vs B: 12.49 ± 18.07; P = .792) nor total analgesic doses (A: 7.29 ± 7.48 vs B: 8.5 ± 5.36; P = .445). However, a significant difference in average percentage of opioid doses was noted (A: 79.71 ± 33.31 vs B: 27.38 ± 31.88; P < .001). CONCLUSION: Patients reported moderate pain scores with low requirements for analgesics after endocrine surgery. The staged analgesic regimen is noninferior to combination opioids and led to reduced overall consumption.

Do General Surgery Residency Program Websites Feature Diversity?

OBJECTIVE: This study assesses ways in which General Surgery residency program websites demonstrate diversity. DESIGN: Literature review and diversity expert opinion informed selection of diversity elements. We limited our evaluation to residency program-specific webpages. We identified 8 program website elements that demonstrate programmatic commitment to diversity: (1) standard nondiscrimination statement; (2) program-specific diversity and inclusion message; (3) community demographics; (4) personalized biographies of faculty, (5) personalized biographies of residents; (6) individual photographs of faculty; (7) individual photographs of residents; and (8) list of additional resources available for trainees. We evaluated the impact of program type (university, independent, or military); city population; region; program director gender and ethnicity; and program size on incorporation of these eight elements. We dichotomized programs that had ≥4 of these elements on their website and determined association with the above factors using chi-square or Fisher's exact test. SETTING: Website review July to December 2019. PARTICIPANTS: All nonmilitary-based general surgery residency program members of the Association of Program Directors in Surgery (APDS) (n = 242/251). RESULTS: General Surgery residency program websites included a mean of 2.7 ± 1.5 elements that showcase diversity. Most program websites (n = 215, 89%) featured ≤4 elements (range 1-4), while 15 (6.2%) had none. When stratified by programs having 4 or more elements on their website, university-based program (p < 0.001) was the only factor associated. Resident photos (n = 147, 61%), resources available to trainees (n = 146, 60%), faculty photos (n = 139, 57%), and community demographics (n = 93, 38%) were the most common of the 8 website elements. CONCLUSIONS: Residency program websites are vital to recruiting applicants. Featuring specific elements on the General Surgery residency website that display a program's commitment to diversity and inclusion may be important in attracting a diverse candidate pool. This research highlights opportunities programs may use to demonstrate more effectively a residency program's commitment to diversity and inclusion.

Systematic Review of Blood-Borne Pathogen Exposure Rates Among Medical Students.

BACKGROUND: Blood-borne pathogen exposures (BBPEs) pose a risk to health care workers (HCWs). Needlestick injuries (NSIs) have declined overall, but not for surgical HCWs. There are limited data regarding BBPEs among medical students (MSs) in their clinical years. We aimed to quantify this risk for third- and fourth-year MSs. METHODS: A literature review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The PUBMED database was searched to identify studies of third- and fourth-year MSs using the terms BBPE, NSI, and MS. Studies of other HCWs were excluded if MS data were not extractable. Additional studies were identified from references. Descriptive analysis was performed. RESULTS: Seven of 171 articles published from 2002 to 2018 met study criteria. All used self-reported data from surveys/questionnaires. One-third of MSs reported BBPEs (n = 194/600, 32.3%) with a mean of 1 in 3.09 and a median of 1 in 3.53 (range: 1 in 1.9-8.3 students). Most events were NSIs (144/194, 74%) with a mean of 1 NSI per 4.05 MSs and median of 1 in 4.625 (range: 1 in 2.47-10.71). The remaining BBPEs reported included blood and bodily fluid splashes (n = 37, 19%), other mucocutaneous exposures (n = 7, 3.6%), and uncategorized injuries (n = 2, 1%). CONCLUSIONS: One-third of senior MSs reported BBPEs during clinical rotations. Most BBPEs were NSIs. Quantifying this risk allows for anticipatory education and protocol development to protect students and other new HCWs. Educational efforts focused on NSI prevention before and during clinical rotations may help reduce BBPEs.

