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BACKGROUND: Patients understandably have concerns about thyroidectomy scars. This study aimed to characterize patients’ perceptions of their thyroidectomy scar before and up to 1-year after surgery. METHODS: Patients with papillary thyroid cancer (n=83) completed semi-structured interviews before and at 2-weeks, 6-weeks, 6-months, and 1-year post-thyroidectomy. Interviews probed about scar concerns and appearance. Content analysis was used to identify themes. RESULTS: The majority of participants did not express concerns about scar appearance. When expressed, preoperative concerns often stemmed from previous surgery experiences or unease with neck incisions. Postoperatively, concerns about scar appearance decreased over time throughout the healing period with most patients being satisfied with their scar appearance by 6-months after surgery. CONCLUSIONS: Patients with papillary thyroid cancer express few concerns about scar thyroidectomy appearance. Surgeons can reassure patients who have preoperative concerns that most patients are satisfied with their scar appearance by 6-months after surgery.

Siblings describe positive and negative aspects of autism and often assume lifelong support roles. Less is known about cultural influences on sibling relationships. This qualitative study characterizes processes linking siblings’ autism conceptualizations, sibling relationships, and self-concept using a multicultural framework. Siblings (12 Latino/a/x, 9 non-Latino/a/x white) participated. Data were stratified by ethnicity and analyzed using applied thematic analysis. Latino/a/x and non-Latino/a/x siblings described processes linking autism, relationships, and self-concept differently. Latino/a/x siblings emphasized family roles and identified as caregivers and protectors. Non-Latino/a/x siblings emphasized general sensitivity toward individuals who differed from themselves. Findings may reflect cultural differences in familism, caregiving expectations, and autism conceptualizations, thereby illuminating foundations of siblings’ lifelong caregiving roles and highlighting the importance of culturally-sensitive, family-centered care.

The 2015 American Thyroid Association guidelines endorsed lobectomy for patients with low-risk papillary thyroid cancer (PTC) measuring 1–4 cm. Attitudes about the use of lobectomy for these patients are lacking, particularly from low-volume surgeons who perform the majority of thyroidectomies in the US. A survey was mailed to 1000 surgeons stratified by specialty (500 general surgeons and 500 otolaryngologists) registered with the American Medical Association, to evaluate beliefs and practices about the extent of surgery for low-risk PTC. Comparisons examined differences by surgeon volume. Of 320 respondents who have performed thyroidectomy since 2015 (150 general surgeons, 170 otolaryngologists), 206 (64.4%) were low volume ( 1 cm. Awareness of guidelines and concerns about increased risk of recurrence after lobectomy may drive surgeons’ preference for total thyroidectomy.

Introduction: Clinical psychologists often treat patients with a sleep disorder. Cognitive-behavioral treatments can independently, or in combination with medical interventions, effectively improve...

OBJECTIVE: The aim of this prospective randomized-controlled trial was to evaluate the risks/benefits of prophylactic central neck dissection (pCND) in patients with clinically node negative (cN0) papillary thyroid cancer (PTC). BACKGROUND: Microscopic lymph node involvement in patients with PTC is common, but the optimal management is unclear. METHODS: 60 patients with cN0 PTC were randomized to a Total Thyroidectomy (TT) or a TT+ pCND. All patients received postoperative laryngoscopies and standardized radioiodine treatment. Thyroglobulin (Tg) levels and/or neck ultrasounds (US) were performed at 6 weeks, 6 months and 1 year. RESULTS: Tumors averaged 2.2 ± 0.2 cm and 11.9% had extra-thyroidal extension. 30 patients underwent a pCND and 27.6% had positive nodes (all ≤6 mm). Rates of post-operative PTH

Background Thyroid cancer diagnoses are often discovered after diagnostic thyroid lobectomy. Completion thyroidectomy (CT) may be indicated for intermediate or high-risk tumors to facilitate surveillance and/or adjuvant treatment. The completeness of thyroid resection and the safety of CT compared to total thyroidectomy (TT) is unclear. We assessed outcomes after TT or CT to determine completeness of resection and risk of complications. Methods Patients undergoing TT or CT between 2000 and 2018 were retrospectively reviewed. Pathology, unstimulated thyroglobulin (uTg), parathyroid hormone (PTH), rates of hematoma, and recurrent laryngeal nerve (RLN) injury were compared. Results Differentiated thyroid cancer (DTC) was identified in 954 patients undergoing TT and 142 patients undergoing CT. Postoperative uTg at 6 months was not different between TT and CT, 0.2 vs 0.2 ng/mL, P = .37. Transient hypoparathyroidism with immediate postoperative PTH less than 10 was more common after TT, 14.3 vs 6.0% (P = .009). No differences were noted regarding postoperative hematoma, transient RLN injury, permanent hypoparathyroidism, and permanent RLN injury. Conclusions If CT is required for DTC, a complete resection, as assessed by postoperative uTg, can be achieved. Furthermore, CT is significantly less likely to result in transient hypoparathyroidism and poses no additional risk of RLN injury, hematoma, or permanent hypoparathyroidism.

