Optimal extent of initial parathyroid resection in patients with multiple endocrine neoplasia syndrome type 1: A meta-analysis

BackgroundHyperparathyroidism is an almost universal feature of multiple endocrine neoplasia type 1 syndrome. We present a systematic review and meta-analysis of the postoperative outcomes of patients undergoing initial operative treatment of primary hyperparathyroidism complicating multiple endocrine neoplasia 1.MethodsA comprehensive literature search was performed with a priori defined exclusion criteria for studies comparing total parathyroidectomy, subtotal parathyroidectomy, and less than subtotal parathyroidectomy.ResultsTwenty-one studies incorporating 1,131 patients (272 undergoing total parathyroidectomy, 510 subtotal parathyroidectomy, and 349 less than subtotal parathyroidectomy) were identified. Pooled results revealed increased risk for long-term hypoparathyroidism in total parathyroidectomy patients (relative risk 1.61; 95% confidence interval, 1.12?2.31; P = .009) versus those undergoing subtotal parathyroidectomy. In the less than subtotal parathyroidectomy or subtotal parathyroidectomy comparison group, a greater risk for recurrence of hyperparathyroidism (relative risk 1.37; 95% confidence interval, 1.05?1.79; P = .02), persistence of hyperparathyroidism (relative risk 2.26; 95% confidence interval, 1.49?3.41; P = .0001), and reoperation for hyperparathyroidism (relative risk 2.48; 95% confidence interval, 1.65?3.73; P < .0001) was noted for less than subtotal parathyroidectomy patients, albeit with lesser risk for long-term for hypoparathyroidism (relative risk 0.47; 95% confidence interval, 0.29?0.75; P = .002).ConclusionSubtotal parathyroidectomy compares favorably to total parathyroidectomy, exhibiting similar recurrence and persistence rates with a decreased propensity for long-term postoperative hypoparathyroidism. The benefit of the decreased risk of hypoparathyroidism in less than subtotal parathyroidectomy is negated by the increase in the risk for recurrence, persistence, and reoperation. Future studies evaluating the performance of less than subtotal parathyroidectomy in specific multiple endocrine neoplasia 1 phenotypes should be pursued in an effort to delineate a patient-tailored, operative approach that optimizes long-term outcomes.     

Outcome of lateral pelvic lymph node dissection with total mesorectal excision in treatment of rectal cancer: A systematic review and meta-analysis

BackgroundTotal mesorectal excision is the gold standard treatment of mid- and low-lying rectal cancer. Lateral pelvic lymph node dissection has been suggested as an approach to decrease recurrence and improve survival. Our meta-analysis presented here aimed to review the current outcomes of lateral pelvic lymph node dissection and total mesorectal excision in comparison with total mesorectal excision alone.MethodsA systematic literature search querying electronic databases was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. We reviewed articles that reported the outcomes of lateral pelvic lymph node dissection combined with total mesorectal excision in comparison with total mesorectal excision alone. The main outcome measures were local recurrence, distant metastasis, overall and disease free-survival, and complications.ResultsThis systematic review included 29 studies of 10,646 patients. Of those patients, 39.4% underwent total mesorectal excision with lateral pelvic lymph node dissection. The median operation time for the lateral pelvic lymph node dissection + total mesorectal excision was significantly longer than total mesorectal excision alone (360 minutes versus 294.7 minutes, P = .02). Lateral pelvic lymph node dissection + total mesorectal excision was associated with higher odds of overall complications (odds ratio = 1.48, 95% confidence interval: 1.18–1.87, P < .001) and urinary dysfunction (odds ratio = 2.1, 95% confidence interval: 1.21–3.67, P = .008) than total mesorectal excision alone. Both groups had similar rates of male sexual dysfunction (odds ratio = 1.62, 95% confidence interval: 0.94–2.79, P = .08), anastomotic leakage (odds ratio = 1.15, 95% confidence interval: 0.69–1.93, P = .59), local recurrence (hazard ratio = 0.96, 95% confidence interval: 0.75–1.25, P = .79), distant metastasis (hazard ratio = 0.96, 95% confidence interval: 0.76–1.2, P = .72), overall survival (hazard ratio = 1.056, 95% confidence interval: 0.98–1.13, P = .13), and disease-free survival (hazard ratio = 1.02, 95% confidence interval: 0.97–1.07, P = .37).ConclusionLateral pelvic lymph node dissection was not associated with a significant reduction of recurrence rates or improvement in survival as compared with total mesorectal excision alone; however, LPLND was associated with longer operation time and increased complication rate.     

Medullary thyroid cancer with RET V804M mutation: more indolent than expected?

