Early Identification of Individuals with Poorly Controlled Diabetes Undergoing Elective Surgery: Improving A1c Testing in the Preoperative Period

ObjectiveTo describe a process improvement strategy that increased the identification of individuals with poorly controlled diabetes (glycated hemoglobin [A1C] ≥ 8%) undergoing elective surgery at a major academic medical center and increased their access to specialist care.MethodsAn algorithm was developed to ensure A1C measurements were obtained as per the American Association of Clinical Endocrinologists/American Diabetes Association (AACE/ADA) guidelines. The diabetes management team worked collaboratively with anesthesiologists, surgeons, and preoperative nurse practitioners to improve the glycemic control of patients with an A1C ≥ 8%.ResultsBefore implementing the program, A1C testing was recorded in 854 out of 2,335 (37%) patients with diabetes seen in the preoperative clinic from January 1, 2011 to December 31, 2012. The program was instituted in February 2013. From February 2013 to February 2014, A1C testing occurred in 1,236 out of 1,334 (93%) patients with diabetes. After excluding those scheduled for same day surgery, 228 patients were considered high risk with A1C ≥ 8%, and 175 were available for endocrine preoperative consultation. The program led to significant blood glucose level improvements on the day of surgery.ConclusionA process improvement strategy to evaluate and treat diabetes in the preoperative period of elective surgery patients was implemented by a multidisciplinary team (endocrinologists, nurse practitioners, anesthesiologists, and surgeons) and resulted in a substantial improvements in obtaining A1C tests, access to specialist diabetes care, and glycemic control on the day of surgery. The impact of improved glycemic control on hospital and surgical outcomes needs further evaluation. (Endocr Pract. 2015;21:231-236)     

Reducing the risk of major elective surgery: randomised controlled trial of preoperative optimisation of oxygen delivery

ObjectivesTo determine whether preoperative optimisation of oxygen delivery improves outcome after major elective surgery, and to determine whether the inotropes, adrenaline and dopexamine, used to enhance oxygen delivery influence outcome.DesignRandomised controlled trial with double blinding between inotrope groups.SettingYork District Hospital, England.Subjects138 patients undergoing major elective surgery who were at risk of developing postoperative complications either because of the surgery or the presence of coexistent medical conditions.InterventionsPatients were randomised into three groups. Two groups received invasive haemodynamic monitoring, fluid, and either adrenaline or dopexamine to increase oxygen delivery. Inotropic support was continued during surgery and for at least 12 hours afterwards. The third group (control) received routine perioperative care.ResultsOverall, 3/92 (3%) preoptimised patients died compared with 8/46 controls (17%) (P=0.007). There were no differences in mortality between the treatment groups, but 14/46 (30%) patients in the dopexamine group developed complications compared with 24/46 (52%) patients in the adrenaline group (difference 22%, 95% confidence interval 2% to 41%) and 28 patients (61%) in the control group (31%, 11% to 50%). The use of dopexamine was associated with a decreased length of stay in hospital.ConclusionRoutine preoperative optimisation of patients undergoing major elective surgery would be a significant and cost effective improvement in perioperative care.

Key messages

• Major elective surgery in UK general hospitals still carries significant mortality and morbidity
• Preoperative administration of fluid and inotropes, guided by invasive monitoring, can significantly reduce mortality, morbidity, and length of hospital stay
• The choice of inotrope may influence the extent of improvements in outcome
• Routine preoperative optimisation would require initial investment in high dependency care facilities but is likely to be cost effective by reducing complications and length of hospital stay

     

Health-related quality of life following ambulatory surgery procedures: assessment by RAND-36

Background

Increasing numbers of elective surgical procedures are performed as day-cases. The impact of ambulatory surgery on health-related quality of life in the recovery period has seldom been described.

Methods

We assessed health-related quality of life in 143 adult outpatients scheduled for arthroscopic procedures of the knee and shoulder joints, laparoscopic cholecystectomy and inguinal hernia repair using the RAND 36-Item Health Survey preoperatively and one week after patients had returned to work or comparable normal daily routines.

