GEMIN4 Variants: Risk Profiling, Bioinformatics, and Dynamic Simulations Uncover Susceptibility to Bladder Carcinoma

BACKGROUND

The relationship between GEMIN4 genetic variants and cancer, especially bladder carcinoma (BLCA), has been explored without conclusive results. This study aims to elucidate the link between GEMIN4 polymorphisms and BLCA susceptibility through genetic analyses, bioinformatics, and molecular dynamics (MD) simulations.

METHODS

A cohort of 249 participants (121 BLCA patients and 128 unrelated controls) was enrolled. PCR was employed for allelic discrimination of GEMIN4 variants, followed by subgroup stratification, haplotype analyses, structural prediction using the AlphaFold2 prediction tool, subsequent MD simulations, structural analysis, and residue interaction mapping using Desmond, UCSF ChimeraX, and Cytoscape softwares.

RESULTS

The rs.2740348*G variant demonstrated a protective role against BLCA in allelic (OR = 0.55, p = 0.002) and recessive (OR = 0.54, p = 0.017) models, whereas the rs.7813*T variant increased BLCA risk under the recessive model (OR = 1.90, p = 0.019). Haplotype analysis revealed a significant association between GEMIN4 haplotype (rs.2740348*C/rs.7813*T) with increased BLCA risk (OR = 2.01, p = 0.004). Univariate analysis revealed associations of the variants with albumin levels and absolute neutrophil count in BLCA patients. Pathogenicity evaluation categorized p.Gln450Glu as neutral and p.Arg1033Cys as deleterious. MD simulations revealed structural alterations and conformational shifts in the GEMIN4 protein induced by the Glu450 and Cys1033 mutations.

CONCLUSIONS

The study highlights the dual role of GEMIN4 variants in BLCA susceptibility, with rs.2740348 conferring protection and rs.7813 increasing risk. The Glu450 residue positively impacted protein stability, while Cys1033 had a detrimental effect on protein function. These findings underscore the significance of GEMIN4 variants in BLCA susceptibility and pave the way for future diagnostic and therapeutic initiatives.

Assessing Adequacy: A Meta-Analysis of Rapid Onsite Evaluation of Thyroid Nodules

INTRODUCTION

Fine-needle aspiration (FNA) is the standard form of preoperative evaluation of thyroid nodule cytological status. A significant number FNAs are classified as inadequate for interpretation, requiring a repeat FNA which is potentially avoidable, costly, and delays treatment. To address these concerns and maximize first-time FNA adequacy, rapid onsite evaluation (ROSE) of FNA specimens was introduced. Our study aims to determine the impact of ROSE on FNA adequacy.

METHODS

PubMed, Embase, and Web of Science were searched for primary articles assessing the adequacy of ROSE in thyroid nodules.

RESULTS

A total of 17 studies were included for a total of 24,649 thyroid nodes. Thirteen thousand two hundred fifteen (53.6%) thyroid nodules were assessed utilizing ROSE and 11,434 (46.4%) were not. Pooled adequacy increased significantly from 76% without ROSE to 92% with rose (P = 0.001). Use of ROSE increased the odds of adequate FNA by 22% (risk ratio (RR) = 1.22, 95% confidence interval (CI) = 1.12-1.32). At institutions with less than 85% effective diagnostic adequacy without ROSE, the risk for diagnostic adequacy increased by 28% with ROSE implementation (RR = 1.28, 95% CI = 1.20-1.37). In contrast, in studies reported from institutions with an effective diagnostic rate greater than 85% without the use of ROSE, the diagnostic adequacy only increased by 5% with ROSE implementation (RR = 1.05, 95% CI = 1.03-1.06).

CONCLUSIONS

The use of ROSE during first-time FNA of thyroid nodules can significantly improve adequacy, especially at institutions with baseline high inadequacy rates. Implementation of ROSE can reduce repeat FNAs and its associated consequences.

Survival Outcomes of Medullary Thyroid Cancer With and Without Amyloid Deposition

OBJECTIVE

Amyloid deposition within tumor stroma is a distinctive histologic feature of medullary thyroid cancer (MTC). However, its prognostic significance remains uncertain. We aimed to elucidate the impact of amyloid status on survival outcomes in a large cohort.

METHODS

The Surveillance, Epidemiology, and End Results registry was queried to identify patients diagnosed with MTC from 2000 to 2019. Patients with amyloid-positive (International Classification of Diseases for Oncology, third edition code 8345/3) and amyloid negative (International Classification of Diseases for Oncology, third edition code 8510/3) tumors were analyzed. Overall and disease-specific survival were compared between matched cohorts using Kaplan-Meier and Cox proportional hazards analyses.

RESULTS

Of the 2526 MTC patients, 511 of which were amyloid-positive and 2015 that were amyloid negative. Amyloid-positive patients displayed lower T stage (T3/4: 28% vs 85%, P < .001) and less extrathyroidal extension (11.3% vs 81.6%, P < .001). No difference in distant metastasis rate was observed between groups (14.5% vs 14.4%, P = .98). However, amyloid-positive patients showed a tendency for distal lymph node metastasis (1.2% vs 0.3%, P = .020). On univariate analysis, amyloid-positive status showed comparable overall survival times (mean 172.2 vs 177.8 months, P = .17), but a trend toward worse cancer-specific survival (hazard ratios [HR] = 1.31, 95% CI = 0.99-1.71, P = .051). After adjusting for covariates, amyloid deposition did not independently predict overall (HR = 1.15, 95% CI = 0.91-1.47, P = .25) or cancer-specific survival (HR = 1.30, 95% CI = 0.96-1.77, P = .09). Initiating therapy later than 1 month following diagnosis was associated with worse overall survival (HR = 1.25, 95% CI = 1.02-1.54, P = .029).

CONCLUSIONS

The presence of amyloid in MTC paradoxically associates with lower T stage yet exhibits a trend toward worse cancer-specific mortality. Amyloid deposition alone does not independently influence prognosis. Delayed treatment adversely impacted overall survival.

Survival benefits of extensive surgery in patients with papillary thyroid microcarcinoma

BACKGROUND

Despite the guidelines recommending thyroid lobectomy, many papillary thyroid microcarcinoma (PTMC) patients still undergo total thyroidectomy. PTMC's optimal treatment remains unclear. We aimed to determine whether total thyroidectomy improves outcomes compared to less extensive surgery.

METHODS

We analyzed 6064 PTMC adult patients from the Surveillance, Epidemiology, and End Results (SEER) database (2000-2019) who underwent either total thyroidectomy (n ​= ​3652) or less extensive surgery (n ​= ​2412). Endpoints were overall survival, cancer-specific survival, and recurrence.

RESULTS

Total thyroidectomy patients had a 5.2 ​% mortality rate versus 8.1 ​% with less extensive surgery. Recurrence occurred in 1 (0.03 ​%) total thyroidectomy patient compared to 24 (1.0 ​%) less extensive surgery patients (HR 0.07, p ​= ​0.01). Median survival was 8.1 years for total thyroidectomy versus 8.8 years for less extensive surgery. Overall survival favored total thyroidectomy (p ​= ​0.001) but cancer-specific survival did not differ.

CONCLUSION

Although total thyroidectomy may not improve cancer-specific survival, it lowers recurrence risk and confers an overall survival advantage for PTMC patients. These findings may help guide surgical decisions.

Risk Factors for Postoperative Infections Following Appendectomy of Complicated Appendicitis: A Meta-analysis and Retrospective Single-institutional Study

Patients with complicated appendicitis have an increased risk for postoperative infections. Potential risk factors for postoperative infections through a meta-analysis and retrospective chart review are discussed. A meta-analysis consisting of 35 studies analyzing complicated appendicitis treated with an appendectomy noting at least 1 postoperative infection was performed. A retrospective review was then conducted in patients diagnosed with complicated appendicitis after appendectomy. Of 5326 patients in total, 15.4% developed postoperative infections. Laparoscopic surgery and perioperative hyperoxygenation were found to be protective factors for the development of infection. Retrospectively, 53.2% of patients presented with complicated appendicitis. Patients with complicated appendicitis were more likely to be older in age and have an increased length of stay. Patient demographics, operative time, and comorbid status had no effect on postoperative infection or readmission rate. Physicians should strongly consider minimally invasive techniques to treat all cases of complicated appendicitis irrespective of comorbidities, age, sex, or body mass index.

Clinical outcomes and tumor microenvironment response to radiofrequency ablation therapy: a systematic review and meta-analysis

Background

Radiofrequency ablation (RFA) utilizes minimally invasive high-energy current to precisely ablate tumor cells. It has been utilized in many cancer types including thyroid, lung, and liver cancer. It has been shown to provide adequate ablative margins with minimal complications; however, incomplete RFA may lead to recurrence of tumor. The underlying cellular mechanism and behavior of ablated cancer tissue is poorly understood.

Methods

A systematic review was performed, searching EMBASE, Web of Science, PubMed, and Scopus for studies published up to March 2022 and reported following PRISMA guidelines. Collection was performed by two groups of investigators to avoid risk of bias. The Cochrane Collaboration's tool was used for assessing risk of bias. We identified human, in vivo, and in vitro research studies utilizing RFA for tumor tissues. We required that the studies included at least one of the following: complications, recurrence, or survival, and took interest to studies identifying cellular signaling pathway patterns after RFA. Descriptive statistical analysis was performed in 'R' software including mean and confidence interval.

Results

The most frequent cancers studied were liver and lung cancers accounting for 57.4% (N=995) and 15.4% (N=267), followed by esophageal (N=190) and breast cancer (N=134). The most common reported complications were bleeding (19%) and post-operative pain (14%). In our literature search, four independent studies showed upregulation and activation of the VEGF pathway following RFA, four showed upregulation and activation of the AKT pathway following RFA, three studies demonstrated involvement of matrix metalloproteinases, and four showed upregulation of c-Met protein following RFA.

Conclusions

In our review and meta-analysis, we identify several proteins and pathways of interest of which are important in wound healing, angiogenesis, and cellular growth and survival. These proteins and pathways of interest may implicate areas of research towards RFA resistance and cancer recurrence.

