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Strobel RJ, Sahli ZT, Mehaffey JH, Hawkins RB, Young AM, Quader M, Dehmer GJ, Teman NR, Yarboro LT, Likosky DS, Badhwar V, Kron IL, Ailawadi G. Appropriateness of Surgical Aortic Valve Replacement for Severe Aortic Stenosis Is Increasing. Ann Thorac Surg 2024; 117:361-368. [PMID: 35948120 DOI: 10.1016/j.athoracsur.2022.07.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 05/23/2022] [Accepted: 07/16/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND The adoption of transcatheter aortic valve replacement led to the development of appropriate use criteria (AUC) for transcatheter and surgical aortic valve replacement (SAVR) for aortic stenosis in 2017. This study hypothesized that appropriateness of SAVR improved after publication of AUC. METHODS All patients undergoing isolated SAVR for severe aortic stenosis in a regional cardiac surgical quality collaborative were evaluated using data from the Society of Thoracic Surgeons Adult Cardiac Surgery Database (2011-2021). After excluding endocarditis and emergency cases, appropriateness of SAVR (rarely appropriate, may be appropriate, or appropriate) was assigned to patients by using established criteria. The relationship of appropriateness with publication of AUC was assessed, as was variation in appropriateness over time and by center. RESULTS Of 3035 patients across 17 centers, 106 (3.5%) underwent SAVR for an indication identified as rarely appropriate or may be appropriate. Patients who underwent SAVR for rarely or may be appropriate indications were significantly more likely to experience operative mortality (5.7% vs 1.6%, P = .001) as well as major morbidity (21.7% vs 10.5%, P < .001). Performance of rarely or may be appropriate SAVR significantly decreased over time (slope -0.51%/year, P trend < .001), and it was decreased after the release of the AUC (before release, 3.83% vs after release, 2.06%; P = .036). Substantial interhospital variation in appropriateness was observed (range of may be or rarely appropriate SAVR, 0%-10%). CONCLUSIONS The majority of isolated SAVR for aortic stenosis was appropriate according to the 2017 AUC. Appropriateness improved after publication of AUC, and this improvement was associated with a significant reduction of major morbidity and mortality.
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Affiliation(s)
- Raymond J Strobel
- Division of Cardiac Surgery, University of Virginia, Charlottesville, Virginia
| | - Zeyad T Sahli
- Division of Cardiac Surgery, University of Virginia, Charlottesville, Virginia
| | - J Hunter Mehaffey
- Division of Cardiac Surgery, University of Virginia, Charlottesville, Virginia
| | - Robert B Hawkins
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Andrew M Young
- Division of Cardiac Surgery, University of Virginia, Charlottesville, Virginia
| | - Mohammed Quader
- Division of Cardiothoracic Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Gregory J Dehmer
- Department of Medicine, Carilion Clinic/Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Nicholas R Teman
- Division of Cardiac Surgery, University of Virginia, Charlottesville, Virginia
| | - Leora T Yarboro
- Division of Cardiac Surgery, University of Virginia, Charlottesville, Virginia
| | - Donald S Likosky
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
| | - Irving L Kron
- Division of Cardiac Surgery, University of Virginia, Charlottesville, Virginia
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan.
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Abstract
The density of tumour-infiltrating lymphocytes (TILs) in melanoma is correlated with improved clinical prognosis; however, standardized TIL immunotyping and quantification protocols are lacking. Herein, we provide a review of the technologies being utilized for the immunotyping and quantification of melanoma TILs.
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Affiliation(s)
- Max O Meneveau
- Department of Surgery, The University of Virginia Health System, Charlottesville, VA, USA
| | - Zeyad T Sahli
- Department of Surgery, The University of Virginia Health System, Charlottesville, VA, USA
| | - Kevin T Lynch
- Department of Surgery, The University of Virginia Health System, Charlottesville, VA, USA
| | - Ileana S Mauldin
- Department of Surgery, The University of Virginia Health System, Charlottesville, VA, USA
| | - Craig L Slingluff
- Department of Surgery, The University of Virginia Health System, Charlottesville, VA, USA.