BackgroundSignificant genotype-phenotype variability among multiple endocrine neoplasia type 2A patients with a RET V804M mutation has been reported.MethodsPatients with a RET V804M mutation treated at a single center were identified (January 1996–December 2020). The baseline characteristics, operative details, pathology, biochemical, and long-term data were analyzed.ResultsThere were 79 patients; none developed pheochromocytoma or hyperparathyroidism or died in the study period. The mean age was 41.5 years (range = 1.0–81.0 years); 46.8% were men. Of 68 surgical patients, 53 (77.9%) underwent total thyroidectomy and 15 (22.1%) underwent total thyroidectomy with central neck dissection with or without lateral neck dissection. Twenty-four patients had elevated preoperative calcitonin, of whom 12 underwent total thyroidectomy (median = 7.5; range = 5.0–237.0 pg/mL), 10 underwent total thyroidectomy + central neck dissection (median = 27.6; range = 5.1–147.0 pg/mL), and 2 underwent total thyroidectomy + central neck dissection + lateral neck dissection (median = 3182.0; range = 361.0–6003.0 pg/mL). Pathology was benign (27.9%), papillary thyroid cancer alone (1.5%), C-cell hyperplasia (23.5%), and medullary thyroid cancer (47.1%; median tumor size = 3.0 mm). Three patients had elevated calcitonin postoperatively (median follow-up time = 60.0 months). In adjusted modeling, a preoperative calcitonin >5 pg/mL was associated with having medullary thyroid cancer on final pathology (odds ratio = 13.3; 95% confidence interval, 3.2–56.3; P < .001).ConclusionIn this large United States cohort of surgical patients with a RET V804M mutation, most had indolent disease and were without classic multiple endocrine neoplasia type 2A features. Calcitonin >5 pg/mL may serve as a meaningful value to guide surveillance and timing of surgery.     

The value of spleen-preserving lymphadenectomy in total gastrectomy for gastric and esophagogastric junctional adenocarcinomas: A long-term retrospective propensity score match study from a high-volume institution in China

BackgroundThe benefit of removing the splenic lymph nodes in patients with proximal gastric cancer has been controversial. The purpose of our study was to investigate the importance of performing a splenic hilar lymph node dissection without splenectomy in patients undergoing total gastrectomy for gastric cancer.MethodsFrom January 2006 to December 2015, we retrospectively reviewed patients who underwent a curative total gastrectomy for gastric cancer. Propensity score matching was used to balance any potential discrepancy of the other covariates between patients with and without splenic hilar lymph node dissection. Survival analysis, Cox univariate and multivariate analysis, and subgroups analysis were conducted to determine the value of splenic hilar lymph node dissection. After matching, 2 nomograms among patients with and without splenic hilar lymph node dissection were established respectively, the C-index, calibration curve and decision curve analysis were used to further evaluate the value of splenic hilar lymph node dissection.ResultsThe rate of metastatic splenic hilar lymph nodes in the 274 patients undergoing splenic hilar lymph node dissection was 16.4% (45/274). Patients undergoing splenic hilar lymph node dissection had better survival outcomes than those not undergoing splenic hilar lymph node dissection before (P = .003) and after (P = .003) propensity score matching. Cox multivariate analysis also confirmed that splenic hilar lymph node dissection was an independent prognostic factor both before (hazard ratio 1.284, 95% confidence interval 1.042–1.583, P = .019) and after (hazard ratio 1.480, 95% confidence interval 1.156–1.894, P = .002) propensity score matching. Subgroup analysis indicted that splenic hilar lymph node dissection offered better survival outcomes for esophagogastric junctional adenocarcinoma (P < .001, P for interaction = .018). After propensity score matching, the nomogram of patients with splenic hilar lymph node dissection (C-index 0.735, 95% confidence interval 0.695–0.774) also indicated a statistically significant advantage compared with that without splenic hilar lymph node dissection (C-index 0.708, 95% confidence interval 0.668–0.748, P < .001).ConclusionOur study suggests that spleen-preserving splenic hilar lymph node dissection should be an essential procedure among patients undergoing total gastrectomy.     

Undertreatment of primary hyperparathyroidism in a privately insured US population: Decreasing utilization of parathyroidectomy despite expanding surgical guidelines