The Internet is a key source of health information, yet little is known about resources for low-risk thyroid cancer treatment. We examined the timeliness, content, quality, readability, and reference to the 2015 American Thyroid Association (ATA) guidelines in websites about thyroid cancer treatment. We identified the top 60 websites using Google, Bing, and Yahoo for “thyroid cancer.” Timeliness and content analysis identified updates in the ATA guidelines (n = 6) and engaged a group of stakeholders to develop essential items (n = 29) for making treatment decisions. Website quality and readability analysis used 4 validated measures: DISCERN; Journal of the American Medical Association (JAMA) benchmark criteria; Health on the Net Foundation certification (HONcode); and the Suitability Assessment of Materials (SAM) method. Of the 60 websites, 22 were unique and investigated. Content analysis revealed zero websites contained all updates from the ATA guidelines and rarely (18.2%) referenced them. Only 31.8% discussed all 3 treatment options: total thyroidectomy, lobectomy, and active surveillance. Websites discussed 28.2% of the 29 essential items for making treatment decisions. Quality analysis with DISCERN showed “fair” scores overall. Only 29.9% of the JAMA benchmarks were satisfied, and 40.9% were HONcode certified. Readability analysis with the SAM method found adequate readability, yet 90.9% scored unsuitable in literacy demand. The overall timeliness, content, quality, and readability of websites about low-risk thyroid cancer treatment is fair and needs improvement. Most websites lack updates from the 2015 ATA guidelines and information about treatment options that are necessary to make informed decisions.

Context Active surveillance (AS) of thyroid cancer with serial ultrasounds is a newer management option in the United States. Objective This work aimed to understand factors associated with the adoption of AS. Methods We surveyed endocrinologists and surgeons in the American Medical Association Masterfile. To estimate adoption, respondents recommended treatment for 2 hypothetical cases appropriate for AS. Established models of guideline implementation guided questionnaire development. Outcome measures included adoption of AS (nonadopters vs adopters, who respectively did not recommend or recommended AS at least once; and partial vs full adopters, who respectively recommended AS for one or both cases). Results The 464 respondents (33.3% response) demographically represented specialties that treat thyroid cancer. Nonadopters (45.7%) were significantly (P Conclusion Widespread adoption of AS will require increased patient and physician awareness, interest, and evaluation of outcomes.

The relatively nascent empirical knowledge base regarding autism in adulthood provides an opportunity to adopt a contextual approach that conceptualizes autism features, outcomes, and supportive services as interactions between the characteristics of the condition and contextual factors across the life course. Although a contextual approach encompasses many aspects of a person's identity and social ecology, we focus here on the closely interrelated family and cultural contexts, which have been poorly integrated into adult autism research. We argue that designing studies with a priori attention to context (e.g., family and culture) will improve the relevance and comprehensiveness of findings, which in turn will improve construct validity and provide a more accurate understanding of autism-related outcomes in adulthood. Similarly, designing and/or selecting measures that have been validated with culturally and linguistically diverse samples will improve the utility of findings and reduce spurious or null effects. More contextually informed methodologies will lead to improved generalizability and practical applications of findings. We offer concrete guidance regarding how to increase the social ecological perspective within adult autism research as it relates to study conceptualization, methodology, and measurement.

Centers for disease control (CDC) Guidelines for Field Triage are effective when proper implementation by EMS personnel is paired with surgeon willingness to care for trauma victims. We hypothesized that in a state with an immature trauma system, a discrepancy exists between medic and surgeon perception of surgical readiness, coinciding with inconsistent implementation of protocols. Surveys were conducted among medics and general surgeons. Destination protocols, trauma center locations, surgeon readiness, and interest in trauma were assessed. A standard clinical trauma scenario was also used. Surgeon willingness to operate is not affected by working outside of trauma centers or interest in trauma. Medics working far from trauma centers are less confident in local surgeon's willingness to operate and less likely to have destination protocols. Trauma center proximity affects medic perception of surgeon willingness to operate, but mere presence of general surgeons does not. In a trauma scenario, surgeon willingness to operate was related to medic perception but not action. In rural states, most surgeons do not work in trauma centers and most medics do not work near them. Although most responding surgeons indicate willingness to operate, medics are confident of such willingness only half the time. This disparity results in inconsistent use of the CDC guidelines. Although most medics report protocols for destination determination, nearly one-fourth of victims are taken to the geographically closest centers, sometimes with no surgeon at all. Efforts at medic training, enhancing surgeon readiness, and alignment of goals are necessary for the CDC Guidelines to be effective.

The Autism Diagnostic Observation Schedule (ADOS) is widely used to assess symptoms of autism spectrum disorder (ASD). Given well-documented differences in social behaviors across cultures, this study examined whether item-level biases exist in ADOS scores across sociodemographic groups (race, ethnicity, and gender). We examined a subset of ten ADOS items among participants (N = 2458). Holding level of overall ADOS behavioral symptoms constant, we found significant item level bias (measurement noninvariance) for race and ethnicity on three ADOS items. Item-level bias was not apparent across gender. Although the magnitude of bias was small, our findings highlight the need to reevaluate norms and operational definitions used in assessments to increase ASD diagnostic accuracy among culturally-diverse groups.