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Sahli ZT, Zhou S, Sharma AK, Segev DL, Massie A, Zeiger MA, Mathur A. Rising Cost of Thyroid Surgery in Adult Patients. J Surg Res 2020; 260:28-37. [PMID: 33316757 DOI: 10.1016/j.jss.2020.11.049] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 08/28/2020] [Accepted: 11/01/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The aim of this study is to describe the economic trends in adults who underwent elective thyroidectomy. METHODS We performed a population-based study utilizing the Premier Healthcare Database to examine adult patients who underwent elective thyroidectomy between January 2006 and December 2014. Time was divided into three equal time periods (2006-2008, 2009-2011, and 2012-2014). To examine trend in patient charges, we modeled patient charges using generalized linear regressions adjusting for key covariates with standard errors clustered at the hospital level. RESULTS Our study cohort consisted of 52,012 adult patients who underwent a thyroid operation. During the study period, the most common procedure changed from a thyroid lobectomy to bilateral thyroidectomy. Over the study period, there was an increase in the proportion of completion thyroidectomies from 1.1% to 1.6% (P < 0.001), malignant diagnoses from 21.7% to 26.8% (P < 0.001), procedures performed at teaching hospitals from 27.7% to 32.9% (P < 0.001), and procedures performed on an outpatient basis from 93.85% to 97.55% (P < 0.001). The annual increase in median patient charge adjusted for inflation was $895 or 4.3% resulting in an increase of 38.8% over 9 y. Higher thyroidectomy charges were associated with male patients, malignant surgical pathology, patients undergoing limited or radical neck dissection, experiencing complications, those with managed health care insurance, and a prolonged length of stay. CONCLUSIONS Despite recent changes in thyroid surgery practices to decrease the economic burden of hospitals, costs continue to rise 4.3% annually. Additional prospective studies are needed to identify factors associated with this increasing cost.
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Affiliation(s)
- Zeyad T Sahli
- Department of Surgery, The University of Virginia Health System, Charlottesville, Virginia.
| | - Sheng Zhou
- Center for Outcomes Research & Evaluation (CORE), Yale School of Medicine, New Haven, Connecticut
| | - Ashwyn K Sharma
- Department of Surgery, University of California San Diego Health System, San Diego, California
| | - Dorry L Segev
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Allan Massie
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Martha A Zeiger
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Aarti Mathur
- Endocrine Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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Sahli ZT, Canner JK, Zeiger MA, Mathur A. Association between age and disease specific mortality in medullary thyroid cancer. Am J Surg 2020; 221:478-484. [PMID: 33010878 DOI: 10.1016/j.amjsurg.2020.09.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 08/07/2020] [Accepted: 09/20/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the association between age and disease specific mortality (DSM) among adults diagnosed with medullary thyroid cancer (MTC). METHOD Surveillance, Epidemiology, and End Results (SEER-18) was used to analyze adult MTC patients stratified by age (18-64, 65-79, ≥80 years). Associations between patient demographics, tumor size, nodal status, metastatic disease, and extent of surgery on DSM was assessed with multivariable Cox regression. RESULTS Among 1457 patients with MTC, 1008 (69.2%) were younger adults, 371 (25.5%) older adults, and 78 (5.4%) were super-elderly. A significantly higher proportion of older adults and super-elderly had less than the recommended operation for MTC. On multivariable analysis, older adults and super-elderly were 2.9 and 6.7 times more likely to have an increased DSM (HR:2.91, 95% CI: 1.83-4.63; p < 0.001 and HR: 6.70, 95%CI: 3.69-12.20; p < 0.001). Extent of surgery or lymphadenectomy did not affect DSM. CONCLUSIONS Increased age is an independent predictor of DSM in patients with MTC.
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Affiliation(s)
- Zeyad T Sahli
- Department of Surgery, The University of Virginia Health System, P.O. Box 800681, Charlottesville, VA, 22908, USA
| | - Joseph K Canner
- Endocrine Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Blalock 606, Baltimore, MD, 21287, USA
| | - Martha A Zeiger
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Aarti Mathur
- Endocrine Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Blalock 606, Baltimore, MD, 21287, USA.
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Luu LA, Rawashdeh B, Goldaracena N, Agarwal A, McCracken EK, Sahli ZT, Oberholzer J, Pelletier SJ. Hepatic Artery Thrombosis and Takotsubo Syndrome After Liver Transplantation - Which Came First? Am J Case Rep 2020; 21:e920263. [PMID: 32287173 PMCID: PMC7176589 DOI: 10.12659/ajcr.920263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Takotsubo syndrome is a transient, reversible, stress-induced cardiomyopathy that affects only 1.4% of liver transplant patients and can cause complications, including cardiogenic shock, arrhythmia, and thromboembolism. Hepatic artery thrombosis is also rare, affecting just 2-4% of these patients, but can have disastrous consequences. Here, we describe a case of concurrent takotsubo syndrome and hepatic artery thrombosis in a postoperative liver transplant recipient. CASE REPORT The patient was a 66-year-old man who underwent living donor liver transplantation for non-alcoholic steatohepatitis. On postoperative day 3, he became lethargic and tachycardic to the 120 s. Work-up, including EKG, troponin I, BNP, and transthoracic echocardiogram, was characteristic for takotsubo syndrome. His LVEF of 15-20% was markedly reduced compared to his baseline of 50-55% from 6 months prior. Hepatic ultrasonography showed no hepatic arterial flow, prompting emergent return to the OR, where intraoperative evaluation revealed hepatic artery thrombosis. The graft was salvaged after hepatic artery thrombectomy and arterial anastomosis revision. We are unable to determine which event caused the other in this case, as both takotsubo syndrome and hepatic artery thrombosis manifested within the same time frame. CONCLUSIONS It is important to recognize takotsubo syndrome as a potential cause of cardiac dysfunction and hepatic artery thrombosis in liver transplant patients, and also be aware that hepatic artery thrombosis can precipitate takotsubo syndrome.