BackgroundPrimary hyperparathyroidism is associated with substantial morbidity, including osteoporosis, nephrolithiasis, and chronic kidney disease. Parathyroidectomy can prevent these sequelae but is poorly utilized in many practice settings.MethodsWe performed a retrospective cohort study using the national Optum de-identified Clinformatics Data Mart Database. We identified patients aged ≥35 with a first observed primary hyperparathyroidism diagnosis from 2004 to 2016. Multivariable logistic regression was used to determine patient/provider characteristics associated with parathyroidectomy.ResultsOf 26,522 patients with primary hyperparathyroidism, 10,101 (38.1%) underwent parathyroidectomy. Of the 14,896 patients with any operative indication, 5,791 (38.9%) underwent parathyroidectomy. Over time, there was a decreasing trend in the rate of parathyroidectomy overall (2004: 54.4% to 2016: 32.4%, P < .001) and among groups with and without an operative indication. On multivariable analysis, increasing age and comorbidities were strongly, inversely associated with parathyroidectomy (age 75–84, odds ratio 0.50 [95% confidence interval 0.45–0.55]; age ≥85, odds ratio 0.21 [95% confidence interval 0.17–0.26] vs age 35–49; Charlson Comorbidity Index ≥2 vs 0 odds ratio 0.62 [95% confidence interval 0.58–0.66]).ConclusionThe majority of US privately insured patients with primary hyperparathyroidism are not treated with parathyroidectomy. Having an operative indication only modestly increases the likelihood of parathyroidectomy. Further research is needed to address barriers to treatment and the gap between guidelines and clinical care in primary hyperparathyroidism.     

Risk factors for breast cancer mortality after ductal carcinoma in situ diagnosis differ from those for invasive recurrence

BackgroundBreast cancer mortality after ductal carcinoma in situ is rare, making it difficult to predict which patients are at risk and to identify whether risk factors for this outcome are the same as those for invasive recurrence. We aimed to identify whether risk factors for invasive recurrences are similar to those for breast cancer death after a diagnosis of pure ductal carcinoma in situ.MethodsThe Surveillance, Epidemiology, and End Results Program was queried for female patients diagnosed with pure ductal carcinoma in situ. Cumulative incidence was estimated by treatment group using competing risks. Competing risks regression was then performed for the development of in-breast invasive recurrence with competing risks of breast and non–breast cancer death. Competing risks regression was then again performed for development of breast cancer mortality with the competing risk of non–breast cancer death.ResultsA total of 29,515 patients were identified. Of them, 164 patients suffered breast cancer mortality without an intervening invasive recurrence, and 44 suffered breast cancer mortality after an invasive in-breast recurrence. On competing risks analysis for invasive in-breast recurrence, significant factors included lesion size >5 cm (hazard ratio = 1.59, 95% confidence interval 1.24–2.04, P < .001), diffuse disease (hazard ratio = 0.0005, 95% confidence interval 0.0003–0.0007, P < .001), other race (hazard ratio = 1.29, 95% confidence interval 1.10–1.52, P = .002), Black race (hazard ratio = 1.21, 95% confidence interval 1.01–1.46, P = .04), age at diagnosis (hazard ratio = 0.99, confidence interval 0.98–1.00, P = .02), low-grade disease (hazard ratio = 0.79, 95% confidence interval 0.64–0.96, P = .02), lumpectomy with radiation (hazard ratio = 0.67, 95% confidence interval 0.58-0.77, P < .001), and mastectomy (hazard ratio = 0.36, 95% confidence interval 0.30–0.44, P < .001). Significant factors for breast cancer mortality included age at diagnosis (hazard ratio = 1.04, 95% confidence interval 1.03–1.05, P < .001), Black race (hazard ratio = 2.88, 95% confidence interval 2.08–3.99, P < .001), diffuse disease (hazard ratio = 6.02, 95% confidence interval 1.39–26.07, P = .02), lumpectomy with radiation (hazard ratio = 0.51, 95% confidence interval 0.36–0.72, P < .001), and mastectomy (hazard ratio = 0.60, 95% confidence interval 0.50–0.92, P = .02).ConclusionOur results suggested that risk factors for in-breast invasive recurrence after a diagnosis of pure ductal carcinoma in situ differ from risk factors for breast cancer mortality and development of metastatic recurrence. In-breast invasive recurrence is not the only consideration for breast cancer specific mortality in ductal carcinoma in situ patients.     

Impact of psychiatric comorbidities on outcomes related to thyroid and parathyroid operations

