Influence of Experience on Performance of Individual Surgeons in Thyroid Surgery: Prospective Cross Sectional Multicentre Study

Objective: To determine the association between surgeons’ experience and postoperative complications in thyroid surgery. Design: Prospective cross sectional multicentre study. Setting: High volume referral centres in five academic hospitals in France. Participants: All patients who underwent a thyroidectomy undertaken by every surgeon in these hospitals from 1 April 2008 to 31 December 2009. Main outcome measures: Presence of two permanent major complications (recurrent laryngeal nerve palsy or hypoparathyroidism), six months after thyroid surgery. We used mixed effects logistic regression to determine the association between length of experience and postoperative complications. Results: 28 surgeons completed 3574 thyroid procedures during a one year period. Overall rates of recurrent laryngeal nerve palsy and hypoparathyroidism were 2.08% (95% confidence interval 1.53% to 2.67%) and 2.69% (2.10% to 3.31%), respectively. In a multivariate analysis, 20 years or more of practice was associated with increased probability of both recurrent laryngeal nerve palsy (odds ratio 3.06 (1.07 to 8.80), P=0.04) and hypoparathyroidism (7.56 (1.79 to 31.99), P=0.01). Surgeons’ performance had a concave association with their length of experience (P=0.036) and age (P=0.035); surgeons aged 35 to 50 years had better outcomes than their younger and older colleagues. Conclusions: Optimum individual performance in thyroid surgery cannot be passively achieved or maintained by accumulating experience. Factors contributing to poor performance in very experienced surgeons should be explored further

First report of bilateral pheochromocytoma in the clinical spectrum of HIF2A-related polycythemia-paraganglioma syndrome.

International audienceCONTEXT: Molecular genetic research has so far resulted in the identification of 10 well-characterized susceptibility genes for hereditary pheochromocytoma (PHEO) or paraganglioma (PGL). Recently, a new syndrome characterized by multiple PGLs and somatostatinomas associated with congenital polycythemia due to somatic mutations in HIF2A has been reported. OBJECTIVE: The aim of the study was to define the genetic defect in a new case of bilateral PHEO and multiple PGLs associated with congenital polycythemia. PATIENT: A female patient presented with neonatal polycythemia (treated by phlebotomies, 1 session approximately every 4 mo), mildly enlarged cerebral ventricles, and bilateral PHEO and multiple PGLs. There was no family history of any neuroendocrine tumor or polycythemia. Surgical removal of the tumors only temporarily normalized plasma erythropoietin (Epo) levels and discontinued phlebotomies. No germline mutations were initially detected in the SDHB, SDHC, SDHD, VHL, and PHD2 genes, known to be associated with polycythemia. The PHEOs presented with a typical noradrenergic biochemical phenotype. RESULTS: A heterozygous missense mutation (c.1589C>T) was identified in exon 12 of HIF2A, resulting in an alanine 530 substitution in the HIF-2α protein with valine (A530V). This somatic mutation was detected in the tissue from 1 PHEO and 1 PGL, with no HIF2A germline mutation found. This mutation led to stabilization of HIF-2α and hence a gain-of-function phenotype, as in previously published studies. CONCLUSION: This case represents the first association of a somatic HIF2A gain-of-function mutation with PHEO and congenital polycythemia, and it alerts physicians to perform proper genetic screening in patients presenting with multiple norepinephrine-producing PHEOs and polycythemia. This report also extends the previous findings of a new syndrome of only multiple PGLs, somatostatinomas, and polycythemia to multiple PHEOs

Medios de comunicación y gobernanza turística en Mar del Plata

Se propone el desarrollo de un proyecto de investigación a través del cual observar el vínculo medios de comunicación local - turismo local, a partir de la indagación del contenido de la información relacionada con el turismo presente en medios de prensa gráfica local, a fin de determinar el papel específico que los mismos juegan en los procesos de gobernanza turística local, como así también, realizar una evaluación integral de la gobernanza turística en Mar del Plata.Fil: Cacciutto, Mariangel. Universidad Nacional de Mar del Plata. Facultad de Ciencias Económicas y Sociales; Argentina.Fil: Roldán, Nadia G. Universidad Nacional de Mar del Plata. Facultad de Ciencias Económicas y Sociales; Argentina.Fil: Castellucci, Daniela I. Universidad Nacional de Mar del Plata. Facultad de Ciencias Económicas y Sociales; Argentina.Fil: Corbo, Yanina A. Universidad Nacional de Mar del Plata. Facultad de Ciencias Económicas y Sociales; Argentina.Fil: Cruz, Gonzalo. Universidad Nacional de Mar del Plata. Facultad de Ciencias Económicas y Sociales; Argentina.Fil: Barbini, Bernarda. Universidad Nacional de Mar del Plata. Facultad de Ciencias Económicas y Sociales; Argentina.Fil: Navarro, Viviana Mariel. Universidad Nacional de la Patagonia Austral; Argentina.Fil: Ferrari, Silvia Noemí. Universidad Nacional de la Patagonia Austral; Argentina

Diagnostic Rechallenge with 18F-FCH PET/CT Often Allows Minimally Invasive Parathyroidectomy While Maintaining Exceptional Cure Rates

International audienc

Risk stratification of adrenal masses by [ 18 F]FDG PET/CT: Changing tactics

International audienc

Surgical performance curves and funnel plots for operative time and postoperative complication.

<p>Perforamnce curves suggested that mean operative time and recurrent laryngeal nerve palsy rate of surgeon A were lower than expected, while surgeon B performance was poorer than what was expected according to his experience (Fig. 1A and 1B). Funnel plots showed that inverse conclusions could be drawn when interpreting outcomes based on either a classical case-mix adjustment or a comprehensive performance adjustment method (i.e. considering both patient’s case-mix and surgeon’s experience). Surgeon A and B had lower and higher operative time, respectively, than the average based on performance adjustment (Fig. 1C). Similar trends were observed for nerve palsy rates (Fig. 1D).</p

Comparison between classical and performance CUSUM charts for recurrent laryngeal nerve palsy.

<p>CUSUM score of recurrent laryngeal nerve palsy for surgeon A crossed the upper limit after 11 procedures on the classical chart (Fig. 3A), whereas it signalled negatively on the performance chart after 89 procedures (Fig. 3B). CUSUM score for surgeon B reached two times the lower limit by the 121st and the 186th procedure on the classical chart (Fig. 3C), whereas it signalled once positively on the performance chart after 61procedures (Fig. 3D).</p

Subject characteristics.

*<p>Exclusion of one participating centre from the recurrent laryngeal nerve palsy analysis.</p