Underrepresented in Surgery: (Lack of) Diversity in Academic Surgery Faculty.

BACKGROUND: A call to increase diversity among academic surgery faculty (ASF) was made in 2008, after recognizing the lack of surgeons considered underrepresented in medicine (URM). We aimed to quantify and assess trends among URM ASF in the interval since that call to action. METHODS: Publicly available data on ASF were reviewed. We calculated the percentage of ASF in 2018 by URM group, then stratified by academic rank of assistant professor, associate professor, and full professor. We compared 2005-2018 ASF of Hispanic or Latino (HL) and African American (AA) background; 2005 data were unavailable for other URM groups. RESULTS: In 2018, URM surgeons accounted for 7.06% (n = 1013/14,340) of ASF (AA: n = 492, 3.43%; HL: n = 485, 3.38%; American Indian or Alaskan Native: n = 23, 0.16%; and Native Hawaiian/Pacific Islander: n = 13, 0.09%). When comparing 2005-2018, AA ASF remained stable across ranks (total: n = 298, 3.12% versus n = 492, 3.43%; P = 0.09), whereas HL ASF decreased across ranks (total: n = 415, 4.35% versus n = 485, 3.38%; P = 0.00007). CONCLUSIONS: Surgeons from URM backgrounds account for 7% of ASF. No increase in AA and a decrease in HL ASF occurred from 2005 to 2018. There is a paucity of data for other URM groups. Active strategies to increase diversity and inclusion in academic surgery are necessary.

The surgical blog: An important supplement to traditional scientific literature.

BACKGROUND: Blogging is a new and innovative means of information exchange in the surgical community. We examined the Association of Women Surgeons (AWS) blog to understand its audience and most read content. METHODS: Google Analytics was used to assess the AWS blog site data. A search was performed from February 2018 to February 2019. Demographic data, blog posts, and tags sorted by unique pageviews were recorded. RESULTS: There were 31,221 unique pageviews during the search period. The AWS Blog readership was mostly women (75%), ages 25-44 years (70.3%). The three tags that elicited the most pageviews were "residency (16.95%)," "medical students (12.12%)," and "family life (10.38%)." The most read blog post was responsible for 9.7% of total pageviews. DISCUSSION & CONCLUSION: Most of the AWS Blog readership are young, women, and interested in content related to graduate and postgraduate medical education or family life. Blogging may be a good vehicle for topics not covered in traditional scientific literature.

Lobectomy Compared to Total Thyroidectomy for Low-Risk Papillary Thyroid Cancer: A Systematic Review.

BACKGROUND: The 2015 American Thyroid Association (ATA) guidelines called for consideration of thyroid lobectomy (TL) as an acceptable surgical treatment for small and less aggressive papillary thyroid cancers (PTC) with no clinical evidence of metastasis or extrathyroidal extension. Optimal extent of surgery, however, remains controversial. METHODS: A systematic literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. PUBMED, EMBASE, Scopus, and Cochrane Library databases were searched to identify studies comparing TL to total thyroidectomy (TT) for low-risk PTC. Studies were grouped according to the major outcomes in the literature: survival and the need for completion thyroidectomy (CT). RESULTS: Overall survival for low-risk PTC patients who underwent TL was comparable to TT. Locoregional recurrence (LRR) rate following TL was less than 6% and salvaged with CT. The proportion of patients meeting the 2015 ATA guidelines selection criteria for TL who subsequently would need CT varied by study but averaged 34%. After excluding microscopic extrathyroidal extension and positive resection margin as indications for CT to facilitate radioactive iodine ablation, the estimated rate across the included studies was 11%. CONCLUSIONS: We performed a systematic review of outcomes following TL or CT for low-risk PTC according to 2015 ATA guidelines. Initial operative approach did not have a negative impact on overall survival. There is a paucity of high-quality data on this topic across the literature. Long-term follow-up studies on oncologic and patient-centered outcomes are essential.