BackgroundWe examined the effect of psychiatric comorbidities on perioperative surgical outcomes and the leading causes of readmissions in patients who underwent thyroid and parathyroid operations.MethodPatient information was retrieved from the Nationwide Readmission Database (2010–2017). Multivariate analysis was used to identify predictors for hospital readmissions.ResultsA total of 181,007 and 53,808 patients underwent thyroid and parathyroid operations, respectively. Of those, 8,468 (4.7%) and 6,112 (11.4%) patients were readmitted within 30 days. Psychiatric comorbidities were more frequent in readmitted cohorts after thyroidectomies (14.9% vs 10.4%; P < .001) and parathyroidectomies (16.8% vs 11.5%; P < .001), with anxiety being the most frequent cause (thyroid: 7.87%, parathyroid: 6.8%). Psychiatric comorbidities were associated with greater risk of in-hospital mortality (thyroid: odds ratio = 2.07, 95% confidence interval = 1.13–3.53; P = .015 and parathyroid: odds ratio = 1.67, 95% confidence interval = 1.04–2.70; P = .005), postoperative complications (thyroid: odds ratio = 1.528, 95% confidence interval = 1.473–1.585; P < .001 and parathyroid: odds ratio = 3.26, 95% confidence interval = 2.84–3.73; P < .001), prolonged duration of stay (thyroid: beta coefficient = 1.142, 95% confidence interval = 1.076–1.207; P < .001 and parathyroid: beta coefficient = 2.15, 95% confidence interval = 1.976–2.32; P < .001), and 30-day readmissions (thyroid: hazard ratio = 1.18, 95% confidence interval = 1.03–1.18; P = .047 and parathyroid: hazard ratio = 1.23, 95% confidence interval = 1.11–1.36; P < .001). Psychosis had the greatest risk of readmission (thyroid: hazard ratio = 1.51 and parathyroid: hazard ratio = 1.42), and dementia (odds ratio = 2.58) had the greatest risk of postoperative complications.ConclusionConcomitant psychiatric conditions after thyroid and parathyroid operations were associated with increased risk of postoperative complications, prolonged hospital stays, and greater rates of readmissions.     

Predictive factors for discharge destination after total hip arthroplasty

BackgroundThis study aimed to investigate factors affecting discharge to an inpatient rehabilitation facility or home following total hip arthroplasty, using a clinical pathway in Japan.MethodsFive hundred hips with osteoarthritis who underwent unilateral total hip arthroplasty at our institution, with no deviation from the pathway, were included in this retrospective study. The variables were examined by univariate analysis. Multivariate logistic regression analysis was used to identify the independent factors that influenced the discharge outcome.ResultsFour hundred and thirty-four hips were discharged home directly, and 66 were discharged to an inpatient rehabilitation facility. Patients discharged to an inpatient rehabilitation facility were significantly older, shorter, lighter, and more likely to live alone. Additionally, the preoperative clinical score was significantly lower in the inpatient rehabilitation facility Group for all items. Logistic regression analysis showed a significant association between being discharged to an inpatient rehabilitation facility and higher age [odds ratio 3.87, 95% confidence interval 2.03–7.38, P < 0.001], lower total score in the preoperative Japanese Orthopaedic Association hip score [odds ratio 2.42, 95% confidence interval 1.38–4.23, P = 0.002] and living alone [odds ratio 1.84, 95% confidence interval 1.01–3.35, P = 0.046].ConclusionsIn this study, age, the preoperative Japanese Orthopaedic Association hip score, and living arrangement impacted the discharge destination after THA.     

A preoperative estimate of central venous pressure is associated with early Fontan failure

ObjectiveEarly Fontan failure is a serious complication after total cavopulmonary connection, characterized by high central venous pressure, low cardiac output, and resistance to medical therapy. This study aimed to estimate postoperative central venous pressure in patients with total cavopulmonary connection using data routinely collected during preoperative assessment. We sought to determine if this metric correlated with measured postoperative central venous pressure and if it was associated with early Fontan failure.MethodsIn this retrospective study, central venous pressure in total cavopulmonary connection was estimated in 131 patients undergoing pre–total cavopulmonary connection assessment by cardiac magnetic resonance imaging and central venous pressure measurement under general anesthesia. Postoperative central venous pressure during the first 24 hours in the intensive care unit was collected from electronic patient records in a subset of patients. Early Fontan failure was defined as death, transplantation, total cavopulmonary connection takedown, or emergency fenestration within the first 30 days.ResultsEstimated central venous pressure in total cavopulmonary connection correlated significantly with central venous pressure during the first 24 hours in the intensive care unit (r = 0.26, P = .03), particularly in patients without a fenestration (r = 0.45, P = .01). Central venous pressure in total cavopulmonary connection was significantly associated with early Fontan failure (odds ratio, 1.1; 95% confidence interval, 1.01-1.21; P = .03). A threshold of central venous pressure in total cavopulmonary connection 33 mm Hg or greater was found to have the highest specificity (90%) and sensitivity (58%) for identifying early Fontan failure (area under receiver operating curve = 0.73; odds ratio, 12.4; 95% confidence interval, 2.5-62.3; P = .002). This association was stronger in patients with single superior vena cava.ConclusionsEstimated central venous pressure in total cavopulmonary connection is an easily calculated metric combining preoperative pressure and flow data. Higher central venous pressure in total cavopulmonary connection is associated with an increased risk of early Fontan failure and is correlated with directly measured post–total cavopulmonary connection pressure. Identification of patients at risk of early Fontan failure has the potential to guide risk-mitigation strategies.     