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Affiliation(s)
- Lydia A Luu
- Department of Surgery, Division of Transplantation, University of Virginia, Charlottesville, VA, USA
| | - Badi Rawashdeh
- Department of Surgery, Division of Transplantation, University of Virginia, Charlottesville, VA, USA
| | - Nicolas Goldaracena
- Department of Surgery, Division of Transplantation, University of Virginia, Charlottesville, VA, USA
| | - Avinash Agarwal
- Department of Surgery, Division of Transplantation, University of Virginia, Charlottesville, VA, USA
| | - Emily K McCracken
- Department of Surgery, Division of Transplantation, University of Virginia, Charlottesville, VA, USA
| | - Zeyad T Sahli
- Department of Surgery, Division of Transplantation, University of Virginia, Charlottesville, VA, USA
| | - Jose Oberholzer
- Department of Surgery, Division of Transplantation, University of Virginia, Charlottesville, VA, USA
| | - Shawn J Pelletier
- Department of Surgery, Division of Transplantation, University of Virginia, Charlottesville, VA, USA
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Russell JO, Sahli ZT, Shaear M, Razavi C, Ali K, Tufano RP. Transoral thyroid and parathyroid surgery via the vestibular approach-a 2020 update. Gland Surg 2020; 9:409-416. [PMID: 32420266 DOI: 10.21037/gs.2020.03.05] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Transoral endoscopic thyroidectomy and parathyroidectomy via the vestibular approach (TOET/PVA or TOETVA-TOEPVA) is the latest remote-access technique employed in the central neck. As the only approach that does not leave any cutaneous incision, (TOET/PVA) has become popular in both the Far East and Western series since its original description in 2015. More than just a "scarless" surgery, (TOET/PVA) has been associated with a short learning curve, access to the bilateral central neck compartments, few surgical contraindications, minimal complications, and minimal additional instrumentation. To date, more than 2,000 cases have been completed, including more than 400 in North America, demonstrating brisk utilization of a novel technique relative to earlier remote access central neck approaches. Herein, we describe updates that continue to improve the safety and efficacy of the procedure.
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Affiliation(s)
- Jonathon O Russell
- Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Zeyad T Sahli
- Department of Surgery, The University of Virginia Health System, Charlottesville, VA, USA
| | - Mohammad Shaear
- Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christopher Razavi
- Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Khalid Ali
- Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ralph P Tufano
- Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Sahli ZT, Sharma AK, Canner JK, Karipineni F, Ali O, Kawamoto S, Hang JF, Mathur A, Ali SZ, Zeiger MA, Sheth S. TIRADS Interobserver Variability Among Indeterminate Thyroid Nodules: A Single-Institution Study. J Ultrasound Med 2019; 38:1807-1813. [PMID: 30467876 PMCID: PMC7103459 DOI: 10.1002/jum.14870] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 10/10/2018] [Accepted: 10/20/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVES A high proportion of cytologically indeterminate, Afirma Gene Expression Classifier "suspicious" thyroid nodules are benign. The Thyroid Imaging Reporting and Data System (TIRADS), was proposed by the American College of Radiology in 2017 to help classify thyroid nodules based on ultrasound characteristics in a standardized fashion to guide management. We aim to determine the interobserver variability of TIRADS classification among cytologically indeterminate and Afirma suspicious nodules. METHODS We retrospectively queried cytopathology archives for thyroid fine-needle aspiration specimens obtained between February 2012 and September 2016 with associated (1) indeterminate diagnosis, (2) ultrasound imaging at our institution, (3) Afirma suspicious result, and (4) surgery at our institution. We compared the TIRADS variability of the 3 blinded radiologists using intraclass correlation coefficients. RESULTS Our cohort consisted of 127 nodules. Intraclass correlation coefficients can be interpreted as follows: less than 0.4, poor; 0.4 to 0.59, fair; 0.6 to 0.74, good; 0.75 to 1.00, excellent. The intraclass correlation coefficients of the raw TIRADS score and category variability was 0.561 (95% confidence interval [CI]: 0.464-0.651) or fair and 0.547 (95% CI, 0.449-0.640) or fair, respectively. When analyzing composition, echogenicity, shape, margin, and echogenic foci, the ICCs were 0.552 (95% CI, 0.454-0.643), fair; 0.533 (95% CI, 0.432-0.627), fair; 0.359 (95% CI, 0.248-0.469), poor; 0.192 (95% CI, 0.084-0.308), poor; and 0.549 (95% CI, 0.451- 0.641), fair, respectively. CONCLUSIONS Our results show that among the subset of cytologically indeterminate and Afirma suspicious nodules, TIRADS interobserver variability was fair. Shape and margin criteria were the biggest sources of disagreement. Large prospective studies are needed to evaluate the interobserver variability of TIRADS in this subset of thyroid nodules.