Results

Postoperatively all patient groups reported significant improvements in bodily pain and vitality. Physical functioning improved significantly in orthopedic and inguinal hernia patients. However, in the orthopedic groups, postoperative scores for physical health were still relatively lower compared to the general population reference values.

Conclusions

Ambulatory surgery has a positive impact on health-related quality of life. Assessment of the recovery process is necessary for recognition of potential areas of improvement in care and postoperative rehabilitation.

     

Changes in lung volume parameters regarding the received dose in the lobes of the lungs after locoregional radiotherapy of breast cancer

AimThe purpose of this study was to evaluate ΔLVP¹ and correlate them with MLD² and V20³ in the lobes of the lung.BackgroundRadiation-induced lung injury after breast irradiation is controversial. The incidence of such an injury could have negative consequences on breast cancer patients.Materials and MethodsTwenty-three women treated with Breast-conserving surgery, chemotherapy, and locoregional RT⁴ underwent body plethysmography pre-RT and 3 and 6 months post-RT. Statistical analysis was used to evaluate ΔLVP over time and relate them with MLD, V20, age, and concurrent hormonal therapy.ResultsLVP decreased after 3 months and then showed a slight improvement by returning partially to their pre-RT values after 6 months. The mean ΔLVP was −0.64% for one Gy increase of MLD and −0.34% for one percent increase of V20 after 3 months. After 6 months, only ΔVC⁵ showed 0.45% reduction with MLD in the upper lobe. Finally, there was no significant correlation between ΔLVP with respect to age and concurrent hormonal therapy.ConclusionsThe results of this study showed that lung volume changes were not a cause for concern in breast cancer patients. There are three reasons to support this conclusion. Lung volume changes and percentage reductions in LVP for each Gy increase of MLD and each percentage increase of V20 in each lobe were small; patients were asymptomatic during the follow-up period; and LVP showed partial improvements after 6 months.     

Age differences in presentation,diagnosis pathway and management of colorectal cancer

BackgroundThe gap in survival between older and younger European cancer patients is getting wider. It is possible that cancer in the elderly is being managed or treated differently than in their younger counterparts. This study aims to explore age disparities with respect to the clinical characteristics of the tumour, diagnostic pathway and treatment of colorectal cancer patients.MethodsWe conducted a multicenter cross sectional study in 5 Spanish regions. Consecutive incident cases of CRC were identified from pathology services. Measurements: From patient interviews, hospital and primary care clinical records, we collected data on symptoms, stage, doctors investigations, time duration to diagnosis/treatment, quality of care and treatment.Results777 symptomatic cases, 154 were older than 80 years. Stage was similar by age group. General symptoms were more frequent in the eldest and abdominal symptoms in the youngest. No differences were found regarding perception of symptom seriousness and symptom disclosure between age groups as no longer duration to diagnosis or treatment was observed in the oldest groups. In primary care, only ultrasound is more frequently ordered in those <65 years. Those >80 years had a significantly higher proportion of iron testing and abdominal XR requested in hospital. We observed a high resection rate independently of age but less adjuvant chemotherapy in Stage III colon cancer, and of radiotherapy in stage II and III rectal cancer as age increases.ConclusionThere are no relevant age disparities in the CRC diagnosis process with similar stage, duration to diagnosis, investigations and surgery. However, further improvements have to be made with respect to adjuvant therapy.     

Preoperative Ultrasonography Findings Predict the Need for Repeated Surgery in Papillary Thyroid Cancer

