Faculty Bibliography
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112
Underdiagnosis of Primary Hyperparathyroidism-The Need for a System-Level Fix [Comment]
PMID: 32725177
ISSN: 2168-6262
CID: 4787982
The Influence of Cosmetic Concerns on Patient Preferences for Approaches to Thyroid Lobectomy: A Discrete Choice Experiment
PMID: 32204688
ISSN: 1557-9077
CID: 4787922
Anatomic Variations From 120 Mental Nerve Dissections: Lessons for Transoral Thyroidectomy
BACKGROUND:Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a promising technique for eliminating a neck incision. A new risk of TOETVA is the potential for injury to the mental nerves during placement of three oral endoscopic ports. A better understanding of the variations in mental nerve anatomy is needed to inform safer TOETVA technique. MATERIALS AND METHODS/METHODS:We performed 120 dissections of mental nerve branches exiting the mental foramen in 60 human cadavers. Anatomic distances and relationships of the foramen to the midline were evaluated. Mental nerve branching patterns were studied and compared with previously reported classification systems to determine surgical safe zones free of nerve branches. RESULTS:The mean midline-to-mental foramen distance was 29.2 ± 3.3 mm, with high variability across individuals (18.8-36.8 mm). There were differences in this distance between the left and right foramina (29.8 ± 3.2 versus 28.8 ± 3.3 mm, P = 0.03). All mental nerve branches exiting the mental foramen distributed medially. The branching patterns were classified into eight distinct categories, three of which are previously undescribed. One of these novel patterns, occurring in 9.2% of cases, had a dense and wide clustering of branches traveling toward the midline. CONCLUSIONS:The location of the mental foramen and mental nerve branching patterns demonstrate high variability. To avoid mental nerve injury in TOETVA, we identify a safe zone for lateral port placement lateral to the plane of the mental foramen. Placement and extension of the middle port incision should proceed with caution, as clustering of mental nerve branches in this area can frequently be present.
PMID: 32799003
ISSN: 1095-8673
CID: 4787992
A model for the institutional adoption of innovative surgical techniques
BACKGROUND:Surgeons have the responsibility to continuously enhance surgical practice. Standardized processes for institutions to validate and approve the introduction of innovative surgical techniques do not exist. The objective of this work was to develop a model for the introduction of innovative surgical techniques, which assists the innovating surgeons and institution with safe implementation. METHOD:A staged model for the institutional introduction of innovative surgical techniques was developed. Relevant concepts were introduced and defined, a framework for preparation and implementation was established, and an oversight structure was delineated. RESULTS:Systematic literature review and expert opinion revealed broad agreement on the core principles and theory of surgical innovation, but also noted a lack of specific processes. Our efforts aimed to both codify principles and provide a model for specific, best-practice workflows. Important concepts and outputs included: (1) appropriate definition of a sufficiently "new technique" requiring oversight; (2) the appropriate groundwork to be performed to plan for the implementation of the new technique; (3) patient-facing responsibilities, including informed consent; and (4) division of the introduction/adoption process into defined phases, starting from initial discovery and preparation to piloting and transition to standard practice, each with distinct, phase-specific tasks. CONCLUSION:We present a generalizable framework for approaching the safe introduction and adoption of innovative surgical techniques.