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Affiliation(s)
- Zeyad T Sahli
- Endocrine Surgery, Department of Surgery, Baltimore, Maryland
- Department of Surgery, The University of Virginia School of Medicine, Charlottesville, VA
| | - Ashwyn K Sharma
- Endocrine Surgery, Department of Surgery, Baltimore, Maryland
| | - Joseph K Canner
- Endocrine Surgery, Department of Surgery, Baltimore, Maryland
| | | | - Osama Ali
- Department of Radiology, Baltimore, Maryland
| | | | - Jen-Fan Hang
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Pathology and Laboratory Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Aarti Mathur
- Endocrine Surgery, Department of Surgery, Baltimore, Maryland
| | - Syed Z Ali
- Department of Radiology, Baltimore, Maryland
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Martha A Zeiger
- Department of Surgery, The University of Virginia School of Medicine, Charlottesville, VA
| | - Sheila Sheth
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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Mehaffey JH, Hawkins RB, Charles EJ, Sahli ZT, Schirmer BD, Hallowell PT. Socioeconomically Distressed Communities Associated With Long-term Mortality After Bariatric Surgery. J Surg Res 2019; 243:8-13. [PMID: 31146087 DOI: 10.1016/j.jss.2019.04.081] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 04/14/2019] [Accepted: 04/26/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Surgical outcomes are affected by socioeconomic status, yet these factors are poorly accounted for in clinical databases. We sought to determine if the Distressed Communities Index (DCI), a composite ranking by zip code that quantifies socioeconomic risk, was associated with long-term survival after bariatric surgery. METHODS All patients undergoing Roux-en-Y gastric bypass (1985-2004) at a single institution were paired with DCI. Scores range from 0 (no distress) to 100 (severe distress) and account for unemployment, education, poverty, median income, housing vacancies, job growth, and business establishment growth. Distressed communities, defined as DCI ≥75, were compared with all other patients. Regression modeling was used to evaluate the effect of DCI on 10-year bariatric outcomes, whereas Cox Proportional Hazards and Kaplan-Meier analysis examined long-term survival. RESULTS Gastric bypass patients (n = 681) come from more distressed communities compared with the general public (DCI 60.5 ± 23.8 versus 50 ± 10; P < 0.0001). A total of 221 (32.3%) patients came from distressed communities (DCI ≥75). These patients had similar preoperative characteristics, including BMI (51.5 versus 51.7 kg/m2; P = 0.63). Socioeconomic status did not affect 10-year bariatric outcomes, including percent reduction in excess body mass index (57% versus 58%; P = 0.93). However, patients from distressed communities had decreased risk-adjusted long-term survival (hazard ratio, 1.38; P = 0.043). CONCLUSIONS Patients with low socioeconomic status, as determined by the DCI, have equivalent outcomes after bariatric surgery despite worse long-term survival. Future quality improvement efforts should focus on these persistent disparities in health care.
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Affiliation(s)
- J Hunter Mehaffey
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Robert B Hawkins
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Eric J Charles
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Zeyad T Sahli
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Bruce D Schirmer
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Peter T Hallowell
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia.
