One-year Thyroglobulin Levels as a Predictive Measure for Recurrence and Need for Continued Surveillance in Treated Differentiated Thyroid Cancer.

PURPOSE: Patients with differentiated thyroid cancer (DTC) undergo posttreatment surveillance for several years. We aim to better define an excellent response to therapy using thyroglobulin (TG) and thyroglobulin antibody (TGab) levels at 1-year to tailor appropriate length of surveillance. METHODS: Patients with DTC who underwent surgical treatment with or without adjuvant radioiodine therapy were followed with standard American Thyroid Association surveillance. TG and TGab levels at 1-year posttreatment were used to define 3 cohorts: undetectable TG (<0.5 ng/mL), detectable TG (≥0.5 ng/mL), and positive TGab (>1 IU/mL). The rates of structural recurrence and the trends of TG and TGab were compared. RESULTS: Of the 268 study patients at 1-year, 210 (78%) had undetectable TG, 29 (11%) had detectable TG, and 29 (11%) had positive TGab. The overall structural recurrence rate was 18/268 (7%): undetectable TG at 1 year, 3/210 (1%), detectable TG at 1-year, 11/29 (38%), and positive TGab at 1-year, 4/29 (13%). At the last follow-up, 196/210 (93%) patients with undetectable TG at 1-year continued to have undetectable TG levels. Regarding patients with detectable TG at 1-year, in 11/29 (38%), detectable TG was converted to undetectable TG at the last follow-up without additional treatments. Of those with positive TGab at 1 year, 6/29 (21%) had resolution of TGab and undetectable TG levels at the last follow-up without additional treatments. CONCLUSION: One year after treatment of DTC, TG levels <0.5 ng/mL, in the absence of TGab, are associated with an exceedingly low risk of recurrence suggesting that further surveillance may not be warranted.

When the first try fails: re-implementation of SIMPL in a general surgery residency.

BACKGROUND: Workplace-based assessment (WBA) can facilitate evaluation of operative performance; however, implementation of WBA is sometimes unsuccessful. The American Board of Surgery Entrustable Professional Activities WBA project was launched in July 2023. Some programs will face the challenge of re-implementation of a WBA following previous failures. It is unknown what interventions are most effective for WBA re-implementation. Our goal is to identify barriers and facilitators to re-implementing SIMPL, an operative performance WBA. METHODS: The System for Improving and Measuring Procedural Learning (SIMPL) was implemented at our residency in 2018, but usage rates were low. We interviewed residents and faculty to identify barriers to usage and opportunities for improvement. Residents reported that SIMPL usage declined because of several factors, including a low faculty response rate, while some faculty reported not responding because they were unable to login to the app and because usage was not mandated. We then re-implemented SIMPL using a plan based on Kotter's Model of Change. To evaluate impact, we analyzed rates of SIMPL usage when it was first implemented, as well as before and after the date of re-implementation. RESULTS: In September 2022, we re-implemented SIMPL at our program with measures addressing the identified barriers. We found that, in the six months after re-implementation, an average of 145.8 evaluations were submitted by residents per month, compared with 47 evaluations per month at the start of the original implementation and 5.8 evaluations per month just prior to re-implementation. Faculty completed 60.6% of evaluations and dictated feedback for 59.1% of these evaluations, compared with 69.1% at implementation (44% dictated) and 43% prior to re-implementation (53% dictated). CONCLUSIONS: After identifying barriers to implementation of a WBA, we re-implemented it with significantly higher usage by faculty and residents. Future opportunities exist to implement or re-implement assessment tools within general surgery programs. These opportunities may have a significant impact in the setting of national standardization of workplace-based assessment among general surgery residencies.

Examining National Guideline Changes Association With Hemithyroidectomy Rates by Surgeon Volume.