BACKGROUND: Current recommendations using Hounsfield units (HU)≤10 to identify adrenal adenomas on unenhanced computed tomography (CT) miss 10-40% of benign adenomas. We sought to determine if changing HU threshold and adding absolute percent contrast washout (APW) criteria would better identify adrenal adenomas than current recommendations. METHODS: Imaging characteristics were compared between patients with adenomas (n=128) and those with non-adenomas (n=54) after unilateral adrenalectomy. Sensitivity, specificity, positive and negative predictive values (PPV, NPV) were calculated. RESULTS: Using HU≤10 to identify adenomas had a sensitivity of 47.6%, specificity of 93.3% (AUC=0.71, p60% for lesions exceeding 16HU, sensitivity increased to 93.4%, specificity was 93.3% and PPV 96.6%, and NPV improved to 85.7% (AUC=0.96, p60% for lesions exceeding 16HU yielded improved sensitivity and specificity in identification of adrenal adenomas.

Introduction Autism spectrum disorder (ASD) service-use disparities are well-documented among racial/ethnic minorities. Yet the nuanced impact that culture has on barriers to ASD service-use has not been sufficiently explored among these populations. This study explores the interrelatedness of culture and service-use barriers (i.e., parent ASD knowledge and adjustment) among culturally diverse mothers of children with ASD. Methods Twenty mothers from the Boston area participated in semi-structured qualitative interviews regarding their experiences with ASD. Applied thematic analysis was used to analyze data stratified by ethnicity (Latina vs. non-Latina) and nativity (immigrant vs. U.S. born). Results All mothers had similar gains in ASD knowledge after their children’s ASD diagnoses. Non-Latina mothers (immigrant and U.S. born) felt empowered by their gained ASD knowledge, while Latina mothers struggled to fully accept their child’s diagnosis and were unable to apply their general ASD knowledge to better understand their child’s ASD-related needs. Culturally based stigma against ASD, including rejection from the Latino community and internalized self-blame, appeared to drive Latina mothers’ beliefs that ASD is an invalid diagnosis for their child. Conclusion Latina mothers’ desire for community acceptance in the context of ASD stigma was a particularly salient cultural value among Latina mothers in this sample. Findings suggest that parent-focused ASD education programs may not sufficiently address ASD service-use disparities for Latina mothers. Rather, ASD education programs that address informational and cultural needs may better promote ASD adjustment among ethnic minority families.

BackgroundPoor sleep is common for children during cancer treatment, but there is limited understanding of the nature of children’s sleep throughout the treatment trajectory. The current exploratory study used an explanatory sequential mixed method approach to examine quantitative associations among sleep problems in children with cancer, parental behavior, and children’s sleep hygiene, with follow-up qualitative characterizations of children’s sleep across cancer treatment stages.ProcedureEighty parents of children with cancer (aged 2–10 years; in active treatment, maintenance treatment, or off treatment) completed an online survey querying the child’s sleep quality (Sleep Disturbance Scale for Children—Disorders of Initiating and Maintaining Sleep subscale) and behaviors (Child Sleep Hygiene Scale) and sleep-related parenting behaviors (Parental Sleep Strategies). A subsample (n = 17 parents) participated in qualitative interviews to better characterize the processes of children’s sleep and parents’ sleep-related behaviors.ResultsChildren’s sleep quality, sleep hygiene, or parental sleep strategies were not significantly different by cancer treatment groups. Greater sleep disturbance in children was associated with their parents’ tendency to accommodate the child’s bedtime requests. Qualitatively, cancer treatment-related anxiety in both children and parents influence the onset of these disruptive sleep behaviors.ConclusionParents’ sleep-related behaviors affect children’s sleep during cancer treatment. Parents’ accommodation may start during active treatment to alleviate cancer-related challenges, and these behaviors may continue into maintenance therapy and off treatment to reinforce sleep disturbance. Behavioral interventions targeting unhelpful parental behaviors may improve sleep in children with cancer during and after cancer treatment.

Background Levothyroxine (LT4) is one of the most prescribed drugs in the United States; however, many patients started on LT4 after thyroidectomy suffer from symptoms of hyper- or hypo-thyroidism before achieving euthyroidism. This study aims to describe the time required for dose adjustment before achieving euthyroidism and identify predictors of prolonged dose adjustment (PDA+) after thyroidectomy. Methods This is a single institution retrospective cohort study of patients who achieved euthyroidism with LT4 therapy between 2008 and 2017 after total or completion thyroidectomy for benign disease. Patients who needed at least three dose adjustments (top quartile) were considered PDA+. Binomial logistic regression was used to identify predictors of PDA+. Results The 605 patients in this study achieved euthyroidism in a median of 116 d (standard deviation 124.9) and one dose adjustment (standard deviation 1.3). The 508 PDA− patients achieved euthyroidism in a median of 101 d and one dose adjustment. The 97 PDA+ patients achieved euthyroidism in a median of 271 d and three dose adjustments. Iron supplementation (odds ratio = 4.4, 95% confidence interval = 1.4-13.5, P = 0.010) and multivitamin with mineral supplementation (odds ratio = 2.4, 95% confidence interval = 1.3-4.3, P = 0.004) were independently associated with PDA+. Age, gender, preoperative thyroid disease, and comorbidities did not independently predict PDA+. Conclusions After thyroidectomy, achieving euthyroidism can take nearly 4 mo. Iron and mineral supplementation are associated with PDA+. This information can inform the preoperative counseling of patients and suggests that this may expedite achieving euthyroidism.