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Sahli ZT, Karipineni F, Hang JF, Canner JK, Mathur A, Prescott JD, Sheth S, Ali SZ, Zeiger MA. The association between the ultrasonography TIRADS classification system and surgical pathology among indeterminate thyroid nodules. Surgery 2018; 165:69-74. [PMID: 30415866 DOI: 10.1016/j.surg.2018.04.094] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 03/05/2018] [Accepted: 04/03/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND A high proportion of cytologically indeterminate, Afirma-suspicious thyroid nodules are benign. The Thyroid Imaging Reporting and Data System was proposed by the American College of Radiology in 2015 to determine appropriate management of thyroid nodules in a standardized fashion. Our aim was to determine the diagnostic value of the Thyroid Imaging Reporting and Data System in cytologically indeterminate and Afirma-suspicious nodules. METHODS We retrospectively queried cytopathology archives for retrospectively for thyroid fine-needle aspiration specimens obtained between February 2012 and September 2016 that were associated with the following: (1) indeterminate diagnosis, (2) ultrasonographic imaging at our institution, (3) an Afirma Gene Expression Classifier-suspicious result, and (4) surgery at our institution. We then calculated the diagnostic value of the Thyroid Imaging Reporting and Data System in predicting surgical pathology. RESULTS Our cohort consisted of 133 nodules among 131 patients who underwent thyroid surgery for cytologically indeterminate, Afirma-suspicious nodules. A total of 9 nodules (6.8%) were assigned TR2 "not suspicious," 25 (18.8%) TR3 "mildly suspicious," 81 (60.9%) TR4 "moderately suspicious," and 18 (13.5%) TR5 "highly suspicious." Among our cohort, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the Thyroid Imaging Reporting and Data System was 71.4%, 38.1%, 40.2%, 69.6%, and 50.4%, respectively. CONCLUSION Among cytologically indeterminate and Afirma-suspicious nodules, the Thyroid Imaging and Reporting and Data System was a poor predictor of final surgical pathology. Additional prospective studies are needed to validate these findings.
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Affiliation(s)
- Zeyad T Sahli
- Endocrine Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Farah Karipineni
- Endocrine Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jen-Fan Hang
- Endocrine Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Pathology and Laboratory Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Joseph K Canner
- Endocrine Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Aarti Mathur
- Endocrine Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jason D Prescott
- Endocrine Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sheila Sheth
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Syed Z Ali
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Martha A Zeiger
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA.
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Sahli ZT, Zhou S, Najjar O, Onasanya O, Segev D, Massie A, Zeiger MA, Mathur A. Octogenarians have worse clinical outcomes after thyroidectomy. Am J Surg 2018; 216:1171-1176. [PMID: 29729944 DOI: 10.1016/j.amjsurg.2018.04.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 02/28/2018] [Accepted: 04/19/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND The rising proportion of older adults in the US population coupled with an increased prevalence of nodular thyroid disease will result in more thyroidectomies being performed. The aim of this study is to evaluate the clinical outcomes among older adults (age ≥65) undergoing thyroidectomy compared to younger adults (18-64). METHODS This was a population-based study of adult thyroidectomy patients using the Premier Healthcare Database, 2005-2014. Discharge status, hospital length of stay (LOS), morbidity, and total patient charge were compared between younger adults and older adults in three different age groups: ≥65, ≥70, and ≥80 years old. RESULTS Among 75,141 thyroidectomy patients, 15,805 (21.0%) patients were ≥65 years, 8834 (11.8%) were ≥70 years, and 1613 (2.2%) were ≥80 years. Patients ≥80 years were 2.6 times (aOR:2.58, 95%CI: 1.72-3.86; p < 0.001) more likely to be discharged to a home health organization than to be discharged to their residence and 1.6 times (aOR:1.61, 95%CI: 1.30-2.00; p < 0.001) more likely to have at least one complication. CONCLUSIONS Age ≥80 is an independent predictor of worse clinical outcomes after thyroidectomy.
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Affiliation(s)
- Zeyad T Sahli
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Sheng Zhou
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Omar Najjar
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Oluwadamilola Onasanya
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Dorry Segev
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Allan Massie
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Martha A Zeiger
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Aarti Mathur
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
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11
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Sharma AK, Sahli ZT, Mathur A. Bilateral chylothorax following reoperative central neck dissection for metastatic papillary thyroid cancer. BMJ Case Rep 2018; 2018:bcr-2018-224916. [PMID: 29666104 DOI: 10.1136/bcr-2018-224916] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Locoregional recurrence of papillary thyroid cancer (PTC) can occur in up to 30% of patients within 10 years after initial treatment. Reoperative surgery can be challenging due to scarring, fibrosis and distorted anatomy and may be associated with increased complications compared with initial operations. Chylothorax is an extremely rare and potentially life-threatening complication that can be associated with neck dissections and thyroid surgery. In this report, we describe an unusual case of bilateral chylothorax following a left central neck dissection for recurrent PTC.