INTRODUCTION: The 2015 American Thyroid Association (ATA) guidelines established that hemithyroidectomy (HT) is an appropriate treatment for patients with low-risk thyroid cancer. HT rates increased since the ATA guidelines were released; however, the relationship between surgeon volume and the initial extent of surgery has not been established. METHODS: A statewide database was used to identify patients with thyroid cancer who underwent initial thyroidectomy from 2013 to 2020. High-volume thyroid surgeons were defined as those who performed >25 thyroid procedures per year. A mixed-effect logistic model was used to compare low- and high-volume surgeons' initial extent of surgery pre-2015 and post-2015 ATA guidelines. Descriptive statistics were used to describe other surgical outcomes. RESULTS: The analysis included 3199 patients with thyroid cancer who underwent initial thyroidectomy. Twenty-four surgeons (6%) were considered high-volume; they performed 48% (n = 1349) of the operations. After the 2015 ATA guidelines were released, the rate of HT increased significantly for low- (23% to 28%, P = 0.042) but not high-volume (19% to 23%, P = 0.149) surgeons. Low-volume surgeons had significantly higher rates of readmission (P = 0.008), re-operation (P = 0.030), complications (P < 0.001), and emergency room visits (P = 0.002) throughout the entire study period. CONCLUSIONS: The publication of the 2015 ATA guidelines was associated with a significant increase in HT rates, primarily in low-volume thyroid surgeons. While low-volume surgeons began performing more HTs, they continued to have higher rates of readmission, reoperations, complications, and emergency room visits than high-volume surgeons.

Barriers to the Use of Active Surveillance for Thyroid Cancer Results of a Physician Survey.

OBJECTIVE: The aim of this study was to determine physician-reported use of and barriers to active surveillance for thyroid cancer. SUMMARY BACKGROUND DATA: It is not clear whether active surveillance for thyroid cancer is widely used. METHODS: Surgeons and endocrinologists identified by thyroid cancer patients from the Surveillance, Epidemiology, and End Results (SEER) registries of Georgia and Los Angeles County were surveyed between 2018 and 2019. Multivariable weighted logistic regression analyses were conducted to determine physician acceptance and use of active surveillance. Results: Of the 654 eligible physicians identified, 448 responded to the survey (69% response rate). The majority (76%) believed that active surveillance was an appropriate management option, but only 44% used it in their practice. Characteristics of physicians who stated that active surveillance was appropriate management, but did not report using it included more years in practice (reference group <10 years in practice): 10 to 19 years [odds ratio, OR 0.50 [95% confidence interval, CI 0.28-0.92]; 20 to 29 years [OR 0.31 (95% CI 0.15-0.62)]; >30 years [OR 0.30 (95% CI 0.15-0.61)] and higher patient volume 11 to 30 patients per year [OR 0.39 (95% CI 0.21 -0.70)] and >50 patients per year [OR 0.33 (95% CI 0.16-0.71)] compared to < 10, with no significant difference in those seeing 31 to 50 patients. Physicians reported multiple barriers to implementing active surveillance including patient does not want (80.3%), loss to follow-up concern (78.4%), more patient worry (57.6%), and malpractice lawsuit concern (50.9%). CONCLUSION AND RELEVANCE: Despite most physicians considering active surveillance to be appropriate management, more than half are not using it. Addressing existing barriers is key to improving uptake.

Interprofessional experiences to bridge the medical school to residency transition: a pilot program.

Interprofessional experiences during medical school are often delivered during pre-clinical years, but less is known about the value of clinical students. Our institution implemented a specialty-specific interprofessiona curriculum during Residency Preparation Courses (RPCs) for senior students including didactics, clinical experiences, and a simulated paging curriculum. Our aim was to determine whether this intervention improved perceptions of interprofesiona roles. We distributed anonymous surveys before (pre-survey) and after (post-survey, collected within 2 weeks of course completion) the RPC to 90 students with questions related to interprofessional roles using a 5-point scale (1 = strongly disagree, 5 = strongly agree). Three months after the start of residency, we sent follow-up surveys inquiring about the usefulness of RPC components (1 = not at all useful, 5 = extremely useful). Response rates were 84.4% pre-survey, 63.3% post-survey, and 41.1% follow-up survey. Post-surveys indicated improvement in self-reported ability in all domains: understanding one's contributions to interprofessional teams (3.9 to 4.4, p < .0001), understanding other team members' contributions (3.9 to 4.4, p < .0001), learning from interprofessional team members (4.2 to 4.6, p = .0002), accounting for interprofessional perspectives (4.2 to 4.6, p < .0001), and co-developing effective care plans (3.9 to 4.4, p < .0001). Follow-up surveys rated clinical experiences as slightly-to-moderately useful (2.3 ± 1.0) and paging curriculum very-to-extremely useful (4.3 ± 1.0). This study demonstrates the value of interprofessional education for advanced students.