Few studies have examined disparities in autism services and functional outcomes over the life course. Transition to adulthood is an especially important developmental period, as it sets up trajectories of adult functioning. This systematic review summarizes patterns of service use and transition outcomes according to race, ethnicity, and socioeconomic characteristics over the transition to adulthood. Forty studies were included. Low-income and racial/ethnic minority youth on the autism spectrum were less likely to participate in transition planning meetings, enroll in postsecondary education, find competitive employment after high school, live independently, participate in social activities, and receive health care transition services than their White and higher income peers on the autism spectrum. Racial/ethnic minority and low-income youth on the autism spectrum were more likely to be disconnected from educational, occupational, and social activities upon entering adulthood. Future research should explore the mechanisms underlying these disparities as a first step to addressing them.

BACKGROUND: Nephrolithiasis is a classic, treatable manifestation of primary hyperparathyroidism (PHPT). We examined predictors of kidney stone formation in PHPT patients and determined how efficiently the diagnosis of PHPT is made in patients whose initial presentation is with stones. MATERIALS AND METHODS: We performed a retrospective analysis of surgically treated PHPT patients, comparing 247 patients who were kidney stone-formers and 1,047 patients with no kidney stones. We also analyzed 51 stone-forming patients whose stone evaluation and treatment were completed within our health system prior to PHPT diagnosis. RESULTS: Stone-forming patients had higher 24-hour urinary calcium (342 vs 304 mg/day, p=0.005), higher alkaline phosphatase (92 vs. 85 IU/L, p=0.012), and were more likely to be normocalcemic (16.9% vs. 26.6%, p=0.001). Surprisingly, 47.3% of stone-formers had normal urinary calcium levels (

The objective of this article is to examine associations among socioeconomic, cultural, and child factors and maternal distress among families of children with intellectual disabilities (ID). Latino and nonLatino White (NLW) mothers of children with and without ID (N = 192) reported on familism, language acculturation, maternal distress, child adaptive functioning, and child behavior problems. Among mothers of children with ID, higher levels of child behavior problems mediated the association between Latina ethnicity and elevated maternal distress. Associations between child behavior problems and maternal distress in Latina mothers of children with ID were moderated by single-parent marital status, higher familism, and lower English usage. Thus, child and cultural factors contribute to elevated distress among Latina mothers of children with ID.

Chikungunya virus (CHIKV) is an arbovirus responsible for causing epidemic outbreaks of human disease characterized by painful and often debilitating arthralgia. Recently CHIKV has moved into the Caribbean and the Americas resulting in massive outbreaks in naïve human populations. Given the importance of CHIKV as an emerging disease, a significant amount of effort has gone into interpreting the virus-host interactions that contribute to protection or virus-induced pathology following CHIKV infection, with the long term goal of using this information to develop new therapies or safe and effective anti-CHIKV vaccines. This work has made it clear that numerous distinct host responses are involved in the response to CHIKV infection, where some aspects of the host innate and adaptive immune response protect from or limit virus-induced disease, while other pathways actually exacerbate the virus-induced disease process. This review will discuss mechanisms that have been identified as playing a role in the host response to CHIKV infection and illustrate the importance of carefully evaluating these responses to determine whether they play a protective or pathologic role during CHIKV infection.

Background Papillary thyroid carcinoma has excellent survival, yet recurrence remains a challenge. We sought to determine the proportion of reoperations performed for persistent, rather than truly recurrent, disease. Methods We conducted a retrospective review of a prospectively maintained database. Patients with papillary thyroid carcinoma who underwent reoperation for disease from 2000–2016 were included. We defined recurrence as disease that developed after a patient had an undetectable thyroglobulin and a negative ultrasonography within 1 year of operation. Results A total of 69 patients underwent 92 reoperations. On initial pathology, mean tumor size was 2.6 cm, 51% were multifocal, and 42% had extrathyroidal extension. Half (46%) of the patients underwent a central/lateral neck dissection at the initial operation, and 77% were treated with postoperative radioactive iodine. The median time to first reoperation was 21 months (range, 1–292), and 42% occurred within 1 year. Only 3 operations met criteria for true “recurrence,” while 71 operations were categorized as persistent disease. Conclusion Many reoperations for papillary thyroid carcinoma are for management of persistent disease. More than half of the patients required reoperation within the first 2 years, which suggests strongly that improvements in the preoperative assessment and adequacy of initial operative therapy need to be made to improve the care of patients with thyroid cancer.

Dramatic increases in damage control and decompressive laparotomies and a significant increase in patients with open abdominal cavities have resulted in numerous techniques to facilitate fascial closure. We hypothesized addition of the abdominal reapproximation anchor system (ABRA) to the KCI Abdominal Wound Vac™ (VAC) or KCI ABThera™ would increase successful primary closure rates and reduce operative costs. Fourteen patients with open abdomens were prospectively randomized into a control group using VAC alone (control) or a study group using VAC plus ABRA (VAC-ABRA). All patients underwent regular VAC changes; patients receiving VAC-ABRA also underwent concomitant daily elastomer adjustment of the ABRA system. Primary end points included abdominal closure, number of operating room (OR) visits, and OR time use. Eight patients were included in the VAC-ABRA group and six patients in the control group. Primary closure rates between groups were not statistically different; however, the number of trips to the OR and OR time use were different. Despite higher Acute Physiology and Chronic Health Evaluation II scores, larger starting wound size, and higher rates of abdominal compartment syndrome, closure rates in the VAC-ABRA group were similar to VAC alone. Importantly, however, fewer OR trips and less OR time were required for the VAC-ABRA group.