From ablation to operation: Unraveling the surgical outcomes and complications of thyroidectomy after radiofrequency ablation

BACKGROUND

Radiofrequency ablation is a minimally invasive treatment for thyroid nodules; however, concerns exist regarding its impact on subsequent thyroid surgery. We compared surgical outcomes and complications between patients undergoing thyroidectomy after radiofrequency ablation (post-radiofrequency ablation thyroidectomy group) and those without prior radiofrequency ablation (non-radiofrequency ablation thyroidectomy group).

METHODS

We retrospectively analyzed thyroidectomy patients, comparing post-radiofrequency ablation thyroidectomy and non-radiofrequency ablation thyroidectomy groups, examining demographics, nodule characteristics, surgical techniques, and complications.

RESULTS

The study included 96 patients (73 in the non-radiofrequency ablation thyroidectomy group and 23 in the post-radiofrequency ablation thyroidectomy group). The mean age was 53.3 ± 14.4 years, with 78.1% female patients and 36.5% African American patients. Median operative time was similar between the post-radiofrequency ablation thyroidectomy (110 minutes) and the non-radiofrequency ablation thyroidectomy (92 minutes) cohorts (P = .40). Complications were reported in 13 patients, without significant differences between groups (P = .54). No permanent complications, including nerve injury or hypoparathyroidism, were reported in either cohort. Prior radiofrequency ablation treatment did not increase the risk of complications (odds ratio = 3.48, 95% confidence interval = 0.70-17.43, P = .16).

CONCLUSION

Our work found no differences in outcomes or safety in patients undergoing thyroidectomy with or without previous radiofrequency ablation treatment, potentiating the post-radiofrequency ablation thyroidectomy group as a safe management option. Accordingly, this may reassure both clinicians and patients of the safety of radiofrequency ablation in treating patients with thyroid nodules.

Completion thyroidectomy: A safe option for high-volume surgeons

BACKGROUND

The risk of complication in patients undergoing completion thyroidectomy (cT) is mixed. Several studies report increased risk in comparison to total thyroidectomy (TT) and still others reporting a comparatively decreased risk. We compared the rates of complication in patients at our institution undergoing thyroid lobectomy (TL), (TT), and cT by a single high-volume surgeon.

METHODS

We performed a single-institution retrospective cohort study. Patients undergoing TL, TT, or cT by a high-volume surgeon were included. Rates of complication were collected and compared between the three cohorts.

RESULTS

A total of 310 patients were included. The overall rate of complication was 4.2%. The complication rates in the TL, TT, and cT cohorts were 1%, 7.1%, and 4.5%, respectively (p = 0.10). Transient hypocalcemia was slightly more common in the TT cohort (6.1%) as opposed to the TL (0%) or cT (0.9%) cohort (p = 0.01). The cohorts also had similar rates of recurrent laryngeal nerve signal loss leading to transient dysphonia (TL: 0% vs. TT: 1% vs. cT: 3.6%, p = 0.10).

CONCLUSIONS

While rates of complication tended to predictably decrease as approaches became less extensive, there were no significant differences in complication rates among the three surgical approaches when performed by a high-volume surgeon. Considering the low rates of complication overall, patient counseling and preference should be emphasized to provide appropriate and tailored treatment plans.

Radiofrequency ablation of benign thyroid nodules: A prospective, multi-institutional North American experience

BACKGROUND

Radiofrequency ablation for benign thyroid nodules aims to achieve a volume reduction rate of ≥50%. However, factors that predict treatment success have not been defined in a large-scale study.

METHODS

A prospective cohort study of biopsy-proven benign thyroid nodules treated with radiofrequency ablation at 3 institutions was performed. Patient demographics, nodule sonographic features, procedural data, and nodule volume reduction were evaluated. Binary logistic regression analysis was performed to identify features associated with treatment response.

RESULTS

A total of 620 nodules were analyzed. The pooled median volume reduction rate at 12 months was 70.9% (interquartile range 52.9-86.6). At 1 year follow-up, 78.4% of nodules reached treatment success with a volume reduction rate ≥50%. The overall complication rate was 3.2% and included temporary voice changes (n = 14), vasovagal episodes (n = 5), nodule rupture (n = 3), and lightheadedness (n = 2). No permanent voice changes occurred. Four patients developed postprocedural hypothyroidism. Large baseline nodule volume (>20 mL) was associated with a lower rate of successful volume reduction (odds ratio 0.60 [0.37-0.976]). Large nodules achieved treatment success by 12-month follow-up at a rate of 64.5%, compared with 81.4% for small nodules and 87.2% for medium nodules.

CONCLUSION

To our knowledge, this is the largest North American cohort of patients with benign thyroid nodules treated with radiofrequency ablation. Overall, radiofrequency ablation was an effective treatment option with a low risk of procedural complications. Large volume nodules (>20 mL) may be associated with a lower rate of successful reduction with radiofrequency ablation treatment.

Recommend with caution: A meta-analysis investigating papillary thyroid carcinoma tumor progression under active surveillance

BACKGROUND

Papillary thyroid carcinoma (PTC) is an indolent disease with favorable outcomes. The non-surgical treatment approach known as active surveillance (AS) has been introduced as an alternative treatment instead of the traditional thyroidectomy. However, 10-15 % of PTC tend to progress. We sought to determine factors predicting the progression of PTC under AS.

METHODS

A systematic search was performed in January 2022 using PubMed, Embase, Google Scholar, Web of Science, and ScienceDirect. PRISMA guidelines were used by multiple reviewers to extract study characteristics (author name, publication date, journal name, country, institution, and study design), as well as main outcomes and measures. A combination of utilization of thyroid replacement therapy, baseline tumor size and volume, follow-up tumor size and volume, and the presence of lymph node metastasis and its distribution, as well as surveillance duration, were the main measures of this study.

RESULTS

Nine studies with 4166 patients were included, of which 354 showed tumor progression during AS (15 %; 95%CI = 7 % - 23 %). The average follow-up period was 41.58 months. The mean tumor maximum diameter was 8.54 mm (95%CI = 7.04-10.03). Tumor progression was most commonly secondary to an increase in volume by ≥50 % (75 %; 95%CI = 68 % - 80 %), then increase in diameter by ≥3 mm (41 %; 95%CI = 13 % - 76 %), and finally the development of lymph node metastasis (13 %; 95%CI = 9 % - 19 %). Approximately only 2 % of all patients thus developed new lymph node metastasis. Patient age, sex, and tumor size were not associated with higher risks of tumor progression. 12 % of AS patients eventually underwent surgery, though only 40 % (95%CI = 27 % - 53 %) of these patients displayed tumor progression.

CONCLUSIONS

Our meta-analysis determined a tumor progression rate of 15 % in patients who underwent AS management, 13 % of which (2 % of all patients) developed lymph node metastasis. We found no protective or risk factors for tumor progression, and that almost half of all patients who underwent delayed surgery did so for reasons other than tumor progression. While not biopsying small (<1 cm) or very low suspicious nodules is already recommended, AS may be an appropriate treatment option in patients appropriately counseled, considering the low risk of advanced tumor progression but also the considerable patient population who fail to adhere to treatment. Alternatively, in aim of preventing overtreatment in patients who would rather take proactive measures against their low-risk carcinoma, minimally-invasive ablation techniques may be an attractive option.

A combination of computed tomography scan and ultrasound provides optimal detection of cervical lymph node metastasis in papillary thyroid carcinomas: A systematic review and meta-analysis

BACKGROUND

Lymph node metastasis (LNM) in patients with papillary thyroid carcinoma (PTC) is common. This meta-analysis assesses the diagnostic accuracy of computed tomography (CT), ultrasound (US), and CT + US in detecting central and lateral LNM.

METHODS

A systematic review and meta-analysis was performed by searching PubMed, Embase, and Cochrane for studies published up to April 2022. The pooled sensitivity, specificity, and diagnostic odds ratio (DOR) were calculated. The area under the curve (AUC) for summary receiver operating curves (sROC) were compared.

RESULTS

The study population included 7902 patients with a total of 15 014 lymph nodes. Twenty-four studies analyzed the sensitivity of the overall neck region in which dual CT + US imaging (55.9%) had greater sensitivities (p < 0.001) than either US (48.4%) or CT (50.4%) alone. The specificity of US alone (89.0%) was greater (p < 0.001) than CT alone (88.5%) or dual imaging (86.8%). The DOR for dual CT + US imaging was greatest (p < 0.001) at 11.134, while the AUCs of the three imaging modalities were similar (p > 0.05). Twenty-one studies analyzed the sensitivity of the central neck region in which both CT (45.8%) and CT + US imaging (43.4%) had greater sensitivities (p < 0.001) than US alone (35.3%). The specificity of all three modalities was higher than 85%. The DOR for CT (7.985) was greater than US alone (4.723, p < 0.001) or dual CT + US imaging (4.907, p = 0.015). The AUC of both CT + US (0.785) and CT alone (0.785) were significantly greater (p < 0.001) than US alone (0.685). Of the 19 studies that reported lateral LNM, CT + US imaging sensitivity (84.5%) was higher than CT alone (69.2%, p < 0.001) and US alone (79.7%, p = 0.038). The specificity of all imaging techniques was all greater than 80.0%. CT + US imaging DOR (35.573) was greater than CT (20.959, p = 0.024) and US (15.181, p < 0.001) individually. The AUC of independent imaging was high (CT: 0.863, US: 0.858) and improved significantly when combined (CT + US: 0.919, p = 0.024 and p < 0.001, respectively).

CONCLUSIONS

We report an up-to-date analysis elucidating the diagnostic accuracy of LNM detection by either CT, US, or in combination. Our work suggests dual CT + US to be the best for overall detection of LNM and CT to be preferable in detecting central LNM. The use of either CT or US alone may detect lateral LNM with acceptable accuracy, yet dual imaging (CT + US) significantly improved detection rates.

Comparison of Medical Management versus Parathyroidectomy in Patients with Mild Primary Hyperparathyroidism: A Meta-Analysis

BACKGROUND

Parathyroidectomy is the definitive cure for patients with primary hyperparathyroidism (pHPT) and has an annual prevalence of 0.2-1% in the United States. Some patients with mild disease are medically managed effectively using calcium-lowering medications and drugs against complications such as osteoporosis; however, many maintain a persistently high calcium level that negatively impacts their skeletal, renal, and psychogenic systems over the long term. This meta-analysis aims to compare the outcomes of medical management versus parathyroidectomy in patients with mild pHPT.