Prophylactic Central Compartment Neck Dissection in Papillary Thyroid Cancer and Effect on Locoregional Recurrence.

BACKGROUND: Prophylactic central compartment neck dissection (pCCND) in addition to total thyroidectomy (TT) includes removal of central compartment lymph nodes in the absence of clinical involvement on preoperative and intraoperative evaluation. The data regarding the influence of pCCND on oncologic outcomes and surgical complication rates is mixed and, therefore, is the focus of this analysis. METHODS: A systematic review of the literature on total thyroidectomy with prophylactic central compartment neck dissection (TT + pCCND) from January 1990 to October 2017 identified 221 abstracts of which 17 met inclusion criteria and were reviewed (1 randomized-control trial, 13 retrospective cohort studies, and 3 meta-analyses). RESULTS: TT + pCCND was found to detect occult lymph node metastasis in approximately 50% of patients who had no clinical evidence of lymph node metastasis on preoperative imaging. Permanent hypoparathyroidism occurs more frequently following TT + pCCND (TT = 1.55% vs. TT + pCCND = 3.45%), but the rates of permanent recurrent laryngeal nerve dysfunction are similar (TT = 0.89% vs. TT + pCCND = 0.96%). The locoregional recurrence rates across all 14 studies included in this analysis was 6.75% for TT alone and 4.55% for TT + pCCND. The rate of locoregional recurrence was significantly lower in patients who underwent pCCND in a few studies and one meta-analysis, but were not significantly different in the majority of studies. CONCLUSIONS: TT + pCCND in clinically node-negative papillary thyroid cancer will detect occult lymph node metastasis in approximately half of patients. This may change their postoperative management with regard to adjuvant radioiodine therapy. There is a higher risk of hypoparathyroidism with pCCND, and the effect on rates of locoregional recurrence remains uncertain.

Surgeons have an opportunity to improve teaching quality through feedback provision.

BACKGROUND: Medical student evaluations of faculty are increasingly incorporated into promotion and tenure decisions, making it imperative to understand learner perceptions of quality teaching. Prior work has shown that students value faculty responsiveness in the form of feedback, but faculty and students differ in their perceptions of what constitutes sufficient feedback. The innovative minute feedback system (MFS) can quantify responsiveness to students' feedback requests. This study assessed how feedback provision via MFS impacts teaching quality scores. MATERIALS AND METHODS: This retrospective observational study compared average faculty teaching quality scores with faculty's percentage response to student feedback requests via the MFS. The data were generated from the core surgical clerkship for third-year medical students at the University of Michigan Medical School. The relationship between average teaching quality scores and response percentage was assessed by weighted regression analysis. RESULTS: Two hundred thirty-seven medical students requested feedback via MFS, and 104 faculty were evaluated on teaching quality. The mean faculty feedback response percentage was 55.78%. The mean teaching quality score was 4.27 on a scale of 1 to 5. Teaching quality score was significantly correlated with response percentage (P < 0.001); for every 10% increase in response percentage, average teaching quality score improved by 0.075. Average teaching quality score was not significantly associated with response time (P = 0.158), gender (P = 0.407), or surgical service (P = 0.498). CONCLUSIONS: Medical students consider responsiveness to feedback requests an important component of quality teaching. Furthermore, faculty development focused on efficient and practical feedback strategies may have the added benefit of improving their teaching quality.

