Teaming: learning, competing, and innovating in the world of reproductive medicine

Healthcare teams must be deliberately cultivated to reach their full potential. Shifting focus from individual performance to a team's collective competence allows for targeted and evidence-based interventions that support teamwork and improve patient outcomes. We reviewed essential concepts drawn from team science and explored the practical applications of teaming. Reproductive endocrinology and infertility healthcare providers play a pivotal role by teaching, modeling, and fostering teaming attitudes and behaviors. Through teaming, we can maximize our teams' ability to learn, innovate, compete with other teams, and thrive in today's healthcare environment.

Reverse Trigger Phenotypes in Acute Respiratory Distress Syndrome

Rationale: Reverse triggering is an underexplored form of dyssynchrony with important clinical implications in patients with acute respiratory distress syndrome.Objectives: This retrospective study identified reverse trigger phenotypes and characterized their impacts on Vt and transpulmonary pressure.Methods: Fifty-five patients with acute respiratory distress syndrome on pressure-regulated ventilator modes were included. Four phenotypes of reverse triggering with and without breath stacking and their impact on lung inflation and deflation were investigated.Measurements and Main Results: Inflation volumes, respiratory muscle pressure generation, and transpulmonary pressures were determined and phenotypes differentiated using Campbell diagrams of respiratory activity. Reverse triggering was detected in 25 patients, 15 with associated breath stacking, and 13 with stable reverse triggering consistent with respiratory entrainment. Phenotypes were associated with variable levels of inspiratory effort (mean 4-10 cm H₂O per phenotype). Early reverse triggering with early expiratory relaxation increased Vts (88 [64-113] ml) and inspiratory transpulmonary pressures (3 [2-3] cm H₂O) compared with passive breaths. Early reverse triggering with delayed expiratory relaxation increased Vts (128 [86-170] ml) and increased inspiratory and mean-expiratory transpulmonary pressure (7 [5-9] cm H₂O and 5 [4-6] cm H₂O). Mid-cycle reverse triggering (initiation during inflation and maximal effort during deflation) increased Vt (51 [38-64] ml), increased inspiratory and mean-expiratory transpulmonary pressure (3 [2-4] cm H₂O and 3 [2-3] cm H₂O), and caused incomplete exhalation. Late reverse triggering (occurring exclusively during exhalation) increased mean expiratory transpulmonary pressure (2 [1-2] cm H₂O) and caused incomplete exhalation. Breath stacking resulted in large delivered volumes (176 [155-197] ml).Conclusions: Reverse triggering causes variable physiological effects, depending on the phenotype. Differentiation of phenotype effects may be important to understand the clinical impacts of these events.

Inter-Observer Variation in the Pathologic Identification of Extranodal Extension in Nodal Metastasis from Papillary Thyroid Carcinoma

BACKGROUND

Extranodal extension (ENE) in lymph node metastases has been shown to worsen the prognosis of papillary thyroid cancer (PTC). Despite the clinical significance of ENE, there are no stringent criteria for its microscopic diagnosis, and its identification is subject to inter-observer variability. The objective of this study was to determine the level of agreement among expert pathologists in the identification of ENE in PTC cases.

METHODS

Eleven expert pathologists from the United States, Italy, and Canada were asked to review 61 scanned slides of representative permanent sections of PTC specimens from Mount Sinai Beth Israel Medical Center in New York. Each slide was evaluated for the presence of ENE. The pathologists were also asked to report the criteria they use to identify ENE.

RESULTS

The overall strength of agreement in identifying ENE was only fair (κ = 0.35), and the proportion of observed agreement was 0.68. The proportions of observed agreement for the identification of perinodal structures (fat, nerve, skeletal, and thick-walled vessel involvement) ranged from 0.61 to 0.997.

CONCLUSIONS

Overall agreement for the identification of ENE is poor. The lack of agreement results from both variation in pathologists' identification of features and disagreement on the histologic criteria for ENE. This lack of concordance may help explain some of the discordant information regarding prognosis in clinical studies when this feature is identified.

Improving the adoption of thyroid cancer clinical practice guidelines

OBJECTIVES/HYPOTHESIS

To present an overview of the barriers to the implementation of clinical practice guidelines (CPGs) in thyroid cancer management and to introduce a computer-based clinical support system.

DATA SOURCES

PubMed.

REVIEW METHODS

A review of studies on adherence to CPGs was conducted.