PMID: 32376046
ISSN: 1532-7361
CID: 4787932
Reducing Opioid Use in Endocrine Surgery Through Patient Education and Provider Prescribing Patterns
BACKGROUND:Postoperative opioid use can lead to dependence, contributing to the opioid epidemic in the United States. New persistent opioid use after minor surgeries occurs in 5.9% of patients. With increased documentation of persistent opioid use postoperatively, surgeons must pursue interventions to reduce opioid use perioperatively. METHODS:We performed a prospective cohort study to assess the feasibility of a preoperative intervention via patient education or counseling and changes in provider prescribing patterns to reduce postoperative opioid use. We included adult patients undergoing thyroidectomy and parathyroidectomy from January 22, 2019 to February 28, 2019 at a tertiary referral, academic endocrine surgery practice. Surveys were administered to assess pain and patient satisfaction postoperatively. Prescription, demographic, and comorbidity data were collected from the electronic health record. RESULTS:Sixty six patients (74.2% women, mean age 58.6 [SD 14.9] y) underwent thyroidectomy (n = 35), parathyroidectomy (n = 24), and other cervical endocrine operations (n = 7). All patients received a preoperative educational intervention in the form of a paper handout. 90.9% of patients were discharged with prescriptions for nonopioid pain medications, and 7.6% were given an opioid prescription on discharge. Among those who received an opioid prescription, the median quantity of opioids prescribed was 135 (IQR 120-150) oral morphine equivalents. On survey, four patients (6.1%) reported any postoperative opioid use, and 94.6% of patients expressed satisfaction with their preoperative education and postoperative pain management. CONCLUSIONS:Clear and standardized education regarding postoperative pain management is feasible and associated with high patient satisfaction. Initiation of such education may support efforts to minimize unnecessary opioid prescriptions in the population undergoing endocrine surgery.
PMCID:7855097
PMID: 32712445
ISSN: 1095-8673
CID: 4787972
Breast and cervical cancer screening for risk assessment in Cambodian women
The estimated mortality rates for breast and cervical cancer in Cambodia are high, perhaps because the Cambodian population lacks information about their detection and prevention. This cross-sectional study assessed the distribution of cervical cancers among and the behavioural and clinical characteristics of Cambodian women. It comprised 1039 Cambodian women who were interviewed between August 2013 and January 2016; the interviews were conducted in person using structured questionnaires. Among the participants, 801 (77.2%) and 709 (68.3%) had heard of cervical cancer and cervical cancer detection tests, respectively. However, 830 (80.2%) had never undergone a Pap smear, and 633 (60.9%) had never heard of breast self-examination. Despite the high mortality rates for breast and cervical cancer in Cambodia, only a small percentage of the participants had risk factors (e.g. smoking, alcohol consumption) for female cancers. A nationwide survey of the knowledge, attitudes and practices related to female cancers is recommended.Impact StatementWhat is already known on this subject? The estimated incidence and mortality rates of breast and cervical cancers in Cambodia are high. How much Cambodian women know about these cancers and whether they are receptive to cancer screening are questions requiring further study.What do the results of this study add? To our knowledge, this is the first study to describe the female cancer-related behavioural and clinical characteristics of Cambodian women. We show that rural Cambodian women are mostly unaware of breast and cervical cancer screening and that only a small percentage had risk factors for these cancers, despite the high incidence of these cancers in Cambodia.What are the implications of these findings for clinical practice and/or further research? Our findings potentially aid the design of programmes that increase awareness of breast and cervical cancers in Cambodia. Such programmes would be expected to reduce the incidence and mortality rates of these cancers in this country. Nationwide screening programmes for female cancers should be implemented in Cambodia.
PMID: 32091288
ISSN: 1364-6893
CID: 4787912
PTH hypersecretion triggered by a GABAB1 and Ca2+-sensing receptor heterocomplex in hyperparathyroidism
Molecular mechanisms mediating tonic secretion of parathyroid hormone (PTH) in response to hypocalcaemia and hyperparathyroidism (HPT) are unclear. Here we demonstrate increased heterocomplex formation between the calcium-sensing receptor (CaSR) and metabotropic γ-aminobutyric acid (GABA) B1 receptor (GABAB1R) in hyperplastic parathyroid glands (PTGs) of patients with primary and secondary HPT. Targeted ablation of GABAB1R or glutamic acid decarboxylase 1 and 2 in PTGs produces hypocalcaemia and hypoparathyroidism, and prevents PTH hypersecretion in PTGs cultured from mouse models of hereditary HPT and dietary calcium-deficiency. Cobinding of the CaSR/GABAB1R complex by baclofen and high extracellular calcium blocks the coupling of heterotrimeric G-proteins to homomeric CaSRs in cultured cells and promotes PTH secretion in cultured mouse PTGs. These results combined with the ability of PTG to synthesize GABA support a critical autocrine action of GABA/GABAB1R in mediating tonic PTH secretion of PTGs and ascribe aberrant activities of CaSR/GABAB1R heteromer to HPT.