Functional and Nonfunctional Forms of CquiOR91, an Odorant Selectivity Subunit of Culex quinquefasciatus.

In Culex quinquefasciatus, CquiOR91 is the ortholog of 2 larvae-specific odorant receptors (ORs) from Anopheles gambiae (Agam\Or40, previously shown to respond to several odorant ligands including the broad-spectrum repellent N,N-diethyl-3-methylbenzamide, DEET) and Aedes aegypti (Aaeg\Or40). When we cloned full-length CquiOR91 from a Culex quinquefasciatus larval head RNA sample, we found 2 alleles of this OR, differing at 9 residues. Functional analysis using the Xenopus oocyte expression system and 2-electrode voltage clamp electrophysiology revealed one allele (CquiOR91.1) to be nonfunctional, whereas the other allele (CquiOR91.2) was functional. Receptors formed by CquiOR91.2 and Cqui\Orco responded to (-)-fenchone, (+)-fenchone, and DEET, similar to what has been reported for Agam\Or40. We also identified 5 novel odorant ligands for the CquiOR91.2 + Cqui\Orco receptor: 2-isobutylthiazole, veratrole, eucalyptol, d-camphor, and safranal, with safranal being the most potent. To explore possible reasons for the lack of function for CquiOR91.1, we generated a series of mutant CquiOR91.2 subunits, in which the residue at each of the 9 polymorphic residue positions was changed from what occurs in CquiOR91.2 to what occurs in CquiOR91.1. Eight of the 9 mutant versions of CquiOR91.2 formed functional receptors, responding to (-)-fenchone. Only the CquiOR91.2 Y183C mutant was nonfunctional. The reverse mutation (C183Y) conferred function on CquiOR91.1 , which became responsive to (-)-fenchone and safranal. These results indicate that the "defect" in CquiOR91.1 that prevents function is the cysteine at position 183.

Assessment of clinical feedback given to medical students via an electronic feedback system.

BACKGROUND: The feedback medical students receive during clinical rotations, traditionally verbal and not formally captured, plays a critical role in student development. This study evaluates written daily feedback given to students through a novel web-based feedback system. METHODS: A Minute Feedback System was used to collect feedback given to medical students during their surgery clerkship from May 2015-April 2016. Using qualitative content analysis, feedback comments were categorized as: encouraging, corrective, specific, and nonspecific. Effective feedback was a combination of specific and either corrective or encouraging feedback; ineffective feedback contained only nonspecific comments; mediocre feedback contained elements of both effective and ineffective comments. RESULTS: 3191 feedback requests were sent by medical students and 2029 faculty/resident feedback responses were received. The overall response rate was 62%. Nonspecific feedback comprised 80% of faculty, 83% of senior resident, and 78% of junior resident comments. Specific feedback was given by only 35% of faculty, 17% of senior residents, and 26% of junior residents. Faculty provided Effective feedback in only 16% of comments, senior residents 8%, and junior residents 17%. Mediocre feedback comprised 13% of faculty, 9% of senior resident, and 7% of junior resident comments. Ineffective feedback comprised 67% of all feedback: 60% of faculty, 72% of senior resident, and 68% of junior resident feedback. CONCLUSIONS: The majority of resident and faculty feedback to medical students using an electronic, email-based application during their surgery clerkship was nonspecific and encouraging and therefore of limited effectiveness. This presents an opportunity for resident/faculty development and education regarding optimal feedback techniques.

Association of patient age with high-risk pathologic features in papillary thyroid cancer.