RESULTS

Awareness and adoption of CPGs is low in thyroid cancer management. Barriers to implementation include unfamiliarity with the CPGs and financial concerns. Effective interventions to improve adherence are possible, especially when they are readily accessible at the point of care delivery. Computerized clinical support systems show particular promise. The authors introduce the clinical decision making modules (CDMMs) of the Thyroid Cancer Care Collaborative, a thyroid cancer-specific electronic health record. These computer-based modules can assist clinicians with implementation of these recommendations in clinical practice.

CONCLUSION

Computer-based support systems can help clinicians understand and adopt the thyroid cancer CPGs. By integrating patient characteristics and guidelines at the point of care delivery, the CDMMs can improve adherence to the guidelines and help clinicians provide high-quality, evidence-based, and individualized patient care in the management of differentiated thyroid cancer. Laryngoscope, 126:2640-2645, 2016.

Inter-Observer Variation in the Pathologic Identification of Minimal Extrathyroidal Extension in Papillary Thyroid Carcinoma

BACKGROUND

Extrathyroidal extension (ETE) is a significant prognostic factor in papillary thyroid carcinoma (PTC). Minimal extrathyroidal extension (mETE) is characterized by involvement of the sternothyroid muscle or perithyroid soft tissue, and is generally identified by light microscope examination. Patients with mETE, identified pathologically, are automatically upstaged to pT3. However, the prognostic implications of mETE have been a source of controversy in the literature. Moreover, there is also controversy surrounding the identification of mETE on pathological specimens. The objective of this study was to determine the level of agreement among expert pathologists in the identification of mETE in PTC cases.

METHODS

Eleven expert pathologists from the United States, Italy, and Canada were asked to perform a review of 69 scanned slides of representative permanent sections of PTC specimens. Each slide was evaluated for the presence of mETE. The pathologists were also asked to list the criteria they use to identify mETE.

RESULTS

The overall strength of agreement for identifying mETE was slight (κ = 0.14). Inter-pathologist agreement was best for perithyroidal skeletal muscle involvement (κ = 0.46, moderate agreement) and worst for invasion around thick-walled vascular structures (κ = 0.02, slight agreement). In addition, there was disagreement over the constellation of histologic features that are diagnostic for mETE, which affected overall agreement for diagnosing mETE.

CONCLUSIONS

Overall agreement for the identification of mETE is poor. Disagreement is a result of both variation in individual pathologists' interpretations of specimens and disagreement on the histologic criteria for mETE. Thus, the utility of mETE in staging and treatment of PTC is brought into question. The lack of concordance may explain the apparent lack of agreement regarding the prognostic significance of this pathologic feature.

ACTIVE SURVEILLANCE FOR PAPILLARY THYROID MICROCARCINOMA: NEW CHALLENGES AND OPPORTUNITIES FOR THE HEALTH CARE SYSTEM

OBJECTIVE

The dramatic increase in papillary thyroid carcinoma (PTC) is primarily a result of early diagnosis of small cancers. Active surveillance is a promising management strategy for papillary thyroid microcarcinomas (PTMCs). However, as this management strategy gains traction in the U.S., it is imperative that patients and clinicians be properly educated, patients be followed for life, and appropriate tools be identified to implement the strategy.

METHODS

We review previous active surveillance studies and the parameters used to identify patients who are good candidates for active surveillance. We also review some of the challenges to implementing active surveillance protocols in the U.S. and discuss how these might be addressed.

RESULTS

Trials of active surveillance support nonsurgical management as a viable and safe management strategy. However, numerous challenges exist, including the need for adherence to protocols, education of patients and physicians, and awareness of the impact of this strategy on patient psychology and quality of life. The Thyroid Cancer Care Collaborative (TCCC) is a portable record keeping system that can manage a mobile patient population undergoing active surveillance.

CONCLUSION

With proper patient selection, organization, and patient support, active surveillance has the potential to be a long-term management strategy for select patients with PTMC. In order to address the challenges and opportunities for this approach to be successfully implemented in the U.S., it will be necessary to consider psychological and quality of life, cultural differences, and the patient's clinical status.