STUDY DESIGN

This meta-analysis was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using PubMed, Embase, and Web of Science by two teams of investigators. Analysis was run using R packages.

RESULTS

A total of 12 publications including seven randomized control, two prospective, and three retrospective trials with a total of 1346 patients were included for analysis. The average follow-up for all patients was 41 ± 23.8 months. Demographics, pre-treatment calcium, PTH, and bone mineral density (BMD) were similar between the medical (N = 632) and surgical (N = 714) cohorts. Post-treatment calcium and PTH levels were significantly higher in the medical cohort (10.46 vs. 9.39, p < 0.01), (106.14 vs. 43.25, p = 0.001), respectively. Interestingly, the post-treatment PTH in the medical cohort increased when compared to pre-treatment (83.84 to 106.14). Patients in the medical cohort had lower BMD in lumbar (0.48 g/cm²; OR = 0.42, 95% CI = 0.21, 0.83), femoral (0.48; OR = 0.42, 95% CI = 0.29, 0.61), and hip (0.61; OR = 0.33, 95% CI = 0.13, 0.85). Incidences of fracture, nephrolithiasis, cardiovascular death, or overall mortality were not significantly different between the cohorts.

CONCLUSIONS

The present study is the most comprehensive meta-analysis on mild pHPT to date. Our findings reflect that parathyroidectomy is the superior option in the treatment of mild pHPT patients as opposed to medical management.

Unleash Multifunctional Role of miRNA Biogenesis Gene Variants (XPO5*rs34324334 and RAN*rs14035) with Susceptibility to Hepatocellular Carcinoma

Numerous reports have explored the roles of different genetic variants in miRNA biogenesis mechanisms and the progression of various types of carcinomas. The goal of this study is to explore the association between XPO5*rs34324334 and RAN*rs14035 gene variants and susceptibility to hepatocellular carcinoma (HCC). In a cohort of 234 participants (107 HCC patients and 127 unrelated cancer-free controls) from the same geographic region, we characterized allelic discrimination using PCR-RFLP and performed subgroup analysis and multivariate regression. We found that the frequency of the XPO5*rs34324334 (A) variant was correlated with elevated risk of HCC under allelic (OR = 10.09, p-value < 0.001), recessive (OR = 24.1, p-value < 0.001), and dominant (OR = 10.1, p-value < 0.001) models. A/A genotype was associated with hepatitis C cirrhosis (p-value = 0.012), ascites (p-value = 0.003), and higher levels of alpha-fetoproteins (p-value = 0.011). Carriers of the RAN*rs14035 (T) variant were more likely to develop HCC under allelic (OR = 1.76, p-value = 0.003) and recessive (OR = 3.27, p-value < 0.001) models. Our results suggest that XPO5*rs34324334 and RAN*rs14035 variants are independent risk factors for developing HCC.

Hashimoto's Thyroiditis: A Protective Factor against Recurrence in BRAF-Wild Type Differentiated Thyroid Carcinoma

A recent work analyzing the concomitant factors BRAF mutation (risk factor) and Hashimoto's thyroiditis (HT) (protective factor) found that the presence of HT reduced lymph node metastasis in BRAF-mutated papillary thyroid carcinoma. Whether this notion is upheld with respect to disease recurrence and differentiated thyroid carcinoma (DTC), however, is unknown. We aimed to investigate the effect of underlying HT in DTC patients and its influence on recurrence with a specific emphasis in BRAF-mutated tumors. A total of 469 patients were included. Patients were stratified according to BRAF and HT status. Multivariate regression analysis was conducted to determine protective and risk factors of disease recurrence in patients with DTC. HT was associated with less-aggressive carcinomas including more frequent microcarcinomas (HT: 45.0% vs. no-HT: 34.0%, p = 0.02), less lymph node involvement (HT: 16.4% vs. no-HT: 26.1%, p = 0.02), and less disease recurrence (HT: 2.9% vs. no-HT: 11.9%, p = 0.002). BRAF mutation was also significantly associated with higher rates of lymph node involvement (BRAF-mutant: 41.9% vs. BRAF-wild type: 14.6%, p < 0.001) and almost two times the rate of recurrence (BRAF-mutant: 14.9% vs. BRAF-wild type: 6.5%, p = 0.004). Underlying HT was the only protective factor determined, reducing the odds of developing recurrence by 70% (HR: 0.30, 95%CI: 0.11-0.88). In the BRAF-wild type cohort, regression analysis continued to determine HT as a protective factor (p = 0.03). However, in the BRAF-mutant cohort, HT was no longer an independent protective factor (p = 0.20) against recurrence. Sub-group regression analysis, including PTC patients, similarly found HT as a protective factor only in BRAF-wild type patients (p = 0.039) and not BRAF-mutant (p = 0.627). The presence of underlying HT is associated with less aggressive tumors and is an independent protective factor against DTC recurrence, reducing the risk by 70%. HT remains a protective factor in BRAF-wild type carcinoma, but not in patients with BRAF-mutant carcinoma. HT may potentially be considered as a parameter which enhances American Thyroid Association patient risk stratification.

Diagnostic Performance of Afirma and Interpace Diagnostics Genetic Testing in Indeterminate Thyroid Nodules: A Single Center Study

Indeterminate thyroid nodules (ITN) represent 20–30% of biopsied nodules, with a 10–60% risk of malignancy. Molecular testing can stratify the risk of malignancy among ITNs, and subsequently reduce the need for unnecessary diagnostic surgery. We aimed to assess the performance of these molecular tests at a single institution. Patients with Bethesda III, IV, and V nodules with Afirma and Interpace Diagnostics genetic testing data from November 2013 to November 2021 were included. Three cohorts were formed, including GSC + XA, ThyGeNEXT + ThyraMIR, and GSC + GEC. Statistical analysis determined the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), diagnostic odds ratio (DOR), and accuracy of each type of testing. The PPV of nodules undergoing genetic testing by ThyGeNEXT + ThyraMIR (45.00%, 95%CI: 28.28–62.93%, p = 0.032) and GSC + XA (57.14%, 95%CI: 29.32–81.08%, p < 0.001) were superior to that of GEC + GSC (30.72%, 95%CI: 26.83–34.90%). The NPV was above 85% in all cohorts, suggesting overall suitable rule-out tests. The Afirma platform (GSC + XA) had the highest NPV at 96.97%. The overall accuracy for nodules undergoing ThyGeNEXT + ThyraMIR was 81.42% (95%CI: 73.01–88.11%, p < 0.001). A total of 230 patients underwent thyroidectomy, including less than 60% of each of the ThyGeNEXT + ThyraMIR and GSC + XA cohorts. Specifically, only 25% of patients in the GSC + XA cohort underwent surgery, considerably decreasing the rate of unnecessary surgical intervention. Sub-group analysis, including only patients with surgical pathology, found that PPV tended to be higher in the GSC + XA cohort, at 66.67% (95%CI: 37.28–87.06%), as compared to the ThyGeNEXT + ThyraMIR cohort, at 52.94% (95%CI: 35.25–69.92%). The Afirma genetic testing platform GSC + XA outperformed the other platforms with regards to both PPV and NPV and decreased the rate of surgery in patients with ITNs by 75%, significantly preventing unnecessary surgical intervention.

Cardiovascular Health by Graves' Disease Management Modality - Surgery Versus Radioactive Iodine Versus Antithyroid Medications: A Network Meta-Analysis

INTRODUCTION

Graves' disease is an autoimmune disorder of the thyroid gland associated with the overproduction of thyroid hormones. Excess secretion of thyroid hormones leads to cardiovascular consequences. Treatment options include antithyroid medications (ATM), radioactive iodine (RAI) ablation, and total thyroidectomy. We examined the cardiovascular outcomes following Graves' disease management modality.

METHODS

A systematic search was performed up to September 22nd, 2021, using PubMed, EMBASE, and Web of Science databases. We conducted a network meta-analysis analyzing cardiovascular outcomes of interest, including congestive heart failure (CHF), arrhythmia, atrial fibrillation (AF), and hypertension.

RESULTS

Three studies were included in this analysis totaling 6700 patients with Graves' disease, of which 74% were female. The mean age was 44.34 y. When compared to pretreatment, management options lowered the risk of maintaining arrhythmia 81% with surgery (relative risk [RR] = 0.19; 95% confidence interval [CI] = 0.12 to 0.31), 67% with ATM (RR = 0.33; 95% CI = 0.23 to 0.49), and 50% with RAI (RR = 0.50; 95% CI = 0.13 to 1.95). Risk of maintaining CHF was reduced 80% with surgery (RR = 0.20; 95% CI = 0.08 to 0.49), 41% with ATM (RR = 0.59; 95%CI = 0.52 to 0.67), and only 7% with RAI (RR = 0.93; 95%CI = 0.68 to 1.26). Treatment-ranking analysis found all parameters, including CHF, arrhythmia, AF, and hypertension, to be in favor of surgical treatment over medical treatment and RAI ablation.

CONCLUSIONS

This is the first network meta-analysis analyzing the cardiovascular outcomes in Graves' disease patients by treatment option. Our study demonstrated that surgery is superior to RAI and medical treatment.

Tendon Transfers to Restore Shoulder Function for Obstetrical Brachial Plexus Palsy: A Systematic Review of the Literature

BACKGROUND

Obstetrical brachial plexus palsy (OBPP) is a relatively common stretch injury of the brachial plexus sustained during delivery. Tendon transfers are commonly performed to improve shoulder function among patients with OBPP. Although several techniques for the surgical management of OBPP exist, it is unclear whether tendon transfers to the rotator cuff vs. posterior humerus yield different outcomes.

METHODS

A systematic search in PubMed, Web of Science, the Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, and Google Scholar up to January 1, 2021, was performed. Relevant publications were classified by surgical technique of tendon transfers to the rotator cuff or posterior humerus. The standard mean difference (SMD) and 95% confidence intervals were calculated to compare preoperative and postoperative aggregate Mallet scores as well as abduction and external rotation scores using the Mallet scale. A p value of <0.01 was considered significant.