Duct stenting versus modified Blalock–Taussig shunt in neonates and infants with duct-dependent pulmonary blood flow: A systematic review and meta-analysis

ObjectiveThe aim of this systematic review and meta-analysis is to evaluate whether duct stenting is associated with better survival and other clinical outcomes compared with the modified Blalock–Taussig shunt in infants with duct-dependent pulmonary flow.MethodsA systematic search of the Medline, Embase, and Cochrane databases was performed by 4 independent reviewers from inception to March 2019. Meta-analysis was performed using the DerSimonian and Laird method with inverse-variance weighting. The quality of evidence was summarized using the Grading of Recommendations, Assessment, Development, and Evaluation framework.ResultsSix comparative observational studies were included, of which 3 were rated low risk of bias. There was no difference in 30-day mortality between the Blalock–Taussig shunt and duct stenting groups (risk ratio, 1.02; 95% confidence interval, 0.46-2.27; P = .96; I² = 0%). However, there was benefit in favor of duct stenting for medium-term mortality (risk ratio, 0.63; 95% confidence interval, 0.40-0.99; P = .05; I² = 0%). Duct stenting demonstrated a reduced risk for procedural complications compared with the Blalock–Taussig shunt (risk ratio, 0.50; 95% confidence interval, 0.31-0.81; P = .005; I² = 0%). However, there was an increased risk for unplanned reintervention for duct stenting (risk ratio, 1.77; 95% confidence interval, 1.39-2.26; P < .00001; I² = 10%). Duct stenting demonstrated shorter mean intensive care unit length of stay (mean difference, ?4.69 days; 95% confidence interval, ?7.30 to ?2.07; P = .0004; I² = 80%), as well as shorter hospital length of stay (mean difference, ?5.78 days; 95% confidence interval, ?9.27 to ?2.28; P = .0009, I² = 75%). The overall quality of evidence was rated low using the Grading of Recommendations, Assessment, Development, and Evaluation framework.ConclusionsDuct stenting demonstrated comparable early mortality, lower medium-term mortality, lower risk of procedural complications, and higher risk of reintervention compared with the Blalock–Taussig shunt.     

Where did the patients go? Changes in acute appendicitis presentation and severity of illness during the coronavirus disease 2019 pandemic: A retrospective cohort study

BackgroundThe coronavirus disease 2019 pandemic restricted movement of individuals and altered provision of health care, abruptly transforming health care-use behaviors. It serves as a natural experiment to explore changes in presentations for surgical diseases including acute appendicitis. The objective was to determine if the pandemic was associated with changes in incidence of acute appendicitis compared to a historical control and to determine if there were associated changes in disease severity.MethodsThe study is a retrospective, multicenter cohort study of adults (N = 956) presenting with appendicitis in nonpandemic versus pandemic time periods (December 1, 2019–March 10, 2020 versus March 11, 2020–May 16, 2020). Corresponding time periods in 2018 and 2019 composed the historical control. Primary outcome was mean biweekly counts of all appendicitis presentations, then stratified by complicated (n = 209) and uncomplicated (n = 747) disease. Trends in presentations were compared using difference-in-differences methodology. Changes in odds of presenting with complicated disease were assessed via clustered multivariable logistic regression.ResultsThere was a 29% decrease in mean biweekly appendicitis presentations from 5.4 to 3.8 (rate ratio = 0.71 [0.51, 0.98]) after the pandemic declaration, with a significant difference in differences compared with historical control (P = .003). Stratified by severity, the decrease was significant for uncomplicated appendicitis (rate ratio = 0.65 [95% confidence interval 0.47–0.91]) when compared with historical control (P = .03) but not for complicated appendicitis (rate ratio = 0.89 [95% confidence interval 0.52–1.52]); (P = .49). The odds of presenting with complicated disease did not change (adjusted odds ratio 1.36 [95% confidence interval 0.83–2.25]).ConclusionThe pandemic was associated with decreased incidence of uncomplicated appendicitis without an accompanying increase in complicated disease. Changes in individual health care–use behaviors may underlie these differences, suggesting that some cases of uncomplicated appendicitis may resolve without progression to complicated disease.     

Does Surgeon Fellowship Training Influence Outcomes in Hemiarthroplasty for Femoral Neck Fracture?