Staged laryngeal reconstruction with a prefabricated flap for radiation recurrent glottic carcinoma

OBJECTIVES/HYPOTHESIS

Although salvage total laryngectomy remains the definitive approach to recurrent/persistent glottic cancer following failed radiation therapy for favorable early-stage disease, it comes at the price of a permanent laryngostome and an impact on quality of life. We describe a three-stage method of laryngeal reconstruction for salvage partial laryngectomy to address the unique challenges of operating on radiation recurrent/persistent cancer.

STUDY DESIGN

This was a single-surgeon retrospective case series of patients who underwent a three-stage laryngeal reconstruction for salvage partial laryngectomy.

METHODS

We performed a comprehensive review of the clinical, pathologic, and radiologic files of all patients who underwent a three-stage laryngeal reconstruction for salvage partial laryngectomy.

RESULTS

Seven male patients underwent a three-stage laryngeal reconstruction following open partial salvage laryngectomy. The average follow-up time since salvage surgery was 55 months. All patients were without evidence of recurrence and demonstrated satisfactory functional outcomes.

CONCLUSION

Staged reconstruction provides a more controlled assessment of wound healing and valuable pathologic information regarding the specific disease virulence and adequacy of the margins.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:1061-1070, 2016.

Extramedullary plasmacytoma of the cricoid cartilage with solitary plasmacytoma of the rib

BACKGROUND

Extramedullary plasmacytoma is a rare plasma cell neoplasm of the soft tissues characterized by the presence of a single, discrete lesion without evidence of systemic disease. Extramedullary plasmacytoma may disseminate into multiple myeloma, a systemic plasma cell disease.

METHODS

A rare case of extramedullary plasmacytoma of the cricoid cartilage with solitary plasmacytoma of the rib was reviewed.

RESULTS

The patient was found to have two discrete lesions; one of the cricoid cartilage and one of the lateral left fifth rib. Despite the presence of multiple tumors, the patient was not diagnosed with multiple myeloma as the bone marrow appeared normal.

CONCLUSIONS

Due to the rarity of these neoplasms and the unusual localization of the extramedullary plasmacytoma tumor, a definitive diagnosis was difficult to make in this case. This case may be instructive for the differential diagnosis of laryngeal lesions.

Reconstruction of expanding tracheoesophageal fistulae in post-radiation therapy patients who undergo total laryngectomy with a bipaddled radial forearm free flap: Report of 8 cases

BACKGROUND

Our surgical approach describes a bipaddled radial forearm free flap (RFFF) for closure of chronic tracheoesophageal fistulae (TEF) in patients who underwent total laryngectomy. The desired functional results were achieved.

METHODS

Eight patients underwent the procedure. The surgical approach includes exposure and resection of the fistula tract, and a bipaddled RFFF transfer. Key surgical maneuvers include: circumferential dissection and mobilization of the trachea; partial sternal resection in select cases; inset of flap's distal paddle into the anterior esophageal wall; and inset of the proximal skin paddle to the posterior tracheal wall and cervical skin.

RESULTS

Successful reconstruction of all 8 cases was done to restore a normal diet and a widely patent tracheal opening. One patient developed a delayed esophageal stricture, which was successfully managed with home dilation.

CONCLUSION

Several TEF treatment approaches have been reported. Our 87.5% esophageal lumen preservation success rate, reestablishment of adequate airway, and uncomplicated postoperative courses demonstrates the reliability of this surgical approach. © 2015 Wiley Periodicals, Inc. Head Neck 38: E172-E178, 2016.

Osteoradionecrosis of the subaxial cervical spine following treatment for head and neck carcinomas

OBJECTIVE

To study MRI and positron emission tomography (PET)/CT imaging of osteoradionecrosis (ORN) of the subaxial cervical spine, a serious long-term complication of radiation therapy (RT) for head and neck cancers that can lead to pain, vertebral instability, myelopathy and cord compression.

METHODS

This is a single-institution retrospective review of patients diagnosed and treated for ORN of the subaxial cervical spine following surgery and radiation for head and neck cancer.

RESULTS

We report PET/CT imaging and MRI for four patients, each with extensive treatment for recurrent head and neck cancer. Osteomyelitis (OM) and discitis are the end-stage manifestations of ORN of the subaxial spine.

CONCLUSION

ORN of the subaxial spine has variable imaging appearance and needs to be differentiated from recurrent or metastatic disease. Surgical violation of the posterior pharyngeal wall on top of the compromised vasculature in patients treated heavily with RT may pre-dispose the subaxial cervical vertebrae to ORN, with possible resultant OM and discitis. MRI and PET/CT imaging are complimentary in this setting. PET/CT images may be misinterpreted in view of the history of head and neck cancer. MRI should be utilized for definitive diagnosis of OM and discitis in view of its imaging specificity.