RESULTS

Data from 26 studies and 951 patients (46.2% male patients) with a mean age of 68.9 ± 29.3 months were included. Eight hundred three patients underwent tendon transfer to the rotator cuff and 148 to the posterior humerus. The average postoperative follow-up period was 45.2 ± 21.7 months. The pooled cohort had an overall improvement in postoperative aggregate Mallet scores (SMD = 5.53, p < 0.001), abduction scores (SMD = 1.79, p < 0.001), and external rotation scores (SMD = 1.99, p < 0.001). Tendon transfer to the rotator cuff had a greater postoperative improvement in abduction (SMD = 1.90, p < 0.001) than transfer to the posterior humerus (SMD = 1.32, p < 0.001) while both techniques yielded similar improvements in external rotation (rotator cuff SMD = 2.01, p < 0.001, posterior humerus SMD = 1.98, p < 0.001).

CONCLUSION

This is the first systematic review comparing outcomes for tendon transfers to the rotator cuff vs. the posterior humerus for improving shoulder function in patients with OBPP. Overall, tendon transfers are an effective treatment for improving shoulder function. Transfer of the latissimus dorsi and teres major to the rotator cuff compared with transfer to the posterior humerus results in greater improvement in abduction while both techniques have similar results in improving external rotation.

LEVEL OF EVIDENCE

Level I Systematic review of Level I and Level II studies.

The Diagnostic Performance of Ultrasonography in the Evaluation of Extrathyroidal Extension in Papillary Thyroid Carcinoma: A Systematic Review and Meta-Analysis

Extrathyroidal extension (ETE) in patients with papillary thyroid carcinoma (PTC) is an indication of disease progression and can influence treatment aggressiveness. This meta-analysis assesses the diagnostic accuracy of ultrasonography (US) in detecting ETE. A systematic review and meta-analysis were performed by searching PubMed, Embase, and Cochrane for studies published up to April 2022. The pooled sensitivity, specificity, and diagnostic odds ratio (DOR) were calculated. The areas under the curve (AUC) for summary receiver operating curves were compared. A total of 11 studies analyzed ETE in 3795 patients with PTC. The sensitivity of ETE detection was 76% (95%CI = 74-78%). The specificity of ETE detection was 51% (95%CI = 49-54%). The DOR of detecting ETE by US was 5.32 (95%CI = 2.54-11.14). The AUC of ETE detection was determined to be 0.6874 ± 0.0841. We report an up-to-date analysis elucidating the diagnostic accuracy of ETE detection by US. Our work suggests the diagnostic accuracy of US in detecting ETE is adequate. Considering the importance of ETE detection on preoperative assessment, ancillary studies such as adjunct imaging studies and genetic testing should be considered.

Gender and Race Demographics of Fellowships After General Surgery Training in the United States: A Five-Year Analysis in Applicant and Resident Trends

INTRODUCTION

The gender and minority gap in general surgery residency is narrowing; however, literature lacks comprehensive data regarding the demographics of fellowship programs following general surgery training.

METHODS

Data from 2017 to 2021 for gender, ethnicity, and surgical subspecialty are publicly available from the ERAS database and ACGME yearly data reports. Cochran-Armitage trend tests were used to determine statistical significance in trends for female and minority applicants and trainees.

RESULTS

The overall trend of female applicants to surgical specialties remained stagnant. However, female applicants to vascular surgery increased significantly from 25% to 35% (P = .045). There was no significant increase in female trainees in any surgical specialties evaluated. Furthermore, the overall trend of minority applicants to surgical specialties also remained stagnant, except for pediatric surgery, which showed significantly fewer minority applicants. Despite pediatric surgery having fewer applicants, minority trainees in this specialty increased significantly from 8% to 19% (P = .008).

CONCLUSION

Several current initiatives, such as intentional mentorship, are being reported to promote diverse and equal representation among female and minority applicants and trainees. However, the current overall margin of increase in diversity among surgical specialty applicants and trainees is minimal, indicating that continued efforts are needed to diversify surgical specialty training programs.

Radiologist versus Non-Radiologist Detection of Lymph Node Metastasis in Papillary Thyroid Carcinoma by Ultrasound: A Meta-Analysis

Papillary thyroid carcinoma (PTC) is the most common thyroid cancer worldwide and is known to spread to adjacent neck lymphatics. Lymph node metastasis (LNM) is a known predictor of disease recurrence and is an indicator for aggressive resection. Our study aims to determine if ultrasound sonographers’ degree of training influences overall LNM detection. PubMed, Embase, and Scopus articles were searched and screened for relevant articles. Two investigators independently screened and extracted the data. Diagnostic test parameters were determined for all studies, studies reported by radiologists, and studies reported by non-radiologists. The total sample size amounted to 5768 patients and 10,030 lymph nodes. Radiologists performed ultrasounds in 18 studies, while non-radiologists performed ultrasounds in seven studies, corresponding to 4442 and 1326 patients, respectively. The overall sensitivity of LNM detection by US was 59% (95%CI = 58–60%), and the overall specificity was 85% (95%CI = 84–86%). The sensitivity and specificity of US performed by radiologists were 58% and 86%, respectively. The sensitivity and specificity of US performed by non-radiologists were 62% and 78%, respectively. Summary receiver operating curve (sROC) found radiologists and non-radiologists to detect LNM on US with similar accuracy (p = 0.517). Our work suggests that both radiologists and non-radiologists alike detect overall LNM with high accuracy on US.

Ultraviolet Light Exposure Decreases Thyroid Cancer Risk: A National Perspective

Ultraviolet (UV) light has been reported to have both pro-oncogenic and anti-oncogenic effects. Since patient pigmentation can influence the role of UV light exposure, we thought to investigate the recent trends in thyroid cancer incidence and survival with an emphasis on patient race and UV exposure. Patients diagnosed with thyroid cancer from the Surveillance, Epidemiology, and End Results (SEER) database were identified. A total of 284,178 patients were enrolled. Data were stratified according to population sex, race, and state. UV exposure data in Watt-Hours Per Square Meter for the state were obtained from the National Cancer Institute Cancer Atlas. Thyroid cancer incidence rate varied by race, ranging from 14.9 cases per 100,000 in Asian or Pacific Islanders and 14.7 per 100,000 in Caucasians, to 8.7 per 100,000 in African American and 8.0 per 100,000 in Native Americans. UV exposure was negatively correlated with thyroid cancer incidence when analyzed across all populations (r = −0.299, p = 0.035). UV exposure was most steeply negatively correlated with thyroid cancer rates in Black populations (r = −0.56, p < 0.001). Despite this, Black men had the worst 5-year survival rate when compared to other ethnic populations. Overall, UV exposure does not increase the risk of thyroid cancer and may serve as a protective factor in the development of thyroid cancer.

Radiofrequency Ablation of Indeterminate Thyroid Nodules: The First North American Comparative Analysis

Thyroid nodules can be classified as benign, malignant, or indeterminate, the latter of which make up 10-30% of nodules. Radiofrequency ablation (RFA) has become an attractive and promising therapy for the treatment of benign thyroid nodules. However, few studies have investigated the safety and efficacy of RFA for the management of indeterminate thyroid nodules. In this study, 178 patients with thyroid nodules diagnosed as benign (Bethesda II) or indeterminate (Bethesda III/IV) by preoperative cytopathological analysis were included. Patients in the benign and indeterminate cohorts had similar thyroid nodule volume reduction rates at 65.60% and 64.20%, respectively (p = 0.68). The two groups had similar nodular regrowth rates, at 11.2% for benign nodules and 9.40% for indeterminate nodules (p = 0.72). A total of three cases of transient dysphonia were reported. RFA of indeterminate thyroid nodules was comparable to that of benign thyroid nodules in all parameters of interest, including volume reduction rate. To our best knowledge, our work is the first North American analysis comparing benign and indeterminate thyroid nodules and suggests RFA to be a promising modality for the management of indeterminate thyroid nodules.

Hashimoto’s Thyroiditis Minimizes Lymph Node Metastasis in BRAF Mutant Papillary Thyroid Carcinomas

Hashimoto’s thyroiditis (HT) (autoimmune thyroiditis) is a clinicopathological entity associated with chronic lymphocytic infiltration resulting in hypothyroidism. HT is a double-edged sword that increases the risk of papillary thyroid cancer (PTC), yet it serves as a protective factor for PTC progression. BRAF mutation in PTCs is associated with rapid cell growth, aggressive tumor characteristics, and higher mortality rates. Here, we aimed to analyze the influence of HT in patients with PTCs and its effect on lymph node metastasis (LNM) in BRAF mutant tumors. Adults diagnosed with PTC between 2008 and January 2021 were retrospectively included. A total of 427 patients, 128 of whom had underlying HT, were included. The HT group had significantly higher rates of microcarcinoma (49.2% vs. 37.5%, p = 0.025) and less lateral LNM (8.6% vs. 17.1%, p = 0.024). Interestingly, BRAF-mutated PTCs were found to have significantly less overall LNM (20.9% vs. 51%, p = 0.001), central LNM (25.6% vs. 45.1%, p = 0.040) and lateral LNM (9.3% vs. 29.4%, p = 0.010) in patients with HT when compared to those without underlying HT. HT was found to be an independent protective predictor of overall and lateral LNM. Altogether, HT was able to neutralize the effect of BRAF mutation and was determined to be an independent protective factor against LNM. Specifically, our work may influence treatment-aggressiveness decision making for endocrinologists, oncologists and surgeons alike.