ObjectiveTo determine the impact of neck ultrasonography in predicting papillary thyroid cancer persistence or recurrence.MethodsBetween March 2005 and March 2009, we identified patients with a preoperative diagnosis of papillary thyroid cancer. Exclusion criteria included no documented preoperative ultrasonography and initial surgery at an outside institution. Patients with positive preoperative ultrasonography were compared with patients who had negative preoperative ultrasonography by assessing rates of neck dissection, complications, disease persistence or recurrence, and the need for repeated surgery.Results:Of 127 patients initially identified, 16 did not have preoperative ultrasonography and 4 did not have their initial surgery at our institution, leaving 107 patients in our cohort. Twenty-two patients had positive preoperative ultrasonography and 85 patients had negative preoperative ultrasonography. Patients with positive preoperative ultrasonography had a higher rate of repeated surgery than those with negative preoperative ultrasonography (27% vs 4.7%, P = .003). There was no difference in postoperative complication rates. No patients with negative preoperative ultrasonography and an ultrasound report stating specifically “no suspicious lymph nodes” required repeated surgery.ConclusionsNegative preoperative ultrasonography with specific lymph node evaluation predicts a low risk of needing early reoperation. Positive preoperative ultrasonography may be a marker for more aggressive disease and the best predictor of the need for additional surgery in the future. (Endocr Pract. 2012;18:403-409)     

Effective Long-Term Treatment of Cushing’s Disease with Pasireotide: A Case Report

ObjectiveCushing’s disease is a rare, devastating condition associated with high morbidity and increased mortality. Primary treatment for Cushing’s disease is transsphenoidal surgery to remove the pituitary adenoma; however, recurrence can occur in up to 25% of patients. Second-line medical therapies do not directly target the pituitary tumor. Thus, normalization of adrenocorticotropic hormone (ACTH) and inhibition of tumor growth is not usually achieved.MethodsIn this case report, we present a de novo patient with a pituitary macroadenoma who was randomized to receive treatment with subcutaneous twice-daily injections of pasireotide 900 μg as part of the double-blind, Phase III CSOM230B2305 clinical trial.ResultsAround one month after treatment initiation, the patient’s urinary free cortisol (UFC) level showed a dramatic reduction (from 151.1 to 7.4 μg/24h) necessitating a dose reduction to 600 μg to relieve the symptoms of corticosteroid withdrawal. One month after dose reduction, the patient’s UFC levels remained stable and were associated with improvements in clinical signs and symptoms. These improvements continued into the 12-month extension phase following a dose increase to 900 μg and were accompanied by a significant reduction in tumor volume (from 0.797 cm³ at baseline to 0.359 and 0.365 cm³ at months 18 and 24, respectively). UFC remained normalized throughout the extension period. During the study, the patient developed hyperglycemia, which was effectively controlled with diet and then medication.ConclusionIn this case study, long-term pasireotide treatment as first-line therapy led to normalization of UFC, reduction of tumor volume and significant improvement in the clinical signs and symptoms of Cushing’s disease. (Endocr. Pract. 2013;19:e92-e96)     

Gender Differences in Questions Asked in an Online Preoperative Patient Education Program

BackgroundAlthough osteoarthritis more commonly affects women than men, women are 3 times less likely to undergo hip or knee replacement surgery compared with men. Disparity in the appropriate utilization of surgery between men and women is a complex subject that must take into account the willingness of a patient to proceed with the operation. Adequately addressing patient concerns before surgery may influence such willingness.ObjectiveWe examined if a gender difference can be identified in the frequency and types of questions submitted by patients scheduled for total hip or total knee arthroplasty.MethodsPatients completed an online interactive preoperative educational program and a database was created containing deidentified information on surgical procedure, sex, year of birth, and any questions that were submitted. Data were also available regarding the total number of patients issued the program, the number of patients who started the program, and the number of patients who completed the program. The results were analyzed by Wilcoxon rank sum test. P values ≤0.05 were considered statistically significant.ResultsAmong the 2770 women and 1708 men included in the study, 935 (34%) and 462 (27%) asked at least 1 question, respectively. Compared with men, women asked a significantly greater number of questions overall (P < 0.001). Women also asked a significantly greater number of questions in the categories Your Condition (P = 0.031), Your Procedure (P < 0.001), and Risks and Benefits (P < 0.001).ConclusionsGender differences in concerns and physicians' ability to adequately address these concerns may contribute to disparity in use of hip and knee replacement surgery between men and women. Effective preoperative counseling for women may require additional resources to address their higher level of questions.     