BackgroundThe aim of this study is to compare the outcomes (90 days and 1 year) of patients with femoral neck fracture undergoing hemiarthroplasty by surgeons with different fellowship training: trauma, arthroplasty, and general orthopedics.MethodsThis study is a retrospective review of consecutive patients undergoing hip hemiarthroplasty for femoral neck fracture from 2010 to 2018. Comorbidities, perioperative details, demographics, injury variables, and time-to-surgery were compared between the fellowship training cohorts, in addition to outcomes including dislocation, periprosthetic joint infection, and mortality at 90 days and 1 year.ResultsA total of 298 hips with an average age of 77.8 years underwent hemiarthroplasty for femoral neck fracture. Arthroplasty surgeons had a significantly shorter operative duration (82 minutes, P = .0014) and utilized the anterior approach more frequently (P < .0001). The general orthopedists had a significantly increased total surgical complication risk compared to both the arthroplasty and trauma fellowship-trained cohorts at both 90 days (11.8% vs 1.6% vs 3.9%, P = .015) and 1 year (18.2% vs 4.9% vs 7.1%, P = .008). The overall mortality risk was 11.7% at 90 days and 22.8% at 1 year. When adjusted for covariates, including comorbidities, gender, age, and preoperative walking capacity, both the arthroplasty fellowship-trained cohort (odds ratio 0.381, 95% confidence interval 0.159-0.912, P = .030) and the general orthopedist cohort (odds ratio 0.495; 95% confidence interval 0.258-0.952, P = .035) had reduced risk of 1-year mortality compared to the trauma fellowship-trained cohort.ConclusionHemiarthroplasty performed for femoral neck fractures may result in fewer complications when performed by arthroplasty fellowship-trained surgeons. An arthroplasty weekly on-call schedule and adjusted institutional protocols may be utilized to improve outcomes and reduce complications.Level of EvidenceLevel II, retrospective cohort.     

Routine blood tests as predictors of mortality in hip fracture patients

ObjectiveThe aim of this study was to assess the evidence for the association between different biochemical markers at admission and mortality through a meta-analysis.Data sourcesPubMed-, Embase-, Cochran Library and the Web of Knowledge were searched for cohort studies.Study selectionEligible studies were observational studies with a study population larger than 150 subjects, a mean age above 60 years and a study duration below 730 days.Data extractionCharacteristics of studies and outcomes of all-cause mortality were extracted from the retrieved articles. Data were pooled across studies for the individual biomarker using random- or fixed-effect analysis.Data synthesis15 eligible studies of 5 different markers on mortality were studied. The following markers were found to be of prognostic value on mortality in hip fracture patients: low haemoglobin (odds ratio, 2.78; 95% confidence interval, 2.17–3.55; P < 0.00001, 3148 subjects included), low total lymphocyte count, TLC (odds ratio, 2.60; 95% confidence interval, 1.61–4.20; P < 0.00001, 1689 subjects included), low albumin (odds ratio, 1.83; 95% confidence interval, 1.31–2.56; P = 0.0004, 1680 subjects included), low albumin/low TLC (odds ratio, 3.00; 95% confidence interval, 1.81–4.99; P < 0.0001, 704 subjects included), low albumin/high TLC (odds ratio, 3.39; 95% confidence interval, 1.83–6.29; P = 0.0001, 704 subjects included), high creatinine (odds ratio, 1.58; 95% confidence interval, 1.25–1.99; P = 0.0001, 3761 subjects included), and high PTH (odds ratio, 15.43; 95% confidence interval, 3.60–66.14; P = 0.0002, 525 subjects included).ConclusionBiochemical markers at admission are valid predictors of mortality in hip fracture patients.     

Risk factors for central neck lymph node metastasis of clinically noninvasive,node-negative papillary thyroid microcarcinoma

Background

To examine predictive factors for subclinical central neck lymph node metastases (LNM) of papillary thyroid microcarcinoma (PTMC).

Methods

The clinical and pathological findings of 287 patients with clinically noninvasive, node-negative, solitary papillary thyroid carcinoma (PTC), who had undergone thyroidectomy plus central compartment neck dissection and showed pathologically confirmed nodal metastases, were analyzed. Predictive risk factors for central LNM were quantified.

Results

Pathologic LNM was identified in 63 (32.6%) PTMC patients and 48 (51.0%) PTC patients (tumor size >1 cm; P = .003). Tumor size (>.7 cm; P = .011), multifocality (P = .010), and microscopic extracapsular extension (P = .050) were significant variables predictive of central LNM from PTMC in univariate analysis. Tumor size (odds ratio 2.28, 95% confidence interval 1.19 to 4.38; P = .014) and multifocality (odds ratio 2.38, 95% confidence interval 1.14 to 4.93; P = .020) were independent variables predictive of central LNM in multivariate analysis.

Conclusions

Cervical LNM is highly prevalent in clinically noninvasive, node-negative PTC. Central neck LNM is associated with larger tumor size and multifocality of PTMC.     

