High-volume endocrine surgeons perform thyroid surgery at decreased cost despite increased case relative value units

BACKGROUND: Healthcare systems are transitioning to value-based payment models based on analysis of quality over cost. To gain an understanding of the relationship between surgeon volume and health care costs, we compared the direct costs of thyroidectomy performed by dedicated high-volume endocrine surgeons and low-volume surgeons within a large health care system. METHODS: We evaluated all thyroid surgeries performed within a single billing year at a single health care system. We defined high-volume surgeons as those who treated \u3e50 thyroid cases yearly and compared them to low-volume surgeons. To account for multicomponent procedures, we added the relative value units for the components of the cases. Then, we divided them into low-relative value units, intermediate-relative value units, and high-relative value units groups. We analyzed categorical and continuous variables using the χ analysis and Wilcoxon rank sum test, respectively. RESULTS: We identified 674 thyroidectomy procedures performed by 27 surgeons, of whom 6 high-volume surgeons performed 79% of cases. Relative value unit distribution differed between the groups, with high-volume surgeons performing more intermediate-relative value unit (58% vs 34.7%, P \u3c .01) and high-relative value unit (24.6% vs 20.6%, P \u3c .01) cases, whereas low-volume surgeons performed more low-relative value unit cases (45% vs 17%, P \u3c .01). Overall, high-volume surgeons incurred a 26% reduction in total costs (P \u3c .01) and a 33% reduction in discretionary expenses (P \u3c .01) across all relative value unit groups. CONCLUSION: High-volume endocrine surgeons perform thyroid procedures at a lower cost than their low-volume counterparts, a difference that is magnified when stratified by relative value unit groups

Development of a machine learning model for the diagnosis of atypical primary hyperparathyroidism

Background: Atypical primary hyperparathyroidism (PHPT), which includes normocalcemic and normohormonal variants, can be a diagnostic challenge. We sought to create a machine learning model to predict the probability of a patient having atypical presentations of PHPT. Methods: A model was constructed using logistic regression of PHPT patients and were compared to controls. Variables included sex, body mass index (BMI), calcium, PTH, 25-hydroxyvitamin D, phosphorus, chloride, sodium, alkaline phosphatase, and creatinine. The performance of the model was evaluated using the area under the curve (AUC). Results: The study included 4987 controls and 433 patients with atypical PHPT. Calcium, PTH, vitamin D, phosphorus, BMI, and sex were found to significantly contribute to the performance of the model, achieving an AUC of 0.999. The sensitivity, specificity, positive and negative predictive values were 92.9 %, 99.7 %, 96.3 % and 99.4 %, respectively. Conclusion: Machine learning can reliably aid in the recognition of PHPT in patients with atypical variants. Clinical relevance: When evaluating patients with atypical variants of primary hyperparathyroidism, the clinician needs to be able to identify subtle relationships in the patient laboratory test to make the diagnosis. These relationships can be found with machine learning and incorporated to predictive models which can ease and improve the diagnosis

Intestinal Lymphangiectasia: Insights on Management and Literature Review

Patient: Male, 24 Final Diagnosis: Intestinal lymphangiectasia Symptoms: Frequent episodes of diarrhea • recurrent infections • swelling in the lower limbs Medication: Octreotide • MCT oils Clinical Procedure: Endoscopic exam • Doppler ultrasound study • abdominal CT scan Specialty: Gastroenterology and Hepatology Objective: Rare disease Background: Intestinal lymphangiectasia (IL) is a rare disease characterized by a dilatation of the intestinal lymphatics and loss of lymph fluid into the gastrointestinal tract leading to hypoproteinemia, edema, lymphocytopenia, hypogammaglobinemia, and immunological abnormalities. Iron, calcium, and other serum components (e.g., lipids, fat soluble vitamins) may also be depleted. A literature search revealed more than 200 reported cases of IL. Herein, we report our observations of a patient diagnosed with IL; we also present our conclusion for our review of the published literature. Case Report: A 24-year-old male was admitted to Aleppo University Hospital with the complaints of abdominal pain, headache, arthralgia, fever, and rigors. His past medical history was remarkable for frequent episodes of diarrhea, recurrent infections, and swelling in the lower limbs. In addition, he had been hospitalized several times in non-academic hospitals due to edema in his legs, cellulitis, and recurrent infections. In the emergency department, a physical examination revealed a patient in distress. He was weak, dehydrated, pale, and had a high-grade fever. His lower extremities were edematous, swollen, and extremely tender to touch. The overlying skin was erythematous and warm. Moreover, the patient was tachycardic, tacypneic, and moderately hypotensive. The patient was resuscitated with IV fluids, and Tylenol was administered to bring the temperature down. Blood tests showed anemia and high levels of inflammatory markers. The patient’s white blood cell count was elevated with an obvious left shift. However, subsequent investigations showed that the patient had IL. Suitable diet modification plans were applied as a long-term management plan. Conclusions: IL is a rare disease of challenging nature due to its systematic effects and lack of comprehensive studies that can evaluate the effectiveness of specific treatments in a large cohort of patients. Medium-chain triglyceride (MCT) oils and diet modification strategies are effective in reducing the loss of body proteins and in maintaining near-normal blood levels of immunoglobulins. However, octreotide and MCT oils had no proven role in reducing lymphedema in our patient

Zollinger-Ellison Syndrome Associated with von Recklinghausen Disease: Case Report and Literature Review