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Affiliation(s)
- Ashwyn K Sharma
- Endocrine Surgery, Johns Hopkins Hospital and Health System, Baltimore, Maryland, USA
| | - Zeyad T Sahli
- Endocrine Surgery, Johns Hopkins Hospital and Health System, Baltimore, Maryland, USA
| | - Aarti Mathur
- Endocrine Surgery, Johns Hopkins Hospital and Health System, Baltimore, Maryland, USA
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Sahli ZT, Ansari G, Gurakar M, Canner JK, Segev D, Zeiger MA, Mathur A. Thyroidectomy in older adults: an American College of Surgeons National Surgical Quality Improvement Program study of outcomes. J Surg Res 2018; 229:20-27. [PMID: 29936990 DOI: 10.1016/j.jss.2018.03.057] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 03/05/2018] [Accepted: 03/21/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND The growth of the US geriatric population coupled with the rise in thyroid nodular disease and cancer will result in an increased number of thyroidectomies performed in older adults. We aim to evaluate outcomes after thyroidectomy in older adults as compared with younger adults. METHODS A retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database from 2012-2015 categorized thyroidectomy patients into three age groups: 18-64 y, 65-79 y, and ≥80 y. Thirty-day perioperative outcomes were analyzed using bivariate χ2 test and multivariate logistic regression to estimate risk of outcomes. RESULTS Our study identified 60,990 patients who underwent thyroidectomy: 47,855 (78.4%) patients between 18 and 64 y old, 11,716 (19.2%) between 65 and 79 y old, and 1419 (2.3%) ≥80 y. Compared with younger adults, patients aged ≥80 y were 2.67 times more likely to develop a complication (95% confidence interval [CI]: 2.02-3.53, P < 0.001), 1.83 times more likely to be readmitted for any reason (95% CI: 1.40-2.38, P < 0.001), 1.54 times more likely to be readmitted for a reason related to the thyroidectomy (95% CI: 1.10-2.16, P < 0.05), and 1.66 times more likely to have an extended hospital stay (95% CI: 1.44-1.91, P < 0.001). Patients aged 65-79 y were 1.40 times more likely to develop a complication (95% CI: 1.19-1.63, P < 0.001). CONCLUSIONS Patients aged ≥65 y have significantly higher rates of overall complications. In addition, patients aged ≥80 y have higher rates of total and thyroidectomy-related readmissions and extended length of hospital stay.
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Affiliation(s)
- Zeyad T Sahli
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ghedak Ansari
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Merve Gurakar
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Joseph K Canner
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Dorry Segev
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Martha A Zeiger
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Aarti Mathur
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
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Abstract
The need for distinguishing benign from malignant thyroid nodules has led to the pursuit of differentiating molecular markers. The most common molecular tests in clinical use are Afirma® Gene Expression Classifier (GEC) and Thyroseq® V2. Despite the rapidly developing field of molecular markers, several limitations exist. These challenges include the recent introduction of the histopathological diagnosis "Non-Invasive Follicular Thyroid neoplasm with Papillary-like nuclear features", the correlation of genetic mutations within both benign and malignant pathologic diagnoses, the lack of follow-up of molecular marker negative nodules, and the cost-effectiveness of molecular markers. In this manuscript, we review the current published literature surrounding the diagnostic value of Afirma® GEC and Thyroseq® V2. Among Afirma® GEC studies, sensitivity (Se), specificity (Sp), positive predictive value (PPV), and negative predictive value (NPV) ranged from 75 to 100%, 5 to 53%, 13 to 100%, and 20 to 100%, respectively. Among Thyroseq® V2 studies, Se, Sp, PPV, and NPV ranged from 40 to 100%, 56 to 93%, 13 to 90%, and 48 to 97%, respectively. We also discuss current challenges to Afirma® GEC and Thyroseq® V2 utility and clinical application, and preview the future directions of these rapidly developing technologies.
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Affiliation(s)
- Zeyad T. Sahli
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Philip W. Smith
- Department of Surgery, University of Virginia, Charlottesville, VA, United States
| | - Christopher B. Umbricht
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Martha A. Zeiger
- Department of Surgery, University of Virginia, Charlottesville, VA, United States
- *Correspondence: Martha A. Zeiger,
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Abstract
BACKGROUND Current thyroid molecular tests are specifically designed for the differential diagnosis of nodules with indeterminate or suspicious fine-needle aspiration (FNA) cytology. SUMMARY However, their clinical validity faces challenges from both variation among institutions in cancer prevalence and, most recently, the new category of non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP). The latter diagnosis was previously classified as malignant. Relevant to this, all molecular panels on the market today were originally tested and validated within the context of these entities being considered malignant. CONCLUSION This review examines possible effects of the NIFTP reclassification as a precancerous lesion on the original validation studies and, investigates the effect of the significant reported variability in thyroid cancer prevalence on the performance of these tests.