Cemented Vs Cementless Femoral Fixation for Total Hip Arthroplasty After Displaced Femoral Neck Fracture: A Nationwide Analysis of Short-Term Complications and Readmission Rates

BackgroundActive patients with displaced femoral neck fractures are often treated with total hip arthroplasty (THA). However, optimal femoral fixation in these patients is controversial. The purpose of this study was to compare early complication and readmission rates in patients with hip fracture treated with THA receiving cemented vs cementless femoral fixation.MethodsThe National Readmissions Database was queried to identify patients undergoing primary THA for femoral neck fracture from 2016 to 2017. Postoperative complications and unplanned readmissions at 30, 90, and 180 days were compared between patients treated with cemented and cementless THA. Univariate and multivariate analyses were performed to compare differences between groups and account for confounding variables.ResultsOf 17,491 patients identified, 4427 (25.3%) received cemented femoral fixation and 13,064 (74.7%) cementless. The cemented group was significantly older (77.2 vs 71.1, P < .001), had more comorbidities (Charlson comorbidity index: 4.44 vs 3.92, P < .001), and had a greater proportion of women (70.5% vs 65.2%, P < .001) compared with the cementless group. On multivariate analysis, cemented fixation was associated with reduced rates of periprosthetic fracture (odds ratio: 0.052, 95% confidence interval: 0.003-0.247, P = .004) at 30 days but similar readmission rates at 30, 90, and 180 days (odds ratio range: 1.012-1.114, P > .05) postoperatively compared with cementless fixation. Cemented fixation was associated with greater odds of medical complications at 180 days postoperatively (odds ratio:: 1.393, 95% confidence interval: 1.042-1.862, P = .025).ConclusionCemented femoral fixation was associated with a lower short-term incidence of periprosthetic fractures, higher incidence of medical complications, and equivalent unplanned readmission rates within 180 days postoperatively compared with cementless fixation in patients undergoing THA for femoral neck fracture.Level of EvidenceLevel III.     

Impact of interhospital transfer on patient outcomes in emergency general surgery

BackgroundEmergency general surgery patients are at an increased risk for morbidity and mortality compared to their elective surgery counterparts. The complex nature of emergency general surgery conditions can challenge community hospitals, which may lack appropriate systems and personnel. Outcomes related to transfer have not been well-established. We aimed to compare postoperative outcomes of patients who were transferred from another hospital to a center with dedicated acute care surgery services with patients admitted directly to the acute care surgery centers.MethodsWe performed a secondary analysis of a national, multicenter review of emergency general surgery patients undergoing complex emergency general surgery at 5 centers across Canada. The primary outcome was the development of any complication. The adjusted odds of postoperative complication was assessed using logistic regression, controlling for age, comorbidities, duration of stay before transfer, American Society of Anesthesiologists classification, and booking priority.ResultsA total of 1,846 patients were included in the study, and 176 (9.5%) were transferred. Of these 21% (n = 37) underwent an operative procedure, and 15% (n = 27) underwent an operation at the transferring center. Transferred patients were more likely to have at least 1 comorbidity (68% vs 57%; P = .004), were classified as greater urgency on arrival (<2 hours booking priority, 43% vs 17%; P < .001), had a greater American Society of Anesthesiologists classification (American Society of Anesthesiologists ≥3 = 81% vs 65%; P < .001), a greater duration of operation (119 vs 110 minutes; P = .004), and were more likely to undergo a second operation (28% vs 14%; P < .001) compared to patients directly admitted to an acute care surgery center. On univariate analysis, transferred patients had greater rates of complications (48% vs 31%; P < .001), mortality (14% vs 7%; P = .005), and admission to the intensive care unit (22% vs 12%; P < .001). Transfer status remained an independent predictor of complication (odds ratio 1.9 [95% confidence interval 1.3–2.7]; P < .001) and intensive care unit admission (odds ratio 1.9 [95% confidence interval 1.2–3.0]; P = .007), but not mortality (odds ratio 1.1 [95% confidence interval 0.6–1.9]; P = .79) on regression analysis.ConclusionComplex emergency general surgery patients transferred to acute care surgery centers may have worse outcomes and greater use of resources compared to those admitted directly. This finding has clinically and financially important implications for the design and regionalization of acute care surgery services as well as resource allocation at acute care surgery centers.     

Effect of prophylactic central neck dissection following total thyroidectomy on surgical site wound infection,hematoma, and haemorrhage in subjects with clinically node-negative papillary thyroid carcinoma: A meta-analysis