The effect of tactile and verbal guidance during scapulothoracic exercises: An EMG and kinematic investigation

BackgroundClinician-led training through tactile and verbal guidance to improve muscle activity and joint motion are a common but understudied focus of therapeutic interventions for shoulder pain. The purpose of this study was to determine if clinician guidance changes scapulothoracic muscle activity and kinematics compared to unguided shoulder exercises.MethodsEleven participants with shoulder pain were studied. Electromyographic (EMG) sensors were placed on the serratus anterior and upper and lower trapezii. Scapulothoracic and sternoclavicular kinematics were collected using electromagnetic sensors. Five common resisted shoulder exercises were performed with the following guidance: unguided, combined (verbal and tactile cues), and verbal guidance only. One-way repeated measures ANOVAs determined the effect of guidance versus unguided conditions for each exercise.ResultsNine of ten combinations of exercise and guidance techniques demonstrated a significant effect of guidance for either muscle activity or joint kinematics. The guidance condition with the most frequent significant improvements across all variables was the combined condition. The exercises with the most frequent significant improvements across all variables were the external rotation exercises. Variables improved most frequently were: upper:lower trapezius EMG ratio (up to 11%), sternoclavicular elevation (up to 6°) and scapulothoracic internal rotation positioning (up to 8°), and sternoclavicular retraction displacement (up to 5°).ConclusionShoulder muscle activity and kinematics during exercises can be modified by tactile and verbal guidance. Most improvements in muscle activity occurred with verbal guidance during external rotation exercises. Most improvements in joint positioning and movement occurred with combined guidance during external rotation exercises.     

Resveratrol promotes cellular glucose utilization in primary cultured cortical neurons via calcium-dependent signaling pathway

Background and PurposeImpairment of glucose utilization contributes to neuronal degeneration of Alzheimer's disease patients. Cellular glucose utilization can be regulated by calcium-dependent signaling pathways. Resveratrol (RSV) is a plant-derived polyphenol with multiple beneficial effects, including neuroprotection and metabolic improvement. Here, we investigated the effect of RSV on neuronal calcium signal and glucose utilization.Experimental MethodsPrimary culture of cortical neurons, calcium imaging, 2-NBDG assay and western blotting were employed to investigate RSV-mediated effects on neuronal calcium signal and glucose utilization.ResultsRSV elevated intracellular calcium in cortical neurons via modulation of secondary messenger system including nitrous oxide, cGMP and cAMP. Secondarily, a calcium-dependent enhancement of neuronal glucose utilization after RSV treatment was observed. The effects on neuronal glucose utilization are largely dependent on RSV-induced calcium-dependent AMP-activated protein kinase activation.ConclusionOur findings show that activation of calcium-dependent signaling pathways by RSV may convey improvements of neuronal glucose utilization.     

Surgical debulking of podoconiosis nodules and its impact on quality of life in Ethiopia

BackgroundIn Ethiopia, severe lymphedema and acute dermato-lymphangio-adenitis (ADLA) of the legs as a consequence of podoconiosis affects approximately 1.5 million people. In some this condition may lead to woody-hard fibrotic nodules, which are resistant to conventional treatment. We present a series of patients who underwent surgical nodulectomy in a resource-limited setting and their outcome.MethodsIn two teaching hospitals, we offered surgical nodulectomies under local anaesthesia to patients with persisting significant fibrotic nodules due to podoconiosis. Excisions after nodulectomy were left to heal by secondary intention with compression bandaging. As outcome, we recorded time to re-epithelialization after surgery, change in number of ADLA episodes, change in quality of life measured with the Dermatology Quality of Live Index (DQLI) questionnaire, and recurrence rate one year after surgery.Results37nodulectomy operations were performed on 21 patients. All wounds re-reepithelialised within 21 days (range 17–42). 4 patients developed clinically relevant wound infections. The DLQI values were significantly better six months after surgery than before surgery (P<0.0001). Also the number of ADLA episodes per three months was significantly lower six months after surgery than before surgery (P<0.0001).ConclusionNodulectomy in podoconiosis patients leads to a significant improvement in the quality of life with no serious complications, and we recommend this to be a standard procedure in resource-poor settings.     