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MESH Headings
- Adenocarcinoma, Follicular/classification
- Adenocarcinoma, Follicular/epidemiology
- Adenocarcinoma, Follicular/genetics
- Adenocarcinoma, Follicular/pathology
- Biomarkers, Tumor/genetics
- Biopsy, Fine-Needle
- Carcinoma, Papillary/classification
- Carcinoma, Papillary/epidemiology
- Carcinoma, Papillary/genetics
- Carcinoma, Papillary/pathology
- Diagnosis, Differential
- Gene Expression Profiling
- Humans
- Predictive Value of Tests
- Prevalence
- Prognosis
- Terminology as Topic
- Thyroid Cancer, Papillary
- Thyroid Neoplasms/classification
- Thyroid Neoplasms/epidemiology
- Thyroid Neoplasms/genetics
- Thyroid Neoplasms/pathology
- Thyroid Nodule/classification
- Thyroid Nodule/epidemiology
- Thyroid Nodule/genetics
- Thyroid Nodule/pathology
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Affiliation(s)
- Zeyad T Sahli
- 1 Endocrine Surgery, Department of Surgery, The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Christopher B Umbricht
- 2 Departments of Oncology, Pathology, and Surgery, The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Eric B Schneider
- 3 Health Services Outcomes Research Center, The Ohio State University College of Medicine , Department of Surgery, Columbus, Ohio
| | - Martha A Zeiger
- 1 Endocrine Surgery, Department of Surgery, The Johns Hopkins University School of Medicine , Baltimore, Maryland
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Abstract
INTRODUCTION Pimavanserin is the first FDA-approved atypical antipsychotic drug indicated for the treatment of hallucinations and delusions associated with Parkinson's disease psychosis (PDP). Areas covered: This review focuses on the preclinical discovery of pimavanserin. It analyzes the pharmacological, behavioral and molecular mechanisms of pimavanserin and their contribution to the therapeutic advantages of the drug as reported in published preclinical and clinical studies, press releases and product labels. Expert opinion: Pimavanserin exhibits a unique pharmacological profile with nanomolar affinity at serotonin 5-HT2A and 5-HT2C receptors. Functionally, it acts as a potent inverse agonist at 5-HT2A receptors, with selectivity over 5-HT2C receptors and no appreciable activity at other neurotransmitter receptors. Behavioral studies found that pimavanserin reversed impaired behaviors in animal models predictive of antipsychotic activity, and with no impairment of motor functions. The drug exhibits long plasma half-life (57 hours), which support its once/day administration. A pivotal phase III clinical trial demonstrated significant improvement in PDP symptoms in patients receiving pimavanserin compared to placebo-treated patients. The drug also displayed relatively benign safety and tolerability profiles. Pimavanserin's mechanism of action might contribute to its unique psychopharmacological properties in the improved treatment of PDP, and perhaps psychosis in other diseases including schizophrenia and dementia-related psychosis.
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Affiliation(s)
- Zeyad T Sahli
- a Department of Psychiatry and Neuroscience Program , Harvard Medical School, McLean Hospital , Belmont , MA , USA
| | - Frank I Tarazi
- a Department of Psychiatry and Neuroscience Program , Harvard Medical School, McLean Hospital , Belmont , MA , USA
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Abstract
Despite improvements in parathyroidectomy success rates, patients with persistent primary hyperparathyroidism (PHPT) after initial surgery continue to challenge clinicians. Some of the challenges are due to ectopic parathyroid adenomas, including thymic, intrathyroidal, carotid sheath and mediastinal glands, and others are because of supernumerary glands. While uncommon in PHPT, multigland disease is also an important consideration in patients requiring reoperative surgery for persistent disease. For this reason, localisation studies including sestamibi, ultrasound, CT scan and venous sampling for abnormal glands may be an essential component of the preoperative workup. In this report, we describe an unusual case of a patient who required a total of four operations to cure PHPT arising from seven parathyroid adenomas.