We performed a meta-analysis to evaluate the effect of prophylactic central neck dissection following total thyroidectomy on surgical site wound infection, hematoma, and haemorrhage in subjects with clinically node-negative papillary thyroid carcinoma. A systematic literature search up to April 2022 was performed and 3517 subjects with clinically node-negative papillary thyroid carcinoma at the baseline of the studies; 1503 of them were treated with prophylactic central neck dissection following total thyroidectomy, and 2014 were using total thyroidectomy. Odds ratio (OR) with 95% confidence intervals (CIs) were calculated to assess the effect of prophylactic central neck dissection following total thyroidectomy on surgical site wound infection, hematoma, and haemorrhage in subjects with clinically node-negative papillary thyroid carcinoma using the dichotomous method with a random or fixed-effect model. The prophylactic central neck dissection following total thyroidectomy subjects had a significantly lower surgical site wound infection (OR, 0.40; 95% CI, 0.20–0.78, P = .007) in subjects with clinically node-negative papillary thyroid carcinoma compared with total thyroidectomy. However, prophylactic central neck dissection following total thyroidectomy did not show any significant difference in hematoma (OR, 0.08; 95% CI, 0.43–2.71, P = .87), and haemorrhage (OR, 0.72; 95% CI, 0.26–1.97, P = .52) compared with total thyroidectomy in subjects with clinically node-negative papillary thyroid carcinoma. The prophylactic central neck dissection following total thyroidectomy subjects had a significantly higher surgical site wound infection, and no significant difference in hematoma, and haemorrhage compared with total thyroidectomy in subjects with clinically node-negative papillary thyroid carcinoma. The analysis of outcomes should be with caution because of the low number of studies in certain comparisons.     

Predicting endocrine function after total pancreatectomy and islet cell autotransplantation: A novel approach utilizing computed tomography texture analysis

BackgroundIslet cell autotransplantation is an effective method to prevent morbidity associated with type IIIc diabetes after total pancreatectomy. However, there is no valid method to predict long-term endocrine function. Our aim was to assess computed tomography texture analysis as a strategy to predict long-term endocrine function after total pancreatectomy and islet cell autotransplantation.MethodsAll patients undergoing total pancreatectomy and islet cell autotransplantation from 2007 to 2020 who had high-quality preoperative computed tomography imaging available for texture analysis were included. The primary outcome was optimal long-term endocrine function, defined as stable glycemic control with <10 units of insulin/day.ResultsSixty-three patients met inclusion criteria. Median yield was 6,111 islet equivalent/kg body weight. At a median follow-up of 64.2 months, 12.7% (n = 8) of patients were insulin independent and 39.7% (n = 25) demonstrated optimal endocrine function. Neither total islet equivalent nor islet equivalent/kg body weight alone were associated with optimal endocrine function. To improve endocrine function prediction, computed tomography texture analysis parameters were analyzed, identifying an association between kurtosis (odds ratio, 2.32; 95% confidence interval, 1.08–4.80; P = .02) and optimal endocrine function. Sensitivity analysis discovered a cutoff for kurtosis = 0.60, with optimal endocrine function seen in 66.7% with kurtosis ≥0.60, compared with only 26.2% with kurtosis <0.60 (P < .01). On multivariate logistic regression including islet equivalent yield, only kurtosis ≥0.60 (odds ratio, 5.61; 95% confidence interval, 1.56–20.19; P = .01) and fewer small islet equivalent (odds ratio, 1.00; 95% confidence interval, 1.00–1.00; P = .02) were associated with optimal endocrine function, with the whole model demonstrating excellent prediction of long-term endocrine function (area under the curve, 0.775).ConclusionComputed tomography texture analysis can provide qualitative data, that when used in combination with quantitative islet equivalent yield, can accurately predict long-term endocrine function after total pancreatectomy and islet cell autotransplantation.     

Black patients are more likely to undergo parathyroidectomy for secondary hyperparathyroidism

BackgroundPrior studies have demonstrated racial disparities in the severity of secondary hyperparathyroidism among dialysis patients. Our primary objective was to study the racial and socioeconomic differences in the timing and likelihood of parathyroidectomy in patients with secondary hyperparathyroidism.MethodsWe used the United States Renal Data System to identify 634,428 adult (age ≥18) patients who were on maintenance dialysis between 2006 and 2016 with Medicare as their primary payor. Adjusted multivariable Cox regression was performed to quantify the differences in parathyroidectomy by race.ResultsOf this cohort, 27.3% (173,267) were of Black race. Compared to 15.4% of White patients, 23.1% of Black patients lived in a neighborhood that was below a predefined poverty level (P < .001). The cumulative incidence of parathyroidectomy at 10 years after dialysis initiation was 8.8% among Black patients compared to 4.3% among White patients (P < .001). On univariable analysis, Black patients were more likely to undergo parathyroidectomy (adjusted hazard ratio = 1.83; 95% confidence interval, 1.74–1.93). This association persisted after adjusting for age, sex, cause of end-stage renal disease, body mass index, comorbidities, dialysis modality, and poverty level (adjusted hazard ratio = 1.35; 95% confidence interval, 1.27–1.43). Therefore, patient characteristics and socioeconomic status explained 26% of the association between race and likelihood of parathyroidectomy.ConclusionBlack patients with secondary hyperparathyroidism due to end-stage renal disease are more likely to undergo parathyroidectomy with shorter intervals between dialysis initiation and parathyroidectomy. This association is only partially explained by patient characteristics and socioeconomic factors.