Latency Trend Analysis as a Guide to Screening Malignancy Survivors for Second Primary Thyroid Cancer

Primary cancer survivors have a higher risk of developing second primary thyroid cancer (SPTC). Patients with SPTC who survived primary malignancies, diagnosed from 1975 to 2016, were identified from the Surveillance, Epidemiology, and End Results (SEER) database (SEER 18 Registry). A total of 33,551 cancer cases were enrolled in the final analysis. Individuals with a primary malignancy were at a significant 90% increased risk of developing SPTC (SIR = 1.90, 95%CI = 1.86−1.93, p < 0.05) compared to the general population. More than half (54.7%) of SPTC diagnoses were made in the first three years after primary cancer diagnosis, and the most aggressive presentations of SPTC occurred within the first year following malignancy. A latency trend analysis identified persistent high risk for development of SPTC after diagnosis of lymphoma, leukemia, soft tissue tumors, kidney, breast, and uterine cancer; elevated 10-year risk for most cancers such as salivary gland, melanoma, stomach, lung, colon, ovarian, pancreas, prostate, and bladder; and high 5-year risk after cancers such as larynx, oral, orbit, bone, small intestine, and liver. Our latency period model identifying risk according to each type of primary cancer may aid clinicians in identifying at-risk patients to be screened for thyroid cancer and guide them in developing a surveillance plan according to the latency period attributed to a patient’s primary cancer.

Dimethyl malonate slows succinate accumulation and preserves cardiac function in a swine model of hemorrhagic shock

BACKGROUND

Succinate (SI) is a citric acid cycle metabolite that accumulates in tissues during hemorrhagic shock (HS) due to electron transport chain uncoupling. Dimethyl malonate (DMM) is a competitive inhibitor of SI dehydrogenase, which has been shown to reduce SI accumulation and protect against reperfusion injury. Whether DMM can be therapeutic after severe HS is unknown. We hypothesized that DMM would prevent SI buildup during resuscitation (RES) in a swine model of HS, leading to better physiological recovery after RES.

METHODS

The carotid arteries of Yorkshire pigs were cannulated with a 5-Fr catheter. After placement of a Swan-Ganz catheter and femoral arterial line, the carotid catheters were opened and the animals were exsanguinated to a mean arterial pressure (MAP) of 45 mm. After 30 minutes in the shock state, the animals were resuscitated to a MAP of 60 mm using lactated ringers. A MAP above 60 mm was maintained throughout RES. One group received 10 mg/kg of DMM (n = 6), while the control received sham injections (n = 6). The primary end-point was SI levels. Secondary end-points included cardiac function and lactate.

RESULTS

Succinate levels increased from baseline to the 20-minute RES point in control, while the DMM cohort remained unchanged. The DMM group required less intravenous fluid to maintain a MAP above 60 (450.0 vs. 229.0 mL; p = 0.01). The DMM group had higher pulmonary capillary wedge pressure at the 20-minute and 40-minute RES points. The DMM group had better recovery of cardiac output and index during RES, while the control had no improvement. While lactate levels were similar, DMM may lead to increased ionized calcium levels.

DISCUSSION

Dimethyl malonate slows SI accumulation during HS and helps preserve cardiac filling pressures and function during RES. In addition, DMM may protect against depletion of ionized calcium. Dimethyl malonate may have therapeutic potential during HS.

State Gun Law Grades and Impact on Mass Shooting Event Incidence: An 8-Year Analysis

BACKGROUND

Gun violence, particularly in the form of mass shooting events (MSE), is a growing, significant public health crisis in the US. Whether stricter gun laws decrease MSE is not known. We hypothesized that stronger state gun laws would be associated with lower MSE incidence.

STUDY DESIGN

Mass shooting events, defined as at least 4 people injured in a single event, and state gun law grade data for years 2014 through 2021 were obtained from the Gun Violence Archive and Giffords Law Center, respectively. An A grade indicated strictest gun control laws, and F indicated the weakest. US 2020 Census data were used to estimate MSE per million per state. The number of MSE per million was examined for association with gun law grades.

RESULTS

From 2014 through 2020, there were a total of 2,736 recorded MSE, with at least a 2-fold increase in incidence from 272 in 2014 to 626 in 2020. Concomitantly, the number of F grade states decreased from 27 to 21 (22%). The MSE mean (SD) per F state increased from 4.0 (5.1) in 2014 to 9.7 (10.3) in 2020 (p = 0.03). No differences were found in unadjusted number of MSE per year by gun law grade for any study year examined (p = 0.67). After adjusting for population, this finding of no difference persisted.

CONCLUSIONS

Strength of state gun law grades does not affect MSE incidence, even after correction for population size. This suggests that legislation by itself is not an effective prevention measure and other broader and meaningful primary gun violence interventions are needed.

New Injury Severity Score and Trauma Injury Severity Score are superior in predicting trauma mortality

BACKGROUND

Trauma scores are used to give clinicians appropriate quantitative context in making decisions. Studies show that anatomical trauma scores predicted intensive care unit admission better, while physiological trauma scores predicted mortality better. We hypothesize that trauma scores have a hierarchy of efficacies at predicting mortality and operative decision making.

METHODS

We performed a retrospective analysis of our trauma patient database at a level 1 trauma center from 2016 to 2020 and calculated the following trauma scores: Glasgow Coma Scale, Revised Trauma Score, Trauma Injury Severity Score, Injury Severity Score, Shock Index, and New Trauma Injury Severity Score (NISS). Receiver operating characteristic curves were used to evaluate the sensitivity and specificity of trauma scores for predicting mortality.

RESULTS

A total of 738 patients were included (mean ± SD age, 35.7 ± 15.6 years). Area under the curve (AUC) results from the DeLong test showed that NISS predicted mortality the best compared with other trauma scores. New Trauma Injury Severity Score was superior in predicting mortality for penetrating trauma (AUC, 0.86 ± 0.02; p < 0.001) compared with blunt trauma (AUC, 0.73 ± 0.04; p < 0.001). Trauma Injury Severity Score was the best predictor of mortality for patients with gunshot wounds (AUC, 0.83; 95% confidence interval [CI], 0.73-0.92; p < 0.001), motor vehicle accidents (AUC, 0.80; 95% CI, 0.61-1.00; p = 0.01), and falls (AUC, 0.73; 95% CI, 0.61-0.85; p = 0.007).

CONCLUSION

New Trauma Injury Severity Score was the best scoring index for predicting mortality in trauma patients, especially for penetrating trauma. Clinicians should consider incorporating other trauma scores, especially NISS and Trauma Injury Severity Score, in determining injury severity and the likelihood of mortality. These scores can help physicians determine the best course of action in patient management.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; level IV.

Deciphering excess healthcare burden in head and neck cancer patients with cardiovascular comorbidity

BACKGROUND

This study aimed to determine the perioperative surgical outcomes for head and neck cancer patients with cardiovascular diseases (CVDs).

METHODS

A cross-sectional analysis was performed using data from the Nationwide Readmissions Database between 2010 and 2014. Logistic regression analysis by enter and backward stepwise methods were used.

RESULTS

A total of 8346 patients met the inclusion criteria. Patients with concomitant CVD had a higher frequency of complications (57.6%) compared with those without (47.4%) (odds ratio [OR] = 1.35, 95% confidence interval [CI] = 1.23-1.48, p < 0.001). Patients with CVD comorbidities were prone to experience in-patient mortality at both admission (OR = 2.4, 95% CI = 1.42-4.05) and readmission (OR = 2.55, 95% CI = 1.10-5.87). CVD patients have prolonged hospital admission (OR = 1.14, 95% CI = 1.02-1.27, p = 0.020) and higher cost (OR = 1.28, 95% CI = 1.15-1.43, p < 0.001). Patients with congestive heart failure were prone to 30 days readmission (OR = 1.67, 95% CI = 1.10-2.53, p = 0.019) and 90 days (OR = 1.65, 95% CI = 1.14-2.39, p = 0.010).

CONCLUSION

This is the first study identifying factors predicting higher risk of perioperative complications of surgical management of head and neck cancer. Those with CVD had higher risk of adverse events.

Nuclear Localization of BRAFV600E Is Associated with HMOX-1 Upregulation and Aggressive Behavior of Melanoma Cells

Simple Summary

Despite some successes of selective anti-BRAF^V600E inhibitors, resistance remains a major challenge. The aim of our study is to determine the role of nuclear BRAF^V600E and its newly identified partner, HMOX1, in melanoma aggressiveness and drug resistance. We identified the mechanism by which drug resistance is developed via the nuclear localization of BRAF^V600E and its partner HMOX1 in melanoma tissues and cell lines. According to our studies, the outcomes of our manuscript have a direct clinical impact on establishing novel prognostic markers and therapeutic intervention strategies in metastatic melanoma. This study provides new information on the ability to selectively classify patients with cytosolic BRAF for selective BRAF inhibitors and offers an alternative treatment to patients with nuclear BRAF^V600E and high HMOX1 expressions.

Abstract

Background: Previously, we have demonstrated that nuclear BRAF^V600E is associated with melanoma aggressiveness and vemurafenib resistance. However, the underlying mechanisms of how nuclear localization of BRAF^V600E promotes cell aggressiveness have not yet been investigated. Despite therapeutic advancements targeting cutaneous melanoma, unknown cellular processes prevent effective treatment for this malignancy, prompting an urgent need to identify new biological targets. This study aims to explore the association of inducible heme oxygenase 1 (HMOX-1) with nuclear BRAF^V600E in promoting melanoma aggressiveness. Methods: Proteomics analysis was performed to identify the interacting partner(s) of nuclear BRAF^V600E. Immunohistochemistry was applied to evaluate the levels of HMOX-1 and nuclear BRAF^V600E expression in melanoma and adjacent healthy tissues. Immunofluorescence assessed the nuclear localization of BRAF^V600E in vemurafenib-resistant A375R melanoma cells. Further study of HMOX-1 knockdown or BRAF^V600E overexpression in melanoma cells suggested a role for HMOX-1 in the regulation of cell proliferation in vivo and in vitro. Finally, Western blot analysis was performed to confirm the pathway by which HMOX-1 mediates Akt signaling. Results: Proteomics results showed that HMOX-1 protein expression was 10-fold higher in resistant A375R cells compared to parental counterpart cells. In vitro and in vivo results illustrate that nuclear BRAF^V600E promotes HMOX-1 overexpression, whereas HMOX-1 reduction represses melanoma cell proliferation and tumor growth. Mechanistic studies revealed that HMOX-1 was associated with nuclear BRAF^V600E localization, thus promoting melanoma proliferation via a persistent activation of the AKT pathway. Conclusions: Our results highlight a previously unknown mechanism in which the nuclear BRAF^V600E/HMOX-1/AKT axis plays an essential role in melanoma cell proliferation. Targeting HMOX-1 could be a novel method for treating melanoma patients who develop BRAF inhibitor resistance.