Durable remission of diabetes after bariatric surgery: What is the underlying pathway?

Background: In the past, type 2 diabetes mellitus (DM) was regarded as a progressive, incurable disease for which palliative therapy could not, over the long term, prevent the associated amputations, blindness, renal failure, and early mortality. This is no longer true. Full and durable remission of type 2 DM, with major decreases in morbidity and mortality, is now achieved regularly with several types of surgery that reduce contact between food and the foregut.Objectives: The aims of this article are to review the impact of bariatric surgery on obesity, remission of DM, and obesity-related morbidity and mortality, and the possible mechanisms for this advance.Methods: This article is based on our 2 meta-analyses of the literature published through April 30, 2006, as well as the most significant reports in the bariatric surgical literature that have been published in English since April 30, 2006. The studies included in our second meta-analysis provided the details of the methodology for the present literature review, including the levels of evidence.Results: Results of our 2 meta-analyses were published previously. Briefly, the analyses revealed that the clinical and laboratory manifestations of type 2 DM resolved or improved in most of the patients who underwent bariatric surgery; the responses were greatest in the patients who lost the most excess body weight; and the improvements were maintained for ≥2 years. The studies reported that intestinal operations such as gastric bypass reduced contact between food and the foregut, produced full and durable remission of DM, reduced mortality, and reversed other comorbidities associated with severe obesity (eg, asthma, gastroesophageal reflux, hypertension, stress incontinence). Insulin levels decreased markedly after surgery, as did glycosylated hemoglobin (A1C) and fasting blood glucose levels. Although these effects were initially attributed to weight loss, the rapid reversal of DM within a matter of days after surgery suggest that bariatric surgery changes the signaling mechanism of the gut with pancreatic islet cells, muscles, fat, the liver, and other organs.Conclusions: Bariatric surgery has opened new vistas, producing durable full remission of type 2 DM—a breakthrough previously considered impossible—with normalization of A1C levels over time and discontinuation of all antidiabetes medication for many patients. These advances create new opportunities for exploring the mechanisms of type 2 DM and its control through pharmaceutical approaches. DM is no longer an irreversible, incurable, or hopeless disease.     

自体吸疱表皮移植术结合搔刮术治疗白癜风的临床评价

目的:观察和比较搔刮术结合负压吸疱术和传统负压吸疱术对白癜风复色的疗效。方法:将90例稳定期白癜风患者随机分成搔刮术结合负压吸疱术组(45例)和传统负压吸疱术组(45例),分别给予搔刮术结合负压吸疱术和传统负压吸疱术治疗。治疗后,比较两组的复色情况,是否留有白斑缝隙,并进行白癜风疗效评价。进一步分析皮损部位、性别、临床类型对搔刮术结合负压吸疱术和传统负压吸疱术临床疗效的影响。结果:治疗后,搔刮术结合负压吸疱术组和传统负压吸疱术组在整体疗效无显著性差异(P0.05)。搔刮术结合负压吸疱术组术后获得成片复色比例显著高于传统负压吸疱术组(88.9%vs. 4.4%,P0.001)。不同性别患者接受搔刮术结合负压吸疱术和传统负压吸疱术的疗效比较均无统计学差异(P0.05)。表皮移植术结合搔抓术组和单一表皮移植术组中,皮损发生在颈部、面部相比于躯干部、四肢、手足部的疗效明显更佳,局限型和节段型相比于散发型、肢端型的疗效更佳。结论:自体吸疱表皮移植术结合搔刮术用于稳定期白癜风的复色效果相比于传统自体吸疱表皮移植术疗效更佳。     

Improvements in the Synthesis of L-Ribonucleosides for the Preparation of Mirror-Image Oligoribonucleotides

Abstract

Different improvements are described for the chemical synthesis of L-ribonucleosides corresponding to the four natural bases. These nucleosides properly protected were used to synthesize successfully a 27-base long L-oligoribonucleotide.     