ADVANCES IN KNOWLEDGE

We identify the end-stage manifestation of ORN in the sub-axial spine on PET/CT and MRI to facilitate its correct diagnosis.

Size distribution of metastatic lymph nodes with extranodal extension in patients with papillary thyroid cancer: a pilot study

BACKGROUND

Extranodal extension (ENE) is a documented negative prognostic factor in patients with papillary thyroid cancer (PTC). ENE is presumed to manifest in larger lymph nodes. Yet, to date, no study has proven this. This is a pilot study that specifically examines the size distribution of positive lymph nodes manifesting ENE in patients with PTC.

METHODS

An Institutional Review Board approved review examined the size of all lymph nodes demonstrating ENE in postoperative PTC patients that underwent surgery for PTC under the care of a single surgeon between 2004 and 2014. All patients in the study had regional metastatic lymph nodes with ENE. Analysis of the size distribution for all lymph nodes with ENE was performed.

RESULTS

A total of 47% of lymph nodes with ENE were ≤10 mm.

CONCLUSIONS

RESULTS indicate that clinically nonevident, small lymph nodes are at risk of harboring aggressive disease biology reflected in ENE. A total of 47% of all nodes fell within Randolph et al.'s classification of "small" lymph nodes, while 59% of the nodes with ENE were <1.5 cm-the threshold size that was deemed to be prognostically significant by Ito et al. It is apparent that clinically nonevident regional lymph nodes can have adverse histologic features and that the previous presumption that nodes with ENE only appear in clinically evident, macroscopic nodes is flawed.

Striving toward standardization of reporting of ultrasound features of thyroid nodules and lymph nodes: a multidisciplinary consensus statement

BACKGROUND

The use of high-resolution ultrasound (US) imaging is a mainstay of the initial evaluation and long-term management of thyroid nodules and thyroid cancer. To fully capitalize on the diagnostic capabilities of a US examination in the context of thyroid disease, many clinicians consider it desirable to establish a universal format and standard of US reporting. The goals of this interdisciplinary consensus statement are twofold. First, to create a standardized set of US features to characterize thyroid nodules and cervical lymph nodes accurately, and second, to create a standardized system for tracking sequential changes in the US examination of thyroid nodules and cervical lymph nodes for the purpose of determining risk of malignancy.

SUMMARY

The Thyroid, Head and Neck Cancer (THANC) Foundation convened a panel of nine specialists from a variety of medical disciplines that are actively involved in the diagnosis and treatment of thyroid nodules and thyroid cancer. Consensus was achieved on the following topics: US evaluation of the thyroid gland, US evaluation of thyroid nodules, US evaluation of cervical lymph nodes, US-guided fine needle aspiration (FNA) of thyroid nodules, and US-guided FNA of cervical lymph nodes.

CONCLUSION

We propose that this statement represents a consensus within a multidisciplinary team on the salient and essential elements of a comprehensive and clinically significant thyroid and neck US report with regards to content, terminology, and organization. This reporting protocol supplements previous US performance guidelines by not only capturing categories of findings that may have important clinical implications, but also delineating findings that are clinically relevant within those categories as specifically as possible. Additionally, we have included the specific features of diagnostic and therapeutic interventions that have not been previously addressed.

Very delayed cervical lymph node metastases from hyalinizing clear cell carcinoma: report of 2 cases

BACKGROUND

Hyalinizing clear cell carcinoma (HCCC) is a rare salivary gland neoplasm most often found in the oral cavity. Although it is generally a low-grade malignancy that is treated with wide local excision, there is a growing body of evidence pointing toward the potential for more aggressive behavior.

METHODS

We reviewed available records of patients with delayed cervical lymph node metastases from HCCC.

RESULTS

Two patients who were treated with wide local resection for HCCC and remained disease-free at the primary site were diagnosed with cervical lymph node metastases 10 and 14 years later. We treated both with neck dissection, and 1 patient received adjuvant radiation therapy.

CONCLUSION

These cases illustrate the risk for occult nodal metastases from HCCC with delayed presentation. Clinician awareness of the presence of subclinical metastases in the neck requires thorough long-term surveillance and potential intervention should nodal disease become manifest.