Nuclear interaction of Arp2/3 complex and BRAFV600E promotes aggressive behavior and vemurafenib resistance of thyroid cancer

The presence of mutant BRAF ^V600E correlates with the risk of recurrence in papillary thyroid cancer (PTC) patients. However, not all PTC patients with BRAF ^V600E are associated with poor prognosis. Thus, understanding the mechanisms by which certain PTC patients with nuclear BRAF ^V600E become aggressive and develop resistance to a selective BRAF inhibitor, PLX-4032, is urgently needed. The effect of nuclear localization of BRAF^V600E using in vitro studies, xenograft mouse-model and human tissues was evaluated. PTC cells harboring a nuclear localization signal (NLS) of BRAF^V600E were established and examined in nude mice implanted with TPC1-NLS-BRAF^V600E cells followed by PLX-4032 treatment. Immunohistochemical (IHC) analysis was performed on 100 PTC specimens previously confirmed that they have BRAF^V600E mutations. Our results demonstrate that 21 of 100 (21%) PTC tissues stained with specific BRAF^V600E antibody had nuclear staining with more aggressive features compared to their cytosolic counterparts. In vitro studies show that BRAF^V600E is transported between the nucleus and the cytosol through CRM1 and importin (α/β) system. Sequestration of BRAF^V600E in the cytosol sensitized resistant cells to PLX-4032, whereas nuclear BRAF^V600E was associated with aggressive phenotypes and developed drug resistance. Proteomic analysis revealed Arp2/3 complex members, actin-related protein 2 (ACTR2 aliases ARP2) and actin-related protein 3 (ACTR3 aliases ARP3), as the most enriched nuclear BRAF^V600E partners. ACTR3 was highly correlated to lymph node stage and extrathyroidal extension and was validated with different functional assays. Our findings provide new insights into the clinical utility of the nuclear BRAF^V600E as a prognostic marker for PTC aggressiveness and determine the efficacy of selective BRAF^V600E inhibitor treatment which opens new avenues for future treatment options.

An Integrative Multi-Omics Analysis of The Molecular Links between Aging and Aggressiveness in Thyroid Cancers

Aging modifies risk in all cancers, but age is used as a clinical staging criterion uniquely in thyroid cancer (TC). The molecular drivers of age-dependent TC onset and aggressiveness remain poorly understood. We applied an integrative, multi-omics data analysis approach to characterize these signatures. Our analysis reveals that aging, independent of BRAF^V600E mutational status, drives a significant accumulation of aggressiveness-related markers and poorer survival outcomes, most noticeably at age 55 and over. We identified that chromosomal alterations in loci 1p/1q as aging-associated drivers of aggressiveness, and that depleted infiltration with tumor surveillant CD8+T and follicular helper T cells, dysregulation of proteostasis- and senescence-related processes, and ERK1/2 signaling cascade are key features of the aging thyroid and TC onset/progression and aggressiveness in aging patients but not in young individuals. A panel of 23 genes, including those related to cell division such as CENPF, ERCC6L, and the kinases MELK and NEK2, were identified and rigorously characterized as aging-dependent and aggressiveness-specific markers. These genes effectively stratified patients into aggressive clusters with distinct phenotypic enrichment and genomic/transcriptomic profiles. This panel also showed excellent performance in predicting metastasis stage, BRAF^V600E, TERT promoter mutation, and survival outcomes and was superior to the American Thyroid Association (ATA) methodology in predicting aggressiveness risk. Our analysis established clinically relevant biomarkers for TC aggressiveness factoring in aging as an important component.

Intraoperative neurophysiologic monitoring prevented iatrogenic spinal cord injury during robotic-assisted transabdominal adrenalectomy: a case report

Cervical spondylotic myelopathy (CSM) is the most common disease of the cervical spinal cord in patients older than 55 and is characterized by an initial asymptomatic period followed by progressive neurological deficit from degenerative changes of the cervical vertebrae. These changes cause compression and vascular compromise to the cervical spinal cord. Because there are no pathognomonic symptoms, its diagnosis is commonly delayed. Herein we report the first case of the use of IONM during a transabdominal adrenalectomy in a patient with CSM, which prevented an iatrogenic spinal cord injury (SCI). The patient is a 74-year-old male with what was proven later as cervical spinal stenosis who presented for robotic-assisted transabdominal adrenalectomy. When positioned supine on the operating table, he exhibited upper and lower extremity neurological symptoms, prompting awake fiberoptic intubation and the use of IONM secondary to suspicion for CSM. After being positioned into lateral decubitus, IONM showed a loss of transcranial motor evoked potentials (TcMEP) and attenuated somatosensory evoked potentials (SSEP) from the right lower extremities and the procedure was aborted and the patient returned supine. TcMEPs returned to baseline, but SSEPs remained attenuated. The patient exhibited normal movement and sensation in post-anesthesia care. A high index of suspicion for CSM is required for older patients, as early diagnosis allows for spinal surgery treatment before acute worsening during anesthesia or non-spinal surgery. Furthermore, a low threshold for the use of IONM in patients with a high likelihood of CSM who require a non-spinal surgery can successfully prevent iatrogenic SCI.

Elevated K/iCa ratio is an ancillary predictor for mortality in patients with severe hemorrhage: A decision tree analysis

INTRODUCTION

Trauma patients receiving massive transfusion protocol (MTP) are at risk of citrate-induced hypocalcemia and hyperkalemia. Here we evaluate potassium (K), ionized calcium (iCa), and K/iCa ratio as predictors of mortality.

METHODS

This retrospective study includes all adult trauma patients who received MTP within 1 h at our level I trauma center between 2014 and 2019. Receiver operating characteristic curve analysis assessed predictive accuracy of K/iCa ratio at admission on 120-day mortality.

RESULTS

Of 614 patients, 146 received MTP within 1 h and 38 expired. Patients who expired had higher K/iCa ratio than survivors (median [IQR] = 5.7 [3.8-7.2] vs 3.7 [3.1-4.9], p < 0.001). Area under the curve of K/iCa was 0.72 (95%CI = 0.62-0.82, p < 0.001) with sensitivity = 63.2% and specificity = 77.6%. At the optimum K/iCa cutoff (5.07), patients with high ratios had 4 times higher mortality risk (HR = 3.97, 95%CI = 1.89-8.32, p < 0.001).

CONCLUSION

Elevated K/iCa ratio was an independent predictor of mortality in trauma patients managed with MTP.

The Effect of Patient Positioning on Intraoperative Neuromonitoring During Thyroid and Parathyroid Surgery

BACKGROUND

Intraoperative neuromonitoring (IONM) has been accepted as a routine adjunct among surgeons who perform thyroid and parathyroid surgeries. Thyroid and parathyroid surgeries use various patient positioning strategies that have poorly understood effects on IONM. The aim of this study was to compare IONM signals between the transaxillary and transcervical approaches.

METHODS

In this retrospective cohort study, we evaluated 463 adult patients who underwent a total of 502 procedures. The procedures performed included total thyroidectomy, right or left hemithyroidectomy, and parathyroidectomy. Vagus nerve and recurrent laryngeal nerve (RLN) latency and amplitude measurements were analyzed intra-operatively. The distances between the vagus nerve and the trachea were measured via ultrasound during transaxillary procedures.

RESULTS

Compared to the transcervical approach, the right vagus nerve latency was significantly decreased in the transaxillary approach. Transaxillary surgery was not associated with increased latency or decreased amplitude on IONM. The distance between the vagus nerve and trachea was significantly decreased post-positioning during transaxillary approaches.

DISCUSSION

Despite differences in patient positioning, a transaxillary approach was not associated with increased stress on the vagus nerve or RLN, according to IONM data. The decreased right vagus nerve latency associated with a transaxillary approach highlights the importance of considering patient positioning and laterality while interpreting IONM data.

Effect of postsurgical chronic hypoparathyroidism on morbidity and mortality: a systematic review and meta-analysis

Background

Hypoparathyroidism (HypoPT) is a common sequela of anterior neck surgeries. While the acute risks of HypoPT are well known, emerging evidence is beginning to define the risks chronic HypoPT poses to patients. This meta-analysis aims to evaluate that risk and give more insight into its consequences.

Methods

A systematic review and meta-analysis were performed, searching EMBASE, Web of Science, and Scopus for studies published up to July 1, 2020 and reported following PRISMA guidelines. Pooled analysis was estimated using the Mantel-Haenszel method and a random-effects model. A sub-analysis of the pooled data for each morbidity was performed and demonstrated in forest plots.

Results

Patients with postsurgical chronic HypoPT had a high risk of cardiac morbidities [odds ratio (OR) =1.43; 95% confidence interval (95% CI): 1.21 to 1.70; P<0.001] in the absence of elevated risk of cardiac arrhythmias (OR =1.35, 95% CI: 0.96 to 1.79, P=0.08). Analysis also showed higher odds of developing renal disease (OR =4.85, 95% CI: 3.54 to 6.67, P<0.001), renal stones (OR =3.86, 95% CI: 1.81 to 8.23, P<0.001), seizures (OR =2.41, 95% CI: 1.66 to 3.5, P<0.001), mental health problems (OR =1.46, 95% CI: 1.21 to 1.77, P<0.001), and infections (OR =1.51, 95% CI: 1.28 to 1.78, P<0.001). Conversely, HypoPT has no effect on mortality risk (OR =1.19, 95% CI: 0.96 to 1.49, P=0.12).

Conclusions

Postsurgical HypoPT patients are vulnerable to a variety of medical and psychiatric diseases. This meta-analysis should guide surgeons in preoperative counseling and postoperative care for patients undergoing anterior neck surgeries.