PMCID:7377265
PMID: 32694772
ISSN: 2522-5812
CID: 4787962
Incidence Patterns of Adrenocortical Carcinomas and Malignant Pheochromocytomas and Paragangliomas in California [Meeting Abstract]
ISI:000526823600096
ISSN: 0885-3177
CID: 4788152
Technical Innovation in Transoral Endoscopic Endocrine Surgery: A Modified "Scarless" Technique
BACKGROUND:The transoral endoscopic approach to thyroidectomy aims to eliminate a visible neck incision. Early experience has demonstrated promising safety and efficacy results but has uncovered unique drawbacks from the middle oral incision. We present a case series of our institutional experience with a technical innovation called the TransOral and Submental Technique (TOaST) designed to address these limitations. MATERIALS AND METHODS:We reviewed all patients who successfully underwent TOaST thyroidectomy at our institution from November 2017 to November 2018. Demographics, surgical indications, technical details, and perioperative outcomes were recorded in a prospective database and analyzed retrospectively. RESULTS:Fourteen patients underwent TOaST thyroidectomy, with mean follow-up of 17Â wk. Mean age was 38Â y, and all but one was female. Most cases were cytologically benign or indeterminate nodules. There were no injuries to the recurrent laryngeal or mental nerves. TOaST had no instances of chin pain or specimen disruption, two complications that have been associated with the standard transoral approach. The cosmetic outcomes remained excellent. CONCLUSIONS:This pilot study of TOaST indicates that it is a technically feasible and safe approach to thyroidectomy for selected patients.
PMID: 31174063
ISSN: 1095-8673
CID: 4787892
Postoperative Pain and Opioid Use After Thyroid and Parathyroid Surgery-A Pilot, Prospective SMS-Based Survey
BACKGROUND:New persistent opioid use has been identified following minor surgical procedures and may contribute to the national opioid epidemic. Prescription patterns vary and we have limited data on patient pain experiences in the outpatient setting. We devised a novel short messaging service survey to record pain scores and opioid use following outpatient thyroid or parathyroid surgery. MATERIALS AND METHODS:Automated short messaging service was sent daily starting the evening of the operation until postoperative day (POD) 10. Pain was assessed on a 0-10 numeric pain rating scale and opioid use over the prior 24 h was queried. RESULTS:A total of 1264 survey questions were sent with overall response rate of 84.3%. Fifty-three of 58 patients had a response rate >50% and were included in the final analysis. Average pain score was highest on POD1 at 3.2. Overall, 42.5% of patients utilized opioids on POD0, 55.6% on POD1, and steadily decreased to 7% by POD10. Overall, 34% of patients did not utilize any opioids postoperatively. Scaled total pain scores were higher in patients with thyroid surgery (23.5 versus 12.1, P = 0.02) and lower in those who reported alcohol use (14.9 versus 31.6, P < 0.02). Scaled total opioid days were lower in those aged >60 (1.5 versus 3.6, P < 0.01) and higher in those with active tobacco use (4.5 versus 2.3, P = 0.04). Pain scores correlated weakly with total opioid days (r = 0.32). CONCLUSIONS:We demonstrate a novel approach of obtaining patient reported daily, prospective pain scores. This may help us understand patient pain and opioid use in the acute postoperative period especially following outpatient surgery.
PMID: 31004971
ISSN: 1095-8673
CID: 4787872