Necrotizing soft tissue infections (NSTIs) can affect any part of the body but are rarely seen in the breast. To date, most cases have presented unilaterally, and all published reports have occurred in female patients. We describe the first case of bilateral NSTI of the breasts in a male patient with history of mastitis and breast biopsies. He was successfully treated with antibiotics and bilateral mastectomy. A history of mastitis or instrumentation of the breast should raise suspicion for a necrotizing soft infection of the breast even in a male, in the setting of systemic and radiologic signs consistent with a necrotizing infection.

Background. Elevated distress has been well documented among parents of children with cancer. Family systems theories suggest that cancer-related stressors and parental distress have the potential to affect child-rearing practices, but this topic has received limited empirical attention. The present work examined self-reported childrearing practices among mothers and fathers of children with cancer and matched comparisons. Procedure. Medical and psychosocial professionals with expertise in pediatric oncology selected items from the Child-Rearing Practices Report (CRPR) likely to differentiate parents of children with cancer from matched comparison parents. Then, responses on these targeted items were compared between parents of children with cancer (94 mothers, 67 fathers) and matched comparisons (98 mothers, 75 fathers). Effect sizes of between-group differences were compared for mothers versus fathers. Results. Pediatric oncology healthcare providers predicted that 14 items woulddifferentiatechild-rearingpracticesof parentsof children with cancer from parents of typically developing children. Differences emerged on six of the 14 CRPR items. Parents of children with cancer reported higher levels of spoiling and concern about their child’s health and development than comparison parents. Items assessing overprotection and emotional responsiveness did not distinguish the two groups of parents. The effect size for the group difference between mothers in the cancer versus comparison groups was significantly greater than that for fathers on one item related to worry about the child’s health. Conclusion. Parents of children with cancer report differences in some, but not all, domains of child-rearing, as predicted by healthcare professionals. Pediatr Blood Cancer 2014; 61:326–332. # 2013 Wiley Periodicals, Inc.

BACKGROUND Prolonged, intensive treatment regimens often disrupt families of children with cancer. Siblings are at increased risk for distress, but factors underlying this risk have received limited empirical attention. In this study, the authors examined associations between the family context and sibling distress. METHODS Siblings of children with cancer (ages 8-18 years; N = 209) and parents (186 mothers and 70 fathers) completed measures of sibling distress, family functioning, parenting, and parent post-traumatic stress. Associations between sibling distress and each family risk factor were evaluated. Then, family risks were considered simultaneously by calculating cumulative family risk index scores. RESULTS After controlling for sociodemographic covariates, greater sibling distress was associated with more sibling-reported problems with family functioning and parental psychological control, lower sibling-reported maternal acceptance, and lower paternal self-reported acceptance. When risk factors were considered together, the results supported a quadratic model in which associations between family risk and sibling distress were stronger at higher levels of risk. CONCLUSIONS The current findings support a contextual model of sibling adjustment to childhood cancer in which elevated distress is predicted by family risk factors, both alone and in combination. Cancer 2013;119:2503-2510. © 2013 American Cancer Society.

Background Potassium iodide often is prescribed prior to thyroidectomy for Graves' disease, but the effect of potassium iodide on the ease and safety of thyroidectomy for Graves' is largely unknown. Methods We conducted a prospective, cohort study of patients with Graves' disease undergoing thyroidectomy. For the first 8 months, no patients received potassium iodide; for the next 8 months, potassium iodide was added to the preoperative protocol for all patients. Outcomes included operative difficulty (based on the Thyroidectomy Difficulty Scale) and complications. Results We included a total of 31 patients in the no potassium iodide group and 28 in the potassium iodide group. According to the Thyroidectomy Difficulty Scale, gland vascularity decreased in the potassium iodide group (mean score 2.6 vs 3.3, P = .04), but there were no differences in friability, fibrosis, or size of the thyroid or in overall difficulty of operation (P = not significant for all). Despite similar operative difficulty, patients prescribed potassium iodide were less likely to experience transient hypoparathyroidism (7% vs 26%, P = .018) and transient hoarseness (0% vs 16%, P = .009) compared with the no potassium iodide group. Conclusion Potassium iodide administration decreases gland vascularity, but does not change the overall difficulty of thyroidectomy. Preoperative use of potassium iodide solution was, however, associated with less transient hypoparathyroidism and transient hoarseness, suggesting that potassium iodide improves the safety of thyroidectomy for Graves' disease.

Well-differentiated thyroid cancer may recur in approximately 30% of patients. Recurrences may involve vital structures, such as the recurrent laryngeal nerve, trachea, and esophagus, or they may present as distant metastatic disease. Careful multidisciplinary evaluation is necessary to determine appropriate treatment of recurrent disease. Surgical treatment is often necessary, but timing and extent of operation should be thoroughly discussed among members of a treatment team.