MicroRNA‑499a (rs3746444A/G) gene variant and susceptibility to type 2 diabetes‑associated end‑stage renal disease

Diabetic nephropathy (DN) is a major risk factor for end-stage renal disease (ESRD). MicroRNAs (miRNAs/miRs) and their variants may be implicated in health and disease, including DN. The present study aimed to investigate the association of the miRNA-499a gene (MIR499A) A/G seed region variant (rs3746444) with DN-associated ESRD susceptibility in patients with diabetes mellitus, and to determine whether there was an association between the different genotypes and the patients' laboratory and clinical data. A case-control pilot study was conducted on 180 adult patients with type 2 diabetes mellitus. A total of 90 patients with ESRD on regular hemodialysis were considered as the cases, and 90 age-, sex- and ethnicity-matched diabetic patients with normo-albuminuria were considered as the controls. MIR499A genotyping was performed using a TaqMan Real-Time allele discrimination assay. Results demonstrated that the MIR499A rs3746444*G variant conferred susceptibility to the development of ESRD under co-dominant [(odds ratio (95% confidence interval): 2.49 (1.41-3.89) and 2.41 (1.61-6.68) for heterozygous and homozygous comparison, respectively], dominant [2.30 (1.18-3.90)] and allelic [1.82 (1.17-2.83)] models. Different genotypes of the specified variant did not exhibit significant associations with the clinic-laboratory data of the studied patients or the circulating miR-499a plasma levels. In conclusion, results of the present study suggested that MIR499A rs3746444 may be a susceptibility variant for DN-associated ESRD in the study population. However, larger sample size studies with different ethnicities are warranted to verify these findings.

Prevalence and mortality of cardiovascular events in patients with hyperthyroidism: a nationwide cohort study in the United States

Background

Little is known about the implications of hyperthyroidism on cardiovascular diseases like myocardial infarctions (MI), ischemic strokes, and hemorrhagic strokes. Previous studies implicate hyperthyroidism as a risk factor for MI and ischemic stroke. Cardiovascular disease is the leading cause of death in the US, and the possibility of hyperthyroidism contributing to this disease burden warrants investigation in a US patient population.

Methods

The National Readmission Database (NRD) from 2010 to 2017 was used to identify adults who had a new-onset diagnosis of MI, ischemic stroke, or hemorrhagic stroke. Risk factors for mortality, prolonged hospital stay, and hospital cost were analyzed with binary logistic regression.

Results

A total of 278,609,748 hospital records were reviewed. Of these, 15,685,461 were hospitalized for adverse cardiovascular events with concomitant hyperthyroidism, roughly 4.5 per 1,000 cases. Patients with MI and hemorrhagic stroke with thyrotoxicosis had a lower mortality rate than euthyroid patients (OR 0.81, 95% CI: 0.78-0.84, P<0.001 and OR 0.72, 95% CI: 0.67-0.77, P<0.001, respectively). Thyrotoxicosis was associated with increased hospital stay (MI: OR 1.35, 95% CI: 1.32-1.38, P<0.001; ischemic: OR 1.38, 95% CI: 1.35-1.41, P<0.001; hemorrhagic: OR 1.33, 95% CI: 1.25-1.40, P<0.001), expenditures in ischemic (OR 1.31, 95% CI: 1.28-1.34, P<0.001) and hemorrhagic stroke patients (OR 1.18, 95% CI: 1.12-1.24, P<0.001).

Conclusions

Patients that experienced MI or hemorrhagic stroke with concomitant thyrotoxicosis were observed to have a lower mortality rate than euthyroid patients but had with an increased length of hospital stay. Patients who had ischemic or hemorrhagic stroke with thyrotoxicosis had a significantly higher hospital cost. The hyperdynamic state underlying hyperthyroidism may be protective in these adverse events. Further studies into these physiological changes are warranted.

What happens to patients undergoing cancer surgery with psychiatric comorbidities?: A nationwide retrospective cohort study

OBJECTIVE

We aimed to describe the surgical outcomes and readmissions rates in patients with psychological comorbidities who underwent surgical intervention for cancer.

BACKGROUND

The Hospital Readmission Reduction Program, a campaign by the Affordable Care Act, penalizes hospitals for greater readmission rates. One prevalent patient risk factor associated with hospital readmission is a comorbid psychiatric condition. Currently, no studies exist identifying psychiatric comorbidities and their effects on patients with cancer undergoing surgical intervention.

METHODS

A cross-sectional analysis was performed using the Nationwide Readmissions Database for 2010-2014 and included adult patients undergoing cancer resection operations. Multivariable logistic regression analyses were utilized to assess determinants of surgical outcomes and readmissions.

RESULTS

Of 1 016 636 eligible patients, 11.6% had psychiatric comorbidities. Patients with psychiatric disorders had greater risks of mortality (odds ratio [OR] = 1.21, 95% confidence interval [CI] = 1.18-1.25), complications (OR = 1.51, 95%CI = 1.50-1.52), extended length of stay (OR = 1.21, 95%CI = 1.20-1.22), and incurred healthcare expenditure at primary admission (OR = 1.16, 95% CI = 1.15-1.18). Psychiatric comorbidities were associated with an increased likelihood of readmission (OR = 1.13, 95%CI = 1.11-1.15).

CONCLUSIONS

Concomitant psychiatric conditions were attributed to poor surgical outcomes and a higher risk of readmissions. Multidisciplinary care within the perioperative setting should be encouraged for patients with psychiatric disorders.

Altered mental status is a predictor of poor outcomes in COVID-19 patients: A cohort study

Introduction

Several studies have described typical clinical manifestations, including fever, cough, diarrhea, and fatigue with COVID-19 infection. However, there are limited data on the association between the presence of neurological manifestations on hospital admission, disease severity, and outcomes. We sought to investigate this correlation to help understand the disease burden.

Methods

We delivered a multi-center retrospective study of positive laboratory-confirmed COVID-19 patients. Clinical presentation, laboratory values, complications, and outcomes data were reported. Our findings of interest were Intensive Care Unit (ICU) admission, intubation, mechanical ventilation, and in-hospital mortality.

Results

A total of 502 patients with a mean age of 60.83 ± 15.5 years, of them 71 patients (14.14%) presented with altered mental status, these patients showed higher odds of ICU admission (OR = 2.06, 95%CI = 1.18 to 3.59, p = 0.01), mechanical ventilation (OR = 3.28, 95%CI = 1.86 to 5.78, p < 0.001), prolonged (>4 days) mechanical ventilation (OR = 4.35, 95%CI = 1.89 to 10, p = 0.001), acute kidney injury (OR = 2.18, 95%CI = 1.28 to 3.74, p = 0.004), and mortality (HR = 2.82, 95%CI = 1.49 to 5.29, p = 0.01).

Conclusion

This cohort study found that neurological presentations are associated with higher odds of adverse events. When examining patients with neurological manifestations, clinicians should suspect COVID-19 to avoid delayed diagnosis or misdiagnosis and lose the chance to treat and prevent further transmission.

How Does Insurance Status Correlate With Trauma Mechanisms and Outcomes? A Retrospective Study at a Level 1 Trauma Center

OBJECTIVE

Studies showed that a lack of insurance is associated with worse trauma outcomes. We examine insurance status and trauma mortality in a diverse metropolitan city and hypothesize that the higher risk of mortality in uninsured patients is due to insurance status and other factors.

METHODS

A retrospective analysis of patients admitted to a Level 1 Trauma center for emergent surgery in a diverse metropolitan city from Jan 2016-May 2020 was conducted. Patients of different insurance statuses were analyzed for their injury mechanism and surgical intervention outcomes. Multivariate logistic regression was performed and the results were presented as odds ratio with 95% confidence intervals and P values. Statistical significance was set at P < .05.

RESULTS

738 patients met study criteria. Medicaid patients made up the largest proportions of injury mechanisms: 65.1% of gunshot wound cases, sharp object (41.7%), and falls (32.5%). Private insurance (OR = .13, 95% CI: .05-.35, P = .000), Medicaid (OR = .19, 95% CI: .10-.35, P = .000), Medicare (OR = .65, 95% CI: 0.28-1.51, P = .31), and other insurance (OR = .44, 95% CI 0.22-.87, P = .01) were associated with survival. Uninsured patients had the highest mortality rate resulting from trauma at 32.6% (P < .001), and the lowest mortality rate belonged to the private insurance cohort (6.3%, P < .001). Uninsured patients accounted for 10.5% of gunshot wound cases, 8.5% of motor vehicle accident cases, 25% of sharp object cases, and 6.6% of falls.

CONCLUSION

Being uninsured was independently associated with mortality, while having insurance improved outcomes. Underlying mechanisms should be further elucidated to improve health equity and trauma outcomes in diverse patient populations.

The burden of readmission after discharge from necrotizing soft tissue infection

BACKGROUND

The need for extensive surgical debridement with necrotizing soft tissue infections (NSTIs) may put patients at high risk for unplanned readmission. However, there is a paucity of data on the burden of readmission in patients afflicted with NSTI. We hypothesized that unplanned readmission would significantly contribute to the burden of disease after discharge from initial hospitalization.

METHODS

The Nationwide Readmission Database was used to identify adults undergoing debridement for NSTI hospitalizations from 2010 to 2017. Risk factors for 90-day readmission were assessed by Cox proportional hazards regression.

RESULTS

There were a total of 82,738 NSTI admissions during the study period, of which 25,076 (30.3%) underwent 90-day readmissions. Median time to readmission was 25 days (interquartile range, 9-49 days). Fragmentation of care, longer length of index stay (>2 weeks), and Medicaid status were independent risk factors for readmission. Median cost of a readmission was US $10,543. Readmission added 174,640 hospital days to episodes of care over the study period, resulting in an estimated financial burden of US $1.4 billion.

CONCLUSION

Unplanned readmission caused by NSTIs is common and costly. Interventions that target patients at risk for readmission may help decrease the burden of disease.

LEVEL OF EVIDENCE

Economic/Epidemiological, level IV.

Firearm homicide mortality is influenced by structural racism in US metropolitan areas

INTRODUCTION

Metropolitan cities in the United States suffer from higher rates of gun violence. However, the specific structural factors associated with increased gun violence are poorly defined. We hypothesized that firearm homicide in metropolitan cities would be impacted by Black-White segregation index.