BACKGROUND: Certain patient demographics and histopathologic features are risk factors for papillary thyroid cancer (PTC) recurrence after initial treatment. Our objective was to determine whether very young age is associated with aggressive pathologic features in patients with PTC. MATERIALS AND METHODS: A retrospective analysis was performed for PTC patients who underwent surgical treatment at the University of Michigan between 2006 and 2012. Patients with known distant metastases were excluded. Demographics, high-risk pathologic features (capsular or vascular invasion, extrathyroidal extension, lymph node metastases, and extranodal extension), and disease recurrence were analyzed. RESULTS: 632 PTC patients were included in the analysis. Median age was 49 y (range 10-87). Tumors in patients aged <25 y had higher rates of extranodal extension (P = 0.002) compared with patients aged 25-44 y. Patients aged <25 y had more vascular invasion (P < 0.001) and lymph node metastasis (P = 0.001) than tumors in patients aged between 45-75 y. Patients aged >75 y had higher rates of vascular invasion (P < 0.001) and extrathyroidal extension (P = 0.001) compared with patients aged 45-75 y and more extrathyroidal extension (P < 0.001) than patients aged 25-44 y. There were no differences in tumor characteristics between the <25 and >75 age groups. CONCLUSIONS: PTC patients aged <25 y of age or older than 75 y exhibit higher rates of aggressive histopathologic features compared to PTC patients aged between 25-75 y.

Applied clinical anatomy: the successful integration of anatomy into specialty-specific senior electives.

PURPOSE: A strong foundation in anatomical knowledge is essential for physicians in all fields. Despite this established importance, anatomy continues to be primarily taught only during the pre-clinical years of medical school. Senior medical students have more mature clinical reasoning and analytical skills; therefore, advanced anatomy courses have great potential to integrate basic and clinical sciences to better prepare senior medical students for residency. METHODS: At our institution, five electives have been implemented that integrate anatomical education in clinical contexts in the fields of emergency medicine, musculoskeletal medicine, radiology, surgery, and obstetrics and gynecology. These 4-week courses are all offered in the spring of the final year of medical school. The course curricula, content, and evaluation data are described for each of the courses. RESULTS: The five electives have been extremely popular at our institution, and all have been consistently filled each year by students entering diverse disciplines. Course evaluations have been positive and students specifically note how these courses allow them the opportunity to integrate basic anatomical knowledge into clinical contexts. Students have marked improvement in anatomical knowledge after completion of these electives. CONCLUSIONS: Advanced anatomy courses that integrate anatomical education with clinical reasoning are important curricular innovations that are popular with students and lead to important improvements in anatomical knowledge. Anatomists can lead the charge for better integration of basic sciences into senior medical school curricula.

Frozen section analysis in the post-Bethesda era.

BACKGROUND: The utility of frozen section (FS) for indeterminate thyroid nodules is controversial. In 2009, the Bethesda System for Reporting Thyroid Cytopathology was established to further subcategorize indeterminate fine-needle aspiration results (follicular lesions, FL) into Bethesda category 3 (BC3) and Bethesda category 4 (BC4). We hypothesize that FS will have less utility in the evaluation of BC3 lesions when compared to BC4. MATERIALS AND METHODS: A total of 479 patients who underwent thyroid lobectomy from January 2008 to July 2014 were retrospectively reviewed. Patients without appropriate Bethesda categorization were excluded. A total of 135 patients (65 FL, 45 BC3, 25 BC4) comprised the study groups. The sensitivity and specificity of FS within these three categories were determined. RESULTS: In the FL group, 6 of 65 patients were found to have thyroid cancer. Three were identified on frozen section (FS) resulting in a sensitivity and specificity of 50% and 100%, respectively. Thus, FS changed the operation in 3 of 65 cases (4.6%). In the BC3 group, 5 of 45 patients were found to have cancer. One was identified on FS resulting in a sensitivity and specificity of 20% and 100%, respectively. Thus, FS changed the operation in 1 of 45 patients (2.2%). In the BC4 group, 4 of 25 patients were found to have cancer. Two were identified on FS resulting in a sensitivity and specificity of 50% and 100% respectively. Thus, FS changed the operation in 2 of 25 patients (8%). CONCLUSIONS: There is improved utility of FS in BC 4 patients as 8% avoided reoperation. However, this benefit hinges on surgeon practice regarding the management of differentiated thyroid cancer >1 cm and <4 cm.