Shoulder function after constraint-induced movement therapy assessed with 3D kinematics and clinical and patient reported outcomes: A prospective cohort study

IntroductionWe hypothesised that reduced shoulder function post stroke improves during constraint-induced movement therapy and that improvement in scapula upward rotation measured with three-dimensional kinematics is associated with improvements in clinical and patient reported outcomes.MethodsThirty-seven patients were tested pre and post constraint-induced movement therapy and again at three-month follow-up. Kinematic outcome measures – with scapula upward rotation as the primary outcome – during tasks 5 (ReachLow) and 6 (ReachHigh) from the Wolf Motor Function Test were included together with clinical and patient reported outcomes. Changes in outcome measures were analysed with linear mixed models and logistic regression analysis.FindingsScapula upward rotation was reduced from 16.2° pre intervention through 15.9° post intervention to 15.6° at three-month follow-up during ReachHigh. Statistically significant reductions of <2° were also found for shoulder flexion during ReachLow and trunk lateral flexion during ReachHigh. The clinical and patient reported outcomes showed improvements post constraint-induced movement therapy, and at follow-up, the outcomes resembled post values.InterpretationThe minimal improvements in selected 3D kinematic measures of upper extremity movements did not reflect any clinically meaningful changes. Therefore, the clinical and patient reported improvements could not be related to restitution of shoulder function.     

Update on: proteome analysis in thyroid pathology – part II: overview of technical and clinical enhancement of proteomic investigation of the thyroid lesions

ABSTRACT

Introduction: An accurate diagnostic classification of thyroid lesions remains an important clinical aspect that needs to be addressed in order to avoid ‘diagnostic’ thyroidectomies. Among the several ‘omics’ techniques, proteomics is playing a pivotal role in the search for diagnostic markers. In recent years, different approaches have been used, taking advantage of the technical improvements related to mass spectrometry that have occurred.

Areas covered: The review provides an update of the recent findings in diagnostic classification, in genetic definition and in the investigation of thyroid lesions based on different proteomics approaches and on different type of specimens: cytological, surgical and biofluid samples. A brief section will discuss how these findings can be integrated with those obtained by metabolomics investigations.

Expert commentary: Among the several proteomics approaches able to deepen our knowledge of the molecular alterations of the different thyroid lesions, MALDI-MSI is strongly emerging above all. In fact, MS-imaging has also been demonstrated to be capable of distinguishing thyroid lesions, based on their different molecular signatures, using cytological specimens. The possibility to use the material obtained by the fine needle aspiration makes MALDI-MSI a highly promising technology that could be implemented into the clinical and pathological units.     

腹膜后腹腔镜技术在泌尿外科的应用

目的:对比腹膜后腹腔镜手术起步阶段和相对成熟阶段的临床资料,总结手术经验,提高应用水平。方法:对2005年1月至2008年12月起步阶段腹膜后腹腔镜手术65例患者,及2016年1月至2016年12月相对成熟阶段腹膜后腹腔镜手术148例患者进行回顾性分析。结果:起步阶段:中转开放手术5例,术后发热及切口延迟愈合7例;相对成熟阶段:中转开放手术4例,术后发热及切口延迟愈合6例,无大血管破裂、腹腔内脏器损伤、死亡等并发症。在肾囊肿去顶减压手术及肾上腺手术中,成熟阶段患者的各项指标包括手术时间、出血量、中转开放手术比例、术后拔除引流管时间及住院时间均显著优于起步阶段,差异有统计学意义(P0.05)。结论:腹膜后腹腔镜技术适于治疗上尿路及肾上腺疾病,具有患者创伤小、安全、术后康复快等优点,早期起步阶段适合选择简单术式,随着手术技术的熟练可逐步开展复杂的手术。     