Orientation of the cleavage site of the herpes simplex virus glycoprotein G-2

During the synthesis of glycoprotein G-2 (gG-2) of herpes simplex virus type 2, the 104,000-Da gG-2 precursor (104K precursor) is cleaved to generate the 72K and the 31K intermediates. The 72K product is processed to generate the mature gG-2 (molecular mass, 108,000 Da), while the 31K product is additionally processed and secreted into the extracellular medium as the 34K component (H. K. Su, R. Eberle, and R. J. Courtney, J. Virol. 61:1735-1737, 1987). In this study, the orientations of the 31K and 72K products on the 104K precursor were determined by using two antipeptide sera produced in rabbits and a monoclonal antibody, 13 alpha C6, directed against gG-2. The sera prepared against synthetic peptides corresponding to the terminal amino acid residues 67 to 78 and an internal peptide at amino acids 247 to 260 of gG-2 recognized the 104K precursor and the 31K cleavage product but not the 72K intermediate. In contrast, 13 alpha C6 detected the 72K cleavage product and the uncleaved precursor but not the 31K cleavage component. The epitope recognized by 13 alpha C6 was mapped within amino acids 486 to 566. These results suggest that the 31K cleavage product is derived from the amino-terminal portion of the 104K precursor molecule and that the 72K intermediate is derived from the carboxyl terminus. In support of our model described above for the synthesis of gG-2, antibodies recognizing either of the cleavage products reacted with the uncleaved precursor but not with the other cleavage product. By using partial endo-beta-N-acetylglucosaminidase H analysis, two N-linked glycosylation sites were found on each of the cleavage products. The distribution of the N-linked glycosylation sites and the reactivities of the antipeptide sera allowed the cleavage region on the precursor to be mapped to within amino acids 260 to 437.

In vitro synthesis and processing of herpes simplex virus type 2 gG-2, using cell-free transcription and translation systems

Translation of in vitro-synthesized herpes simplex virus type 2 (HSV-2) gG-2 mRNA in a reticulocyte lysate system was used to study the processing of HSV-2 gG-2. In the presence of canine pancreatic microsomal membranes, a single species that is protected from trypsin digestion was detected. This product comigrates with the 104,000-Mr (104K) high mannose intermediate seen in HSV-2-infected-cell lysates. Endo-beta-N-acetylglucosaminidase H treatment of the in vitro-synthesized 104K protein yielded a single product migrating at 100 K. The 72K and 31K cleavage products of gG-2 were not observed in the in vitro system. These data show that the molecular weight of the nonglycosylated form of the gG-2 protein is 100,000 and that the cotranslational processing of this protein in the endoplasmic reticulum yields the 104K high-mannose intermediate.

Inducible expression of herpes simplex virus type 2 glycoprotein gene gG-2 in a mammalian cell line

The gG-2 glycoprotein gene of herpes simplex virus type 2 (HSV-2) was cloned into the mammalian expression vector pMSG under the control of the inducible mouse mammary tumor virus promoter. Transfection of this cloned gG-2 construct into NIH 3T3 cells resulted in the stable expression of gG-2 upon induction with dexamethasone. In addition, the 104,000-molecular-weight (104K) and 72K gG-2 precursors as well as the 34K secreted component were generated in the transformed cells. The synthesis of gG-2 in these transformed cells appeared to follow the same cleavage-processing pathway as gG-2 synthesis during an HSV-2 infection. These results indicate that the processing of gG-2 can occur in the absence of an HSV-2 infection.

Processing of the herpes simplex virus type 2 glycoprotein gG-2 results in secretion of a 34,000-Mr cleavage product

Herpes simplex virus type 2 glycoprotein gG-2 undergoes a cleavage event during its synthesis and processing. The focus of this report is on the detection and fate of the small-molecular-weight component of gG-2, designated the 34K component. In cultures containing the inhibitor monensin, a 31K component accumulated within infected cells. In contrast, the intracellular accumulation of this 31K precursor was not detected in cultures grown in the absence of the inhibitor. However, the 34K component of gG-2 was found in the extracellular culture fluid. The data suggest that the 31K high-mannose cleavage product of gG-2 is further glycosylated and rapidly secreted from herpes simplex virus type 2-infected cells; however, if glycosylation is perturbed, the 31K high-mannose form remains cell associated.