Outcomes of total thyroidectomy with therapeutic central and lateral neck dissection with a single dose of radioiodine in the treatment of regionally advanced papillary thyroid cancer and effects on serum thyroglobulin.

BACKGROUND: Achieving an undetectable serum thyroglobulin (Tg) level (<1.0 ng/mL) after surgical and radioiodine treatment for papillary thyroid cancer (PTC) is associated with low recurrence rates and has been termed biochemical remission. This study aimed to determine the effectiveness of total thyroidectomy with therapeutic central and lateral neck dissection for regionally advanced (T1-4bN1bM0) PTC with regard to posttreatment Tg levels. METHODS: This is a single-institution retrospective cohort study of patients with regionally advanced PTC initially treated with total thyroidectomy and therapeutic levels 2-7 neck dissection from 2002 to 2012. Pathologic findings, complications, serum Tg levels, and outcomes were analyzed. RESULTS: Sixty-one patients were initially treated with total thyroidectomy and therapeutic central and lateral neck dissection for PTC involving the lateral cervical nodes (N1b). The median number of lymph nodes excised and positive was 27 (range 5-112) and 9 (range 1-67), respectively. Extranodal extension occurred in 48 %. Radioiodine was administered after surgery with a median total dose of 150 mCi (range 30-244 mCi). Recurrent or persistent cervical disease occurred in 8 (13 %) and 3 (5 %) patients, respectively, and required additional radioiodine treatment in 2 and reoperative neck dissection in 10. Three patients developed new distant metastasis, and 1 died during the median follow-up of 20 months (range 1-109 months). Undetectable unstimulated Tg (<1.0 ng/mL) without clinically detectable recurrence was experienced in 68 % of patients with initial treatment. CONCLUSIONS: Biochemical remission can be experienced in most patients presenting with regionally advanced PTC with total thyroidectomy and compartment based therapeutic neck dissection followed by a single dose of radioiodine.

A determinant of odorant specificity is located at the extracellular loop 2-transmembrane domain 4 interface of an Anopheles gambiae odorant receptor subunit.

To explore the structural basis for odorant specificity in odorant receptors of the human malaria vector mosquito, Anopheles gambiae, odorant-binding subunits (Agam\Ors) expressed in Xenopus oocytes in combination with Agam\Orco (coreceptor subunit) were assayed by 2-electrode voltage clamp against 25 structurally related odorants. Agam\Or13 and Agam\Or15 display 82% amino acid identity and had similar, but somewhat distinct odorant response profiles. The ratio of acetophenone to 4-methylphenol responses was used in a mutation-based analysis of Agam\Or15, interchanging 37 disparate residues between Agam\Or15 and Agam\Or13. Eleven mutations caused significant changes in odorant responsiveness. Mutation of alanine 195 resulted in the largest shift in response ratio from Agam\Or15 toward Agam\Or13. Concentration-response analysis for a series of mutations of residue 195 revealed a large effect on acetophenone sensitivity, with EC50 values varying by >1800-fold and correlating with residue side chain length. Similar results were obtained for propiophenone and benzaldehyde. But, for other odorants, such as 4-methylphenol, 4-methylbenzaldehyde, and 4-methylpropiophenone, the effect of mutation was much smaller (EC50 values varied by ≤16-fold). These results show that alanine 195, putatively located at the second extracellular loop/fourth transmembrane domain interface, plays a critical role in determining the odorant response specificity of Agam\Or15.

Potential effects of molecular testing of indeterminate thyroid nodule fine needle aspiration biopsy on thyroidectomy volume.