Patient: Female, 28 Final Diagnosis: Gastrinoma Symptoms: Vomiting • diarrhea • epigastric soreness • heartburn • nausea • significant weight loss Medication: — Clinical Procedure: Esophagogastroduodenoscopy • blood tests • abdomen CT scan • surgery Specialty: Gastroenterology and Hepatology Objective: Rare co-existance of disease or pathology Background: Pancreatic endocrine tumors (PETs) are rare and can occur as part of neurofibromatosis type 1 (NF1). Gastrinomas are functional PETs that are rarely associated with NF1. Only two cases of their occurrence have been reported in the literature. Case Report: A 28-year-old woman was admitted for further evaluation of epigastric soreness, heartburn, nausea, vomiting, diarrhea, and a significant weight loss. Physical examination was remarkable for cutaneous findings (axillary freckling and multiple café-au-lait spots) as well as neurofibromas (dermal, plexiform). A diagnosis of NF1 was confirmed. Esophagogastroduodenoscopy (EGD) revealed multiple ulcers in the duodenum and the upper jejunum. A fasting gastrin level exceeded ten times the normal limit. An abdominal multi-slice 128 computed tomography (CT) scan revealed an oval mass of 26 mm in diameter adjacent to the second segment of the duodenum. The patient was examined carefully to rule out multiple endocrine neoplasia type 1 (MEN1). Surgical resection was performed and a gastrinoma, causing Zollinger-Ellison syndrome (ZES), was diagnosed by histological examinations of the extirpated mass. The serum gastrin level decreased to normal limits shortly after surgery. Continuous follow-up revealed that the symptoms and the EGD findings completely resolved without recurrences. Conclusions: Although NF1 has common skeletal, visual, neurological, and cardiovascular complications, it also has a rare association with duodenal or pancreatic gastrinomas. Vigilance for this possible association is important to promote timely and careful management to help eliminate serious and potentially life-threatening complications

Transoral thyroidectomy and parathyroidectomy \ue2\u80\u93 A North American series of robotic and endoscopic transoral approaches to the central neck

Objective Most thyroid surgery in North America is completed via a cervical incision, which leaves a permanent scar. Approaches without cutaneous incisions offer aesthetic advantages. This series represents the largest series of transoral vestibular approaches to the central neck in North America, and the first published reports of robotic transoral vestibular thyroidectomy for thyroid carcinoma. Materials and methods Data was prospectively collected for patients that underwent transoral vestibular approach thyroidectomy and/or parathyroidectomy between April 2016 and February 2017. Results Fifteen patients underwent the procedure for removal of the thyroid (n\uc2\ua0=\uc2\ua012), parathyroid (n\uc2\ua0=\uc2\ua02) or both thyroid and parathyroid glands (n\uc2\ua0=\uc2\ua01). The first case was converted to an open procedure. Fourteen were completed through these remote access incisions, including patients with a body mass index as high as 44. There were no permanent complications. The postoperative median Dermatology Life Quality Index score was 3, which indicates a small effect on quality of life. Conclusion The transoral vestibular approach to the central neck is a promising technique for patients who desire to optimize aesthetics

Free Flap Reconstruction Monitoring Techniques and Frequency in the Era of Restricted Resident Work Hours

Importance: Free flap reconstruction of the head and neck is routinely performed with success rates around 94% to 99% at most institutions. Despite experience and meticulous technique, there is a small but recognized risk of partial or total flap loss in the postoperative setting. Historically, most microvascular surgeons involve resident house staff in flap monitoring protocols, and programs relied heavily on in-house resident physicians to assure timely intervention for compromised flaps. In 2003, the Accreditation Council for Graduate Medical Education mandated the reduction in the hours a resident could work within a given week. At many institutions this new era of restricted resident duty hours reshaped the protocols used for flap monitoring to adapt to a system with reduced resident labor. Objectives: To characterize various techniques and frequencies of free flap monitoring by nurses and resident physicians; and to determine if adapted resident monitoring frequency is associated with flap compromise and outcome. Design, Setting, and Participants: This multi-institutional retrospective review included patients undergoing free flap reconstruction to the head and/or neck between January 2005 and January 2015. Consecutive patients were included from different academic institutions or tertiary referral centers to reflect evolving practices. Main Outcomes and Measures: Technique, frequency, and personnel for flap monitoring; flap complications; and flap success. Results: Overall, 1085 patients (343 women [32%] and 742 men [78%]) from 9 institutions were included. Most patients were placed in the intensive care unit postoperatively (n = 790 [73%]), while the remaining were placed in intermediate care (n = 201 [19%]) or in the surgical ward (n = 94 [7%]). Nurses monitored flaps every hour (q1h) for all patients. Frequency of resident monitoring varied, with 635 patients monitored every 4 hours (q4h), 146 monitored every 8 hours (q8h), and 304 monitored every 12 hours (q12h). Monitoring techniques included physical examination (n = 949 [87%]), handheld external Doppler sonography (n = 739 [68%]), implanted Doppler sonography (n = 333 [31%]), and needle stick (n = 349 [32%]); 105 patients (10%) demonstrated flap compromise, prompting return to the operating room in 96 patients. Of these 96 patients, 46 had complete flap salvage, 22 had partial loss, and 37 had complete loss. The frequency of resident flap checks did not affect the total flap loss rate (q4h, 25 patients [4%]; q8h, 8 patients [6%]; and q12h, 8 patients [3%]). Flap salvage rates for compromised flaps were not statistically different. Conclusions and Relevance: Academic centers rely primarily on q1h flap checks by intensive care unit nurses using physical examination and Doppler sonography. Reduced resident monitoring frequency did not alter flap salvage nor flap outcome. These findings suggest that institutions may successfully monitor free flaps with decreased resident burden