Purpose: Severe skin and soft tissue infections in children are a common cause of hospital admission. Surgical drainage is often required for definitive therapy. Our aim was to review common characteristics of children requiring surgical incision and drainage (I&D) for subcutaneous abscesses. Methods: IRB approval was obtained for a retrospective chart review of children requiring I&D of subcutaneous abscesses between July 2006 and June 2011. Data points included patient demographics, abscess location, surgical procedure, microbiology cultures, and hospital length of stay. Results: Surgical I&D were performed on 1042 children, and 781 patients (75%) were admitted to the surgical service. The average age was 3.4 years. 605 patients (58%) were female. 637 abscesses (61%) were located in the groin/buttock/perineum area. Methicillin-resistant Staphylococcus aureus (MRSA) was identified in 70% of the culture specimens. The average length of stay was 2.8 days. The rate of recidivism was 10.9%. Conclusions: Soft tissue infections requiring hospital admission and I&D are common in the pediatric population. The vast majority of these are due to MRSA infections. Infections requiring drainage most frequently occurred in the diaper area of girls less than 3 years old. A significant number of children have recurrent skin infections and represent an important patient subpopulation.

Several guidelines for patients with multiple endocrine neoplasia 2A (MEN2A) take into account genotype and family history of medullary thyroid carcinoma (MTC) disease aggressiveness. We sought to determine if an association exists independent of genotype, which could provide important information for counseling MEN2A patients in management of their MTC. Pedigrees of patients with ≥5 family members with MEN2A were retrospectively reviewed. Analysis was performed among kindreds with the most frequently observed codon mutation (RET 634). Familial MTC disease aggressiveness was evaluated using: (1) mean age at diagnosis of MTC, (2) current mean age of carriers without MTC, (3) proportion of kindred with MTC with metastatic disease at diagnosis, (4) proportion of kindred with MTC with metastasis/death from MTC as worst outcome, and (5) proportion of kindred with disease progression. 170 affected patients from 12 different MEN2A kindreds met inclusion criteria. The number of affected family members available for study per kindred ranged from 8 to 43 individuals. A difference in mean age of MTC diagnosis was found in screened patients (p = 0.01); mean age of MTC-free patients did not differ (p = 0.93). No differences were noted among kindreds in disease stage at presentation, worst outcome, or progression; marked variation in these measures was noted within families. In conclusion, a difference in age of MTC diagnosis among different RET 634 kindreds was identified. In contrast, notable intra-familial variability in disease aggressiveness was observed. Based on these findings, we recommend counseling patients with codon 634 mutations that their MTC disease course cannot be predicted by that of their relatives.

Despite the global presence of autism spectrum disorder (ASD), a paucity of treatment services exists in Tanzania and other low- and middle-income countries. The effect of delayed or low-quality treatments is enduring and contributes to lifelong variability in ASD-related functional impairments. Service disparities in Tanzania derive in part from a widespread lack of national ASD knowledge. Historically, in Western countries, parents have played a major role in increasing ASD awareness, advancing research, and encouraging empirically supported treatments. In the absence of established treatment services, parents of children with ASD have also learned to implement behavioral interventions to reduce the widening skills gaps. This article describes the development of an intervention designed to inform parents in Tanzania about ASD and empirically supported behavioral strategies. Preliminary data, collected from a clinical implementation with 29 Tanzanian families of children diagnosed with ASD or general developmental delays, support the initial feasibility and acceptability of this intervention. This brief intervention may help to ameliorate treatment disparities due to insufficient regional knowledge, language barriers, or limited service availability and may help improve functional outcomes among Tanzanian children with ASD.

Each year, 14,000 children are diagnosed with cancer in the United States. Prolonged, intensive treatment regimens disrupt the entire family system, but effects on siblings are poorly understood. In this preliminary investigation, we employed a risk and resistance framework to study adjustment among 30 siblings (aged 10-17) of children undergoing cancer treatment. We examined whether or not objective stress associated with the cancer experience (contextual threat) predicted sibling distress and explored demographic and disease-related predictors of sibling adjustment. Contextual threat was positively associated with sibling-reported distress, independent of sibling age, gender, birth order relative to the child with cancer, and cancer treatment intensity. From among the demographic and disease-related factors, only younger birth order relative to the child with cancer was independently associated with sibling distress. These results suggest that a subset of siblings may be at increased risk for elevated distress in the face of their brother's or sister's illness.

Parathyroid carcinoma (PC) is a rare disease and presents clinical challenges in diagnosis, management and adjuvant treatment. Rarely diagnosed preoperatively, PC is often discovered in the treatment of primary hyperparathyroidism. PC is predominantly treated surgically with minimal additional treatments available. Given the rarity of the disease, current and future efforts, as discussed in this article, are focused on increasing preoperative diagnosis, recognizing genetic patterns and pathologic markers and delineating nonsurgical options for patients with advanced disease.

Objective. The objective was to evaluate the feasibility of delivering a pediatric weight management intervention adapted for low-income families.Academic researchers, a Medicaid health plan, a State Medicaid agency, and community pediatric providers partnered in the project. Methods. Participants were 48 families with 52 overweight/obese children aged 4 to 12 recruited from Medicaid health plan and providers’ offices. Elements of efficacious pediatric obesity interventions were modified for low literacy and implemented in person and telephonically with parents. Results. Families report ents in food shopping and preparation, and child eating and activity habits. The retention rate was 88%. Children grew significantly taller ( F = 7.1; P = .012) but did not gain significant weight ( F = 0.91; P = .35), with a trend toward decreased BMI ( F = 3.2; P = .08). Conclusions. The authors demonstrate the feasibility of delivering an adapted pediatric obesity intervention with low-income families. They also discuss implications for public—private partnerships among key stakeholders to address pediatric obesity in this high-risk population.