BACKGROUND: Increasing utilization of genetic expression profiling (GEP) for thyroid nodules with indeterminate fine needle aspiration (FNA) results will potentially decrease the number of patients requiring diagnostic thyroidectomy. This study sought to determine the potential effects of GEP for indeterminate thyroid FNA results on thyroidectomy volume. METHODS: A retrospective review of thyroidectomy procedures performed over 1 year at the University of Michigan in the endocrine surgery division evaluated the indications for thyroidectomy, FNA Bethesda classification, and final surgical pathology to determine how application of GEP on indeterminate FNA results would affect decision for surgery and subsequent thyroidectomy volume. RESULTS: During the study period, 358 thyroidectomies were performed. The indication for procedure included: FNA findings, n = 122; symptomatic multinodular goiter, n = 85; nodule >4 cm, n = 30; Graves', n = 26; other, n = 95. FNA was performed in 231 patients. Bethesda classification included: benign, n = 69; malignant, n = 55; follicular lesion of undetermined significance, n = 59; follicular neoplasm, n = 20; suspicious for malignancy, n = 16; nondiagnostic, n = 12. If standard GEP was performed for all indeterminate FNA results, it would have influenced the decision for surgery in 68 (19 %) patients. Assuming 38 % of indeterminate FNA specimens will have benign results on genetic profiling, 27 patients would not have undergone thyroidectomy, translating into a 7.2 % decrease in overall thyroidectomy volume over a year. CONCLUSIONS: In an academic endocrine surgery program, the most common indication for thyroidectomy is an FNA result; however, standard application of GEP for all indeterminate thyroid FNAs would result in a minimal reduction in overall thyroidectomy volume.

Referral patterns for endocrine surgical disease.

OBJECTIVE: Referrals between physician specialties are common practice, and clear patterns develop. The increasing availability of high-volume endocrine surgery subspecialists with better outcomes may change these patterns. This study aimed to determine what factors influence endocrinologists' referral patterns for the surgical treatment of endocrine disease. METHODS: A national, cross-sectional, voluntary survey of members of the American Association of Clinical Endocrinologists examined physician demographics, physician's opinions on referral to endocrine surgery, preferred surgeon specialty, knowledge about surgeon characteristics, and how these factors influenced which surgeons they referred patients, as well as what changes in these factors would alter their referral patterns. RESULTS: The survey response rate was 15% (73/500), and 97% were endocrinologists. On average, 0 to 5 patients/week were referred for surgery. Most respondents (91.8%) felt that endocrinologists should decide which surgeon to refer. General surgery was the preferred surgeon specialty (43.7%), and endocrine surgery was the preferred subspecialty (70.8%). The factors most often cited as very important in referral to a surgeon included surgeon outcome/complications (71%), familiarity with surgeon (65%), surgeon's communication with referring physician (61%), and surgeon volume (59%). The factors most often cited as likely to change physician referral patterns included patient satisfaction (62%), complication rates (57%), surgeon outcomes (54%), and surgeon volume (50%). The factors most often cited as unlikely to change referral patterns included new surgeon availability (70%) and hospital/surgeon advertising (58%). CONCLUSION: Referring physicians want experienced endocrine surgeons with high operative volumes and good outcomes whom they are familiar with. The promotion of referral to high-volume surgeons requires communication, good outcomes, and satisfied patients.

Chemical sensing in mammalian host-bacterial commensal associations.

The mammalian gastrointestinal (GI) tract is colonized by a complex consortium of bacterial species. Bacteria engage in chemical signaling to coordinate population-wide behavior. However, it is unclear if chemical sensing plays a role in establishing mammalian host-bacterial commensal relationships. Enterohemorrhagic Escherichia coli (EHEC) is a deadly human pathogen but is a member of the GI flora in cattle, its main reservoir. EHEC harbors SdiA, a regulator that senses acyl-homoserine lactones (AHLs) produced by other bacteria. Here, we show that SdiA is necessary for EHEC colonization of cattle and that AHLs are prominent within the bovine rumen but absent in other areas of the GI tract. We also assessed the rumen metagenome of heifers, and we show that it is dominated by Clostridia and/or Bacilli but also harbors Bacteroidetes. Of note, some members of the Bacteroidetes phyla have been previously reported to produce AHLs. SdiA-AHL chemical signaling aids EHEC in gauging these GI environments, and promotes adaptation to a commensal lifestyle. We show that chemical sensing in the mammalian GI tract determines the niche specificity for colonization by a commensal bacterium of its natural animal reservoir. Chemical sensing may be a general mechanism used by commensal bacteria to sense and adapt to their mammalian hosts. Additionally, because EHEC is largely prevalent in cattle herds, interference with SdiA-mediated cattle colonization is an exciting alternative to diminish contamination of meat products and cross-contamination of produce crops because of cattle shedding of this human pathogen.

