Objective To examine genotypic and clinical differences between encapsulated, non-encapsulated and diffuse follicular variant of papillary thyroid carcinoma (EFVPTC, NFVPTC, diffuse FVPTC), in order to characterize the entities and identify predictors of their behavior. Design Retrospective chart review and molecular analysis. Setting Referral center of a university hospital. Patients The pathology of 484 consecutive patients with differentiated thyroid cancer who underwent surgery by the 3 members of the NYU Endocrine Surgery Associates from January 1, 2007 to August 1, 2010 was reviewed. Forty-five patients with FVPTC and in whom at least 1 central compartment lymph node was removed were included. Main Outcome Measures Patients with FVPTC were compared in terms of age, gender, tumor size, encapsulation, extrathyroid extension, vascular invasion, central nodal metastases, and the presence or absence of mutations in BRAF, H-RAS 12/13, K-RAS 12/13, N-RAS 12/13, H-RAS 61, K-RAS 61, N-RAS 61 and RET/PTC1. Results No patient with EFVPTC had central lymph node metastasis and in this group, 1 patient (4.5%) had a BRAFV600E mutation and 2 patients (9%) had RAS mutations. Of the patients with NFVPTC, 0 had central lymph node metastasis (p=1) and 2 (11%) had a BRAFV600E mutation (p=0.59). Of the patients with diffuse FVPTC, all had central lymph node metastasis (p=0.0001) and 2 (50%) had a BRAFV600E mutation (p=0.12). Conclusions FVPTC consists of several distinct subtypes. Diffuse FVPTC seems to present and behave in a more aggressive fashion. It has a higher rate of central nodal metastasis and BRAFV600E mutation in comparison to EFVPTC and NFVPTC. Both EFVPTC and NFVPTC behave in a similar fashion. The diffuse infiltrative pattern and not just presence/absence of encapsulation seems to determine the tumor phenotype. Understanding the different subtypes of FVPTC will help guide appropriate treatment strategies.

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Alcohol use is a significant risk factor for pedestrians who are struck by motor vehicles. These patients are more likely to cross the street in an unsafe manner and sustain more serious injuries. Traffic safety and injury prevention programs must address irresponsible alcohol use by pedestrians.

Objectives The mortality of patients with Clostridum Dificile Associated Disease (CDAD) requiring surgery continues to be very high. Loop ileostomy (LI) was introduced as an alternative procedure to total colectomy (TC) for CDAD by a single center study. To date, no reproducible results have been published. The objective of this study is to compare these two procedures in a multicentric approach to help the surgeon decide what procedure is best suited for the patient in need. Methods This was a retrospective multicenter study conducted under the sponsorship of the Eastern Association for the Surgery of Trauma (EAST). Demographics, medical history, clinical presentation, APACHE score, and outcomes were collected. We used the Research Electronic Data Capture (REDCap) tool to store the data. Mann-Whitney (continuous data) and Fisher’s Exact (categorical data) were utilized to compare TC with LI. Logistic regression was performed to determine predictors of mortality. A propensity score analysis was done to control for potential confounders and determine adjusted mortality rates by procedure type. Results We collected data from 10 centers of patients that presented with CDAD requiring surgery between July 1of 2010 to July 30 of 2014. Two patients died during the surgical procedure leaving 98 individuals in the study. The overall mortality was 32% and 75% suffered postoperative complications. Median age was 64.5 years, 59% were male. Concerning preoperative patient conditions 54% were on pressors, 47% had renal failure, and 36% suffered respiratory failure. When comparing TC and LI, there was no statistical difference regarding these conditions. Univariate pre-procedure predictors of mortality were age, lactate, timing of operation, vasopressor use, and acute renal failure. There was no statistical difference between the APACHE score of patients undergoing either procedure (TC=22 vs LI= 16). Adjusted mortality (controlled for pre-procedure confounders) was significantly lower in the LI group (17.2% vs. 39.7%, p=0.002). Conclusions This is the first multicenter study comparing TC with LI for the treatment of CDAD. In this study LI carried less mortality than TC. In patients without contraindications, LI should be considered for the surgical treatment of CDAD. Level of evidence prognostic retrospective multi-centric level III