METHODS

This cross-sectional analysis evaluated 51 US metropolitan statistical areas (MSAs) using data from 2013 to 2017. Several measures of structural racism were examined, including the Brooking Institute's Black-White segregation index. Demographic data were derived from the US Census Bureau, US Department of Education, and US Department of Labor. Crime data and firearm homicide mortality rates were obtained from the Federal Bureau of Investigation and the Centers for Disease Control. Spearman ρ and linear regression were performed.

RESULTS

Firearm mortality was associated with multiple measures of structural racism and racial disparity, including White-Black segregation index, unemployment rate, poverty rate, single parent household, percent Black population, and crime rates. In regression analysis, percentage Black population exhibited the strongest association with firearm homicide mortality (β = 0.42, p < 0.001). Black-White segregation index (β = 0.41, p = 0.001) and percent children living in single-parent households (β = 0.41, p = 0.002) were also associated with higher firearm homicide mortality. Firearm legislation scores were associated with lower firearm homicide mortality (β = -0.20 p = 0.02). High school and college graduation rates were not associated with firearm homicide mortality and were not included in the final model.

CONCLUSION

Firearm homicide disproportionately impacts communities of color and is associated with measures of structural racism, such as White-Black segregation index. Public health interventions targeting gun violence must address these systemic inequities. Furthermore, given the association between firearm mortality and single-parent households, intervention programs for at-risk youth may be particularly effective.

LEVEL OF EVIDENCE

Epidemiological level II.

Surgical stabilization of traumatic rib fractures is associated with reduced readmissions and increased survival

BACKGROUND

Surgical stabilization for rib fractures (SSRF) in trauma patients remains controversial, with guidelines currently suggesting the procedure for only select patient groups. How surgical stabilization for rib fractures affect hospital readmission in patients with traumatic rib fractures is unknown. We hypothesized that surgical stabilization for rib fractures would not decrease the risk of readmission.

METHODS

The National Readmission Database was examined for adults with any rib fractures from 2010 to 2017. Readmission up to 90 days was examined. Patients receiving surgical stabilization for rib fractures were compared with those receiving nonoperative treatment.

RESULTS

In total, 864,485 patients met criteria, with 13,701 (1.6%) receiving SSRF. For patients receiving SSRF, 338 (1.5%) were readmitted. Readmitted patients had higher Charlson Comorbidity Index and were more likely to have flail chest. On multivariate propensity score-matched analysis, SSRF (Hazard Ratio [HR]: 0.55, 95% confidence interval [CI] 0.33-0.92, P = .022) was associated with reduced readmission. Addition of surgical stabilization for rib fractures to video-assisted thoracoscopic surgery (VATS) (Odds Ratio [OR]: 0.95, 95% CI 0.52-1.73, P = .86) or thoracotomy (OR: 1.97, 95% CI 0.83-4.70, P = .13) was not associated with increased readmission. On further propensity matched analysis, VATS + SSRF when compared with SSRF alone (HR: 0.75, 95% CI 0.18-3.20, P = .696), and VATS + SSRF when compared with VATS alone (HR: 0.49, 95% CI 0.11-2.22, P = .355) was also not associated with increased readmission. SSRF on primary admission was associated with increased in-hospital survival (HR: 0.27, 95% CI 0.22-0.32, P < .001). For patients with retained hemothorax who underwent VATS, addition of SSRF did not improve survival (HR = 0.92, 95% CI 0.58-1.46, P = .72). However, for patients requiring thoracotomy for retained hemothorax, concomitant SSRF was associated with improved survival (HR = 0.14, 95% CI 0.06-0.32, P < .001).

CONCLUSION

Surgical stabilization for rib fractures is associated with reduced readmission risk while also being associated with improved survival. Patients who had a thoracotomy for retained hemothorax appear to especially benefit from concomitant surgical stabilization for rib fractures.

The efficacy of the use of presumptive antibiotics in tube thoracostomy in thoracic trauma-results of a meta-analysis

INTRODUCTION

The purpose of this study was to determine the impact of presumptive antibiotics, used in chest traumas requiring thoracostomies, in preventing infections such as empyema and pneumonia.

METHODS

According to PRISMA guidelines, a systematic search of PubMed, Embase and Cochrane Library databases was conducted by two independent reviewers. Studies evaluating the role of antibiotics were included.

RESULTS

Antibiotic administration was associated with a lower incidence of overall infectious complications (OR:0.6, 95%CI: 0.43 to 0.84, p = 0.003). Subgroup analysis revealing that the best protective effect against empyema (OR:0.35, 95%CI to 0.65, p = 0.001). When stratified by trauma type, antibiotic use was protective in penetrating injuries, against empyema (OR:0.14, 95%CI: 0.04 to 0.47, p = 0.001) and pneumonia (OR:0.24, 95%CI:, 0.12 to 0.53, p = 0.001) while there was no protective effect in blunt trauma against empyema (OR:0.25 95%CI: 0.03 to 1.73, p = 0.16) or pneumonia (OR:1.22, 95%CI: 0.38 3.90, p = 0.72).

CONCLUSION

Presumptive antibiotic use in thoracostomies has a clear role in preventing infectious complications in trauma patients. This role is primarily attributed to their protective effect on penetrating trauma patients.

Prognostic Factors of Mortality in Vibrio vulnificus Sepsis and Soft Tissue Infections: Meta-Analysis

Background: Vibrio vulnificus is a rare but life-threatening infection that effects the population near warm coastal areas. This infection could be fulminant and rapidly progress to severe sepsis and necrotizing soft tissue infection. Early diagnosis and treatment are critical to saving patients' lives. With multiple studies reporting discrepancies in prognostic factors and different treatment protocols, we aimed through this meta-analysis to assess these factors and protocols and the impact on the outcome of the infection. Materials and Methods: In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic search of PubMed, Embase, and Cochrane Library databases by two independent reviewers was reported. Studies evaluating prognostic factors and treatment outcomes of Vibrio vulnificus infections were included. Comprehensive Meta-Analysis, version 3.0 was used. Results: Two hundred eleven studies were identified. Of those, eight studies met our inclusion criteria. The following factors on presentation were associated with higher mortality rates; concomitant liver disease (odds ratio [OR], 4.38; 95% confidence interval [CI], 2.43-7.87; p < 0.001), renal disease (OR, 3.90; 95% CI, 1.37-11.12; p = 0.011), septic shock (OR, 2.82; 95% CI, 1.84-4.31; p < 0.001), higher Acute Physiology and Chronic Health Evaluation (APACHE) II score (OR, 3.40; 95% CI, 2.26-5.12; p < 0.001), elevated band cells count (OR, 2.61; 95% CI, 1.13-6.0; p = 0.024), hypoalbuminemia (OR, 3.41; 95% CI, 1.58-7.35; p = 0.002), and infection involving multiple limbs (OR, 4.36; 95% CI, 1.72-11.07; p = 0.002). Interestingly, different antibiotic regimens did not have any impact on outcomes, however, delayed surgical intervention after the first 12 or 24 hours was associated with higher mortality rates (OR, 2.64; 95% CI, 1.39-5.0; p = 0.003 and OR, 2.99; 95% CI, 1.54-5.78; p = 0.001, respectively). Conclusion: The presence of liver or renal disease, higher APACHE II scores, septic shock, hypoalbuminemia, or elevated band cell on presentation should alert the physician to the higher risk of mortality. Different antibiotic regimens did not impact the outcomes in these patients and delayed surgical intervention is associated with worsening of mortality.

Ulcerative colitis immune cell landscapes and differentially expressed gene signatures determine novel regulators and predict clinical response to biologic therapy

The heterogeneous pathobiology underlying Ulcerative Colitis (UC) is not fully understood. Using publicly available transcriptomes from adult UC patients, we identified the immune cell landscape, molecular pathways, and differentially expressed genes (DEGs) across patient cohorts and their association with treatment outcomes. The global immune cell landscape of UC tissue included increased neutrophils, T CD4 memory activated cells, active dendritic cells (DC), and M0 macrophages, as well as reduced trends in T CD8, Tregs, B memory, resting DC, and M2 macrophages. Pathway analysis of DEGs across UC cohorts demonstrated activated bacterial, inflammatory, growth, and cellular signaling. We identified a specific transcriptional signature of one hundred DEGs (UC100) that distinctly separated UC inflamed from uninflamed transcriptomes. Several UC100 DEGs, with unidentified roles in UC, were validated in primary tissue. Additionally, non-responders to anti-TNFα and anti-α4β7 therapy displayed distinct profiles of immune cells and pathways pertaining to inflammation, growth, and metabolism. We identified twenty resistant DEGs in UC non-responders to both therapies of which four had significant predictive power to treatment outcome. We demonstrated the global immune landscape and pathways in UC tissue, highlighting a unique UC signature across cohorts and a UC resistant signature with predictive performance to biologic therapy outcome.

Robotic-assisted parathyroidectomy via transaxillary approach: feasibility and learning curves

Background

There have been few reports of robotic-assisted transaxillary parathyroidectomy in the literature. We aim to report our experience with robotic-assisted transaxillary parathyroidectomy for primary hyperparathyroidism (PHPT) in the Western population.

Methods

A retrospective study was performed from July 2010 through July 2019 at two institutions, one in the United States and one in France. Demographic characteristics and perioperative data were collected for all patients undergoing robotic-assisted transaxillary parathyroidectomy by a single surgeon at each institution. A linear regression model was developed to describe the learning curve for this procedure at each institution.

Results

One-hundred and two patients with PHPT were included with a median age of 55.6±12.4 years and median body mass index (BMI) of 25.5±6.1 kg/m². The majority of patients were female (80.4%). Median total operative time was 116±53 minutes. Minor complications were reported in 2 patients (1.96%), and one case was converted to a trans-cervical approach (TCA) for four-gland exploration. Median patient follow-up time was 6.5±12.2 months, and disease recurrence was reported in one patient. Calculated learning curves showed that one surgeon achieved proficiency by the eighth case, and the other achieved proficiency by the fourteenth case.

Conclusions

This is the largest reported experience of robotic-assisted transaxillary parathyroidectomy for PHPT in the Asian and Western population. Analysis of the procedural learning curve demonstrates that proficiency in this technique was achieved after performance of less than 15 surgeries. This procedure is safe and feasible in the hands of experienced surgeons for select patients with localized disease.