Objective To develop a Web-based resource for families of children newly diagnosed with cancer and examine the viability of this modality of providing support. Methods Twenty-one children (8–17 years) newly diagnosed with cancer and their families were enrolled. Quantitative data on Web site utilization and frequency of accessing specific sections and qualitative data on participant satisfaction are reported. Results Twenty-one families comprising 51 participants (children with cancer, parents, and siblings) had access to the Web site. Utilization was lower than anticipated, with members of only nine families accessing the site. The majority of these hits were on peer discussion groups. Conclusion Further research is warranted to examine whether the Internet is a viable method of delivering support to families affected by childhood cancer. The current pattern of results suggests that the timing of its introduction and the method used to train families may affect utilization.

Appreciating the luxury of our modern operating rooms and arsenal of surgical instruments never seemed easier than when forced to operate in a very low-resource setting. As we have both experienced during short-term humanitarian surgical mission trips to Africa, performing specialized endocrine surgical procedures in resource-limited settings can make technically difficult cases seem all the more challenging. The article by O Donohoe et al. highlights a collection of key points regarding endocrine surgery in Sub-Saharan Africa [1]. First and foremost, continued development of the surgical workforce in Sub-Saharan Africa is of paramount importance. Local surgeons are often required to perform procedures that are frequently funneled to fellowshiptrained subspecialists in developed countries. Mission surgical specialists can provide invaluable onsite, personalized, one-on-one committed teaching and consultation to these surgeons. The experienced, sage surgeon comfortable with complex endocrine procedures is poised to do this and could increase the chances of excellent outcomes—a necessity with limited care [2]. Improved training of local non-specialist African surgeons is undoubtedly one of the most effective methods to establish sustainability and reliable endocrine surgical care in areas such as these. For decades, humanitarian surgical efforts have often focused on short-term surgical excursions, where teams of specialists and equipment fly in, operate around the clock, and fly out like a whirlwind. While compassion and care was clearly extended to the local patient population during the short visit, minimal emphasis was placed on long-term results and little or no patient follow-up occurred. Today, increasing emphasis is placed on patient outcomes, and humanitarian surgery is no different. Papers from McClenaghan and colleagues and Grimes et al., strongly support tracking outcomes and improving patient follow-up for surgical interventions in low-resource settings [3, 4]. Finally, tracking outcomes in a prospective manner for thyroid resections performed in resource-poor settings allows surgeons to better delineate local guidelines and standards of care as well as identifying specific areas for performance and quality improvement. In short, ‘‘A prospective analysis of thyroidectomy outcomes in a resource-limited setting’’ serves as an important example of the beginnings of quality and outcomes research in areas of the world crippled by endemic disease with significant disparities in available surgical care. This paper can easily serve as an inspiration and valuable reference for endocrine surgeons interested in effective and sustainable humanitarian surgical efforts.

Chondromyxoid fibromas are benign tumors which are found most frequently in the metaphyses of long bones. They comprise less than 1% of primary bone neoplasms and display a hypermetabolic appearance on PET imaging. Oftentimes, they are misdiagnosed as chondrosarcomas and are excised due to concern for malignancy. We present a case of a condromyxoid fibroma originating from the second rib of a 15-year-old girl.

Branchial cleft anomalies are a common cause of lateral neck masses and may present with infection, cyst enlargement or fistulas. They may affect any of the nearby neck structures, causing compressive symptoms or vessel thrombosis. We present a case of a branchial cleft cyst in a 10-year-old boy who had been present for 1year. At the time of operation, the cyst was found to completely envelop the hypoglossal nerve. While reports of hypoglossal nerve palsies due to external compression from cysts are known, we believe this to be the first report of direct nerve involvement by a branchial cleft cyst.

Primary hyperparathyroidism from a parathyroid adenoma is common. Ectopic parathyroid glands have been reported in numerous locations, including the chest. We present a single case report of an intrapericardial parathyroid gland found after failed bilateral neck exploration. The patient presented with severe, recurrent nephrolithiasis and acute renal failure prior to his surgical intervention. Repeat imaging identified a parathyroid adenoma in the mediastinum that was localized to the aortopulmonary window. After attempts at minimally invasive thoracotomy and posterolateral thoracotomy, a median sternotomy was ultimately required to identify the adenoma.

Thyroid cancer incidence is increasing worldwide. Though long-term survival rates are excellent, recurrence remains a significant problem, which highlights potential areas of needed improvement, including the surgical care of these patients. This review paper identifies tools and markers that can be used to improve surgical quality in thyroid cancer. Preoperative surgical planning starts with an adequate ultrasound evaluation of the cervical lymph node basins. Postoperatively, thyroglobulin and radioactive iodine uptake scans can track adequacy of resection. In addition, lymph node yield and lymph node ratios serve as indirect markers for assessing the quality of lymph node dissections. Current research also suggests that high-volume surgeons have improved oncological outcomes. Surgeons can use these tools and information to follow and potentially improve the care provided to patients.