Performance of Afirma genomic sequencing classifier and histopathological outcome in Bethesda category III thyroid nodules: Initial versus repeat fine-needle aspiration.

BACKGROUND: There is limited data comparing the performance of Afirma Genomic Sequencing Classifier (GSC) in thyroid nodules carrying an initial versus a repeat diagnosis of atypia of undetermined significance (AUS). This study reported an institutional experience in this regard. MATERIALS AND METHODS: This retrospective study included consecutive thyroid nodules that had an initial or a repeat AUS diagnosis and had a subsequent GSC diagnostic result (benign or suspicious) from 2017 to 2021. All nodules were followed by surgical intervention or by clinical and/or ultrasound monitoring. GSC's benign call rate (BCR), rate of histology-proven malignancy associated with a suspicious GSC result, and diagnostic parameters of GSC were calculated and compared between the two cohorts (initial versus repeat AUS). Statistical significance was defined with a p-value of <.05 for all analysis. RESULTS: A total of 202 cases fulfilled inclusion criteria, including 67 and 135 thyroid nodules with an initial and a repeat AUS diagnosis, respectively. BCR was 67% and 66% in initial and repeat AUS cohorts, respectively. Rate of histology-proven malignancy associated with a suspicious GSC result were 22% and 24% in initial and repeat AUS cohorts, respectively. Compared with the repeat AUS cohort, the initial AUS cohort showed slightly lower sensitivity (83% vs. 100%), specificity (70% vs. 73%), PPV (23% vs. 24%), NPV (98% vs. 100%), and diagnostic accuracy (72% vs. 75%). Nevertheless, these differences did not reach statistical significance. CONCLUSION: GSC demonstrated comparable performance in thyroid nodules with a repeat AUS diagnosis versus nodules with an initial AUS diagnosis.

Reoperative lymph node dissection for recurrent papillary thyroid cancer and effect on serum thyroglobulin.

BACKGROUND: Papillary thyroid cancer (PTC) has an excellent prognosis with current treatment methods. However, the rates of locoregional recurrence after initial surgical management remain significant. This study evaluates the effect of reoperative neck dissection for locoregional recurrence of PTC after initial total thyroidectomy and radioiodine therapy on the incidence of cervical recurrence and postoperative serum thyroglobulin (Tg) levels. METHODS: This is a retrospective cohort study conducted in a single academic medical center of patients with recurrent or persistent PTC isolated to the neck after previous total thyroidectomy with or without lymph node dissection and adjuvant I(131) therapy who were treated with reoperative lymph node dissection. Outcomes including operative complications, pathologic findings, and effect of surgery on Tg levels and rates of recurrent disease were analyzed. RESULTS: From 2001 to 2010, a total of 61 patients had reoperative neck dissections for recurrent cervical PTC with a complication rate of 5 %. Seventy-two percent of patients were clinically free of detectable disease, and 28 % of patients had recurrent, persistent, or newly metastatic disease detected during the follow-up period. All patients had significant decreases in Tg levels, with a median 98 % reduction in preoperative levels. However, only 21 % of patients had an undetectable stimulated Tg (<0.5 ng/mL) during the follow-up period of 15.5 months. CONCLUSIONS: Reoperative treatment of recurrent or persistent PTC can be performed with low complication rates, and Tg levels greatly decrease in most patients; however, few achieve undetectable stimulated Tg.