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Affiliation(s)
- Zeyad T Sahli
- Department of Endocrine Surgery, Johns Hopkins Hospital and Health System, Baltimore, Maryland, USA
| | - Farah Karipineni
- Department of Endocrine Surgery, Johns Hopkins Hospital and Health System, Baltimore, Maryland, USA
| | - Martha A Zeiger
- Department of Endocrine Surgery, Johns Hopkins Hospital and Health System, Baltimore, Maryland, USA
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Abstract
INTRODUCTION Major depressive disorder (MDD) is the leading cause of disability worldwide, and according to the STAR*D trial, only 33% of patients with MDD responded to initial drug therapy. Augmentation of the leading class of antidepressant treatment, selective serotonin reuptake inhibitors (SSRIs), with the 5-HT1A receptor agonist buspirone has been shown to be effective in treating patients that do not respond to initial SSRI therapy. This suggests that newer treatments may improve the clinical picture of MDD. The US Food and Drug Administration (FDA) approved the antidepressant drug vilazodone (EMD 68843), a novel SSRI and 5-HT1A receptor partial agonist. Vilazodone has a half-life between 20-24 hours, reaches peak plasma concentrations at 3.7-5.3 hours, and is primarily metabolized by the hepatic CYP450 3A4 enzyme system. AREAS COVERED The authors review the preclinical and clinical profile of vilazodone. The roles of serotonin, the 5-HT1A receptor, and current pharmacotherapy approaches for MDD are briefly reviewed. Next, the preclinical pharmacological, behavioral, and physiological effects of vilazodone are presented, followed by the pharmacokinetic properties and metabolism of vilazodone in humans. Last, a brief summary of the main efficacy, safety, and tolerability outcomes of clinical trials of vilazodone is provided. EXPERT OPINION Vilazodone has shown efficacy versus placebo in improving depression symptoms in several double-blind, placebo-controlled trials. The long-term safety and tolerability of vilazodone treatment has also been established. Further studies are needed that directly compare patients treated with an SSRI (both with and without an adjunctive 5-HT1A partial agonist) versus patients treated with vilaozodone.
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Affiliation(s)
- Zeyad T Sahli
- a Department of Psychiatry and Neuroscience Program , Harvard Medical School, McLean Hospital , Belmont , MA , USA.,b School of Medicine , American University of Beirut , Beirut , Lebanon
| | - Pradeep Banerjee
- c Forest Research Institute , Jersey City , NJ , USA , an affiliate of Allergan Inc
| | - Frank I Tarazi
- a Department of Psychiatry and Neuroscience Program , Harvard Medical School, McLean Hospital , Belmont , MA , USA
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Tarazi FI, Sahli ZT, Wolny M, Mousa SA. Emerging therapies for Parkinson's disease: from bench to bedside. Pharmacol Ther 2014; 144:123-33. [PMID: 24854598 DOI: 10.1016/j.pharmthera.2014.05.010] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 05/01/2014] [Indexed: 02/08/2023]
Abstract
The prevalence of Parkinson's disease (PD) increases with age and is projected to increase in parallel to the rising average age of the population. The disease can have significant health-related, social, and financial implications not only for the patient and the caregiver, but for the health care system as well. While the neuropathology of this neurodegenerative disorder is fairly well understood, its etiology remains a mystery, making it difficult to target therapy. The currently available drugs for treatment provide only symptomatic relief and do not control or prevent disease progression, and as a result patient compliance and satisfaction are low. Several emerging pharmacotherapies for PD are in different stages of clinical development. These therapies include adenosine A2A receptor antagonists, glutamate receptor antagonists, monoamine oxidase inhibitors, anti-apoptotic agents, and antioxidants such as coenzyme Q10, N-acetyl cysteine, and edaravone. Other emerging non-pharmacotherapies include viral vector gene therapy, microRNAs, transglutaminases, RTP801, stem cells and glial derived neurotrophic factor (GDNF). In addition, surgical procedures including deep brain stimulation, pallidotomy, thalamotomy and gamma knife surgery have emerged as alternative interventions for advanced PD patients who have completely utilized standard treatments and still suffer from persistent motor fluctuations. While several of these therapies hold much promise in delaying the onset of the disease and slowing its progression, more pharmacotherapies and surgical interventions need to be investigated in different stages of PD. It is hoped that these emerging therapies and surgical procedures will strengthen our clinical armamentarium for improved treatment of PD.
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Affiliation(s)
- F I Tarazi
- Department of Psychiatry and Neuroscience Program, Harvard Medical School, McLean Hospital, Belmont, MA 02478, USA.
| | - Z T Sahli
- Department of Psychiatry and Neuroscience Program, Harvard Medical School, McLean Hospital, Belmont, MA 02478, USA; School of Medicine, American University of Beirut, Beirut, Lebanon
| | - M Wolny
- The Pharmaceutical Research Institute at Albany College of Pharmacy and Health Sciences, Rensselaer, NY 12144, USA
| | - S A Mousa
- The Pharmaceutical Research Institute at Albany College of Pharmacy and Health Sciences, Rensselaer, NY 12144, USA
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