Biochemical and immunocytochemical analyses were performed to evaluate the composition of the amyloid β protein (Aβ) deposited in the brains of patients with Alzheimer's disease (AD). To quantitate all Aβs present, cerebral cortex was homogenized in 70% formic acid, and the supernatant was analyzed by sandwich enzyme-linked immunoabsorbent assays specific for various forms of Aβ. In 9 of 27 AD brains examined, there was minimal congophilic angiopathy and virtually all Aβ (96%) ended at Aβ42(43). The other 18 AD brains contained increasing amounts of Aβ ending at Aβ40. From this set, 6 brains with substantial congophilic angiopathy were separately analyzed. In these brains, the amount of Aβ ending at Aβ42(43) was much the same as in brains with minimal congophilic angiopathy, but a large amount of Aβ ending at Aβ40 (76% of total Aβ) was also present. Immunocytochemical analysis with monoclonal antibodies selective for Aβs ending at Aβ42(43) or Aβ40 confirmed that, in brains with minimal congophilic angiopathy, virtually all Aβ is Aβ ending at Aβ42(43) and showed that this Aβ is deposited in senile plaques of all types. In the remaining AD brains, Aβ42(43) was deposited in a similar fashion in plaques, but, in addition, widely varying amounts of Aβ ending at Aβ40 were deposited, primarily in blood vessel walls, where some Aβ ending at Aβ42(43) was also present. These observations indicate that Aβs ending at Aβ42(43), which are a minor component of the Aβ in human cerebrospinal fluid and plasma, are critically important in AD where they deposit selectively in plaques of all kinds.

Arthralgia-associated alphaviruses, including chikungunya virus (CHIKV) and Ross River virus (RRV), pose significant public health threats because of their ability to cause explosive outbreaks of debilitating arthralgia and myalgia in human populations. Although the host inflammatory response is known to contribute to the pathogenesis of alphavirus-induced arthritis and myositis, the role that Toll-like receptors (TLRs), which are major regulators of host antiviral and inflammatory responses, play in the pathogenesis of alphavirus-induced arthritis and myositis has not been extensively studied. Using a mouse model of RRV-induced myositis/arthritis, we found that myeloid differentiation primary response gene 88 (Myd88)-dependent TLR7 signaling is involved in protection from severe RRV-associated disease. Infections of Myd88- and TLR7-deficient mouse strains with RRV revealed that both Myd88 and TLR7 significantly contributed to protection from RRV-induced mortality, and both mouse strains exhibited more severe tissue damage than wild-type (WT) mice following RRV infection. While viral loads were unchanged in either Myd88 or TLR7 knockout mice compared to WT mice at early times postinfection, both Myd88 and TLR7 knockout mice exhibited higher viral loads than WT mice at late times postinfection. Furthermore, while high levels of RRV-specific antibody were produced in TLR7-deficient mice, this antibody had very little neutralizing activity and had lower affinity than WT antibody. Additionally, TLR7- and Myd88-deficient mice showed defects in germinal center activity, suggesting that TLR7-dependent signaling is critical for the development of protective antibody responses against RRV.

A 7-day-old male infant born to a healthy 33-year-old female at 37 weeks of gestation was brought to the local emergency department (ED) with sudden-onset tonic–clonic seizures. Laboratory testing revealed extreme hypocalcemia (ionized calcium of 3.2 mg/dl) and undetectable parathyroid hormone (PTH

Background Chikungunya virus (CHIKV) and o’nyong nyong virus (ONNV) are mosquito-borne alphaviruses endemic in East Africa that cause acute febrile illness and arthritis. The objectives of this study were to measure the seroprevalence of CHIKV and ONNV in coastal Kenya and link it to demographics and other risk factors. Methodology Demographic and exposure questionnaires were administered to 1,848 participants recruited from two village clusters (Milalani-Nganja and Vuga) in 2009. Sera were tested for alphavirus exposure using standardized CHIKV IgG ELISA protocols and confirmed with plaque reduction neutralization tests (PRNT). Logistic regression models were used to determine the variables associated with seropositivity. Weighted K test for global clustering of houses with alphavirus positive participants was performed for distance ranges of 50–1,000 meters, and G* statistic and kernel density mapping were used to identify locations of higher seroprevalence. Principal Findings 486 (26%) participants were seropositive by IgG ELISA. Of 443 PRNT confirmed positives, 25 samples (6%) were CHIKV+, 250 samples (56%) were ONNV+, and 168 samples (38%) had high titers for both. Age was significantly associated with seropositivity (OR 1.01 per year, 95% C.I. 1.00–1.01); however, younger adults were more likely to be seropositive than older adults. Males were less likely to be seropositive (p, Author Summary Alphaviruses, such as chikungunya and o’nyong nyong viruses, are likely important causes of human disease in endemic regions, but are often misdiagnosed as malaria in the acute care setting. Our objective was to uncover the burden of alphavirus exposure in our study region, rural coastal Kenya. Of 1848 participants tested, 26% were seropositive by screening ELISA, demonstrating intense transmission to humans in this area. Surprisingly, confirmatory PRNT testing revealed that the majority of alphavirus exposures were due to o’nyong nyong virus, rather than chikungunya virus. Both CHIKV and ONNV antibodies were confirmed in young children, demonstrating undocumented and ongoing transmission in this region. Of the examined risk factors, older age and female gender were associated with alphavirus seropositivity.

Epithelioid hemangioendotheliomas are rare vascular tumors, often arising from medium to large veins in the extremities. Symptoms of these tumors vary depending upon location. Rarely, tumors may arise in chest and involve large vessels in the mediastinum. We present a case of a 17-year-old male presenting with compressive symptoms of the left upper extremity who was found to have a large epithelioid hemangioendothelioma encasing the left brachiocephalic vein.