卡那霉素致聋豚鼠耳蜗电极植入模型的建立及意义

目的:探讨人工耳蜗电极的插入对耳蜗功能的影响,为研究人工耳蜗植入建立相应的动物模型。方法:取听力正常的豚鼠8只,4只注射卡那霉素联合呋塞米致聋,为致聋组;4只仅注射生理盐水,为对照组。对两组动物行听性脑干反应(ABR)及耳声发射(DPOAE)检查后,将耳蜗电极植入左侧耳蜗。结果:致聋组术侧4个频率段ABR阈移随着时间的推移逐渐减小,术后24 h、48 h、72 h时间段比较无显著性差异(P0.05);对照组术侧ABR阈移随着时间的推移逐渐减小,32 kHz频率的三个时间段比较有显著性差异(P0.05),其余3个频率无显著性差异。此外,致聋组与对照组术侧耳ABR阈移比较均无显著性差异(P0.05)。致聋组术前5个频率的DPOAE无法引出,术后DPOAE仍无法引出;对照组术前DPOAE均可引出,术后术侧的DPOAE均无法引出。术后72 h可见电极周围有组织包绕,固定良好,局部未见明显炎症反应。结论:本实验成功建立了卡那霉素致聋的豚鼠耳蜗电极植入模型,可为人工耳蜗植入术后颞骨病理改变的研究提供实验基础。     

Current Trainee and Workforce Patterns for Thyroid and Parathyroid Surgery in the United States

ObjectiveThyroid and parathyroid surgery is performed by both general surgeons and otolaryngologists. We describe the proportion of surgeries performed by specialty, providing data to support decisions about when and to whom to direct research, education, and quality improvement interventions.MethodsWe tabulated case numbers for privately insured patients undergoing thyroid and parathyroid surgery in Marketscan: 2010–2016 and trainee case logs for residents and fellows in general surgery and otolaryngology. Summary statistics and tests for trends and differences were calculated.ResultsMarketscan data captured 114 500 thyroid surgeries. The proportion performed by each specialty was not significantly different. Otolaryngologists performed 58 098 and general surgeons performed 56 402. Otolaryngologists more commonly performed hemithyroidectomy (n = 25 148, 43.29% of all thyroid surgeries performed by otolaryngologists) compared to general surgeons (n = 20 353, 36.09% of all thyroid surgeries performed by general surgeons). Marketscan data captured 21 062 parathyroid surgeries: 6582 (31.25%) were performed by otolaryngologists, and 14 480 (68.75%) were performed by general surgeons. The case numbers of otolaryngology and general surgery trainees completing residency and fellowship varied 6- to 9-fold across different sites. The wide variation may reflect both the level of exposure a particular training program offers and trainee level of interest.ConclusionThyroid surgical care is equally provided by general surgeons and otolaryngologists. Both specialties contribute significantly to parathyroid surgical care. Both specialties should provide input into and be targets of research, quality, and education interventions.     

A validation of SpekPy: A software toolkit for modelling X-ray tube spectra

PurposeTo validate the SpekPy software toolkit that has been developed to estimate the spectra emitted from tungsten anode X-ray tubes. The model underlying the toolkit introduces improvements upon a well-known semi-empirical model of X-ray emission.Materials and methodsUsing the same theoretical framework as the widely-used SpekCalc software, new electron penetration data was simulated using the Monte Carlo (MC) method, alternative bremsstrahlung cross-sections were applied, L-line characteristic emissions were included, and improvements to numerical methods implemented. The SpekPy toolkit was developed with the Python programming language. The toolkit was validated against other popular X-ray spectrum models (50 to 120 kVp), X-ray spectra estimated with MC (30 to 150 kVp) as well as reference half value layers (HVL) associated with numerous radiation qualities from standard laboratories (20 to 300 kVp).ResultsThe toolkit can be used to estimate X-ray spectra that agree with other popular X-ray spectrum models for typical configurations in diagnostic radiology as well as with MC spectra over a wider range of conditions. The improvements over SpekCalc are most evident at lower incident electron energies for lightly and moderately filtered radiation qualities. Using the toolkit, estimations of the HVL over a large range of standard radiation qualities closely match reference values.ConclusionsA toolkit to estimate X-ray spectra has been developed and extensively validated for central-axis spectra. This toolkit can provide those working in Medical Physics and beyond with a powerful and user-friendly way of estimating spectra from X-ray tubes.