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Background BRAF V600E mutation is the most common genetic alteration in papillary thyroid cancer (PTC). We utilized a mutation-specific antibody for immunohistochemical (IHC) detection of the BRAF V600E mutation and correlated expression with clinicopathological features. The study was designed to validate the accuracy and determine the significance of IHC detection of the BRAF V600E mutation in PTC. Methods Direct sequencing and IHC for BRAF V600E mutation was performed in 37 consecutive PTCs. IHC was scored on an intensity, proportion scale. IHC positive tumors were stratified into intensity categories. The categories were assessed for clinicopathologic variables including age, extrathyroidal extension, lymphovascular invasion, and lymph node metastases. Results 25 PTCs were BRAF V600E positive and 12 were BRAF mutation negative on IHC. The BRAF V600E mutation-specific antibody showed a sensitivity of 89% and specificity of 100% for detecting the mutation. Tumors with high intensity staining were significantly more likely to have extrathyroidal extension. Conclusions IHC is an accurate method for the detection of the BRAF V600E mutation in PTC and its ability to quantify the mutation expression may serve as a better predictor of tumor behavior than molecular sequencing. It provides a potentially rapid, easily applicable and economical alternative to current techniques.

INTRODUCTION:Current guidelines recommend nonoperative management (NOM) of low-grade (American Association for the Surgery of Trauma-Organ Injury Scale Grade I-II) pancreatic injuries (LGPIs), and drainage rather than resection for those undergoing operative management, but they are based on low-quality evidence. The purpose of this study was to review the contemporary management and outcomes of LGPIs and identify risk factors for morbidity. METHODS:Multicenter retrospective review of diagnosis, management, and outcomes of adult pancreatic injuries from 2010 to 2018. The primary outcome was pancreas-related complications (PRCs). Predictors of PRCs were analyzed using multivariate logistic regression. RESULTS:Twenty-nine centers submitted data on 728 patients with LGPI (76% men; mean age, 38 years; 37% penetrating; 51% Grade I; median Injury Severity Score, 24). Among 24-hour survivors, definitive management was NOM in 31%, surgical drainage alone in 54%, resection in 10%, and pancreatic debridement or suturing in 5%. The incidence of PRCs was 21% overall and was 42% after resection, 26% after drainage, and 4% after NOM. On multivariate analysis, independent risk factors for PRC were other intraabdominal injury (odds ratio [OR], 2.30; 95% confidence interval [95% CI], 1.16-15.28), low volume (OR, 2.88; 1.65, 5.06), and penetrating injury (OR, 3.42; 95% CI, 1.80-6.58). Resection was very close to significance (OR, 2.06; 95% CI, 0.97-4.34) (p = 0.0584). CONCLUSION:The incidence of PRCs is significant after LGPIs. Patients who undergo pancreatic resection have PRC rates equivalent to patients resected for high-grade pancreatic injuries. Those who underwent surgical drainage had slightly lower PRC rate, but only 4% of those who underwent NOM had PRCs. In patients with LGPIs, resection should be avoided. The NOM strategy should be used whenever possible and studied prospectively, particularly in penetrating trauma.

BACKGROUND Unaddressed alcohol use among injured patients may result in recurrent injury or death. Many trauma centers incorporate alcohol screening, brief intervention, and referral to treatment for injured patients with alcohol use disorders, but systematic reviews evaluating the impact of these interventions are lacking. METHODS An evidence-based systematic review was performed to answer the following population, intervention, comparator, outcomes question: Among adult patients presenting for acute injury, should emergency department, trauma center, or hospital-based alcohol screening with brief intervention and/or referral to treatment be instituted compared with usual care to prevent or decrease reinjury, hospital readmission, alcohol-related offenses, and/or alcohol consumption? A librarian-initiated query of PubMed, MEDLINE, and the Cochrane Library was performed. The Grading of Recommendations Assessment, Development and Evaluation methodology was used to assess the quality of the evidence and create recommendations. The study was registered with PROSPERO (registration number CRD42019122333). RESULTS Eleven studies met criteria for inclusion, with a total of 1,897 patients who underwent hospital-based alcohol screening, brief intervention, and/or referral to treatment for appropriate patients. There was a relative paucity of data, and studies varied considerably in terms of design, interventions, and outcomes of interest. Overall evidence was assessed as low quality, but a large effect size of intervention was present. CONCLUSION In adult trauma patients, we conditionally recommend emergency department, trauma center, or hospital-based alcohol screening with brief intervention and referral to treatment for appropriate patients in order to reduce alcohol-related reinjury. LEVEL OF EVIDENCE Systematic review, Level III.