ICG angiography allows for visualization of the parathyroid gland’s feeding vessels by enhancing their vascular map, as well as to evaluate their viability. Parathyroid gland vessel identification and its preservation using ICG angiography-guided thyroidectomy have proven to aid in maintaining parathyroid function and reducing transitory and permanent hypocalcaemia. 1 Preservation of inferior parathyroid glands’ vascularization during thyroidectomy is difficult due to their position, as they often have long pedicles, and especially for the right inferior parathyroid gland, as its feeding vessel can be intertwined with the recurrent laryngeal nerve. Furthermore, it may become especially challenging when their vessels are subcapsular. We present the video of a right lobectomy, focusing on the angiography-guided dissection of the inferior parathyroid gland with its vascularization in a subcapsular position. We use our described technique of ICG angiography guided thyroidectomy 2 in order to identify vascularization of the parathyroid glands before starting dissection of the right lobe. We administer 1 mL of a diluted solution of 25 mg of ICG and 10 mL of bidistilled water intravenously. After 10–30 seconds, we are able to identify a well-perfused right inferior parathyroid gland and a main identifiable feeding vessel with a defined pattern of vascularization. In this case, the right superior gland shows no perfusion with ICG angiography, and, therefore, we are not able to identify the gland’s feeding vessel before starting dissection. Visualization of the vessels with ICG also permits the use of high-energy devices with safety, as we are able to maintain the distance of thermal injury. Identification of the recurrent laryngeal nerve is an important step in preserving the inferior parathyroid gland’s vascularization. 2 Cranial dissection of the nerve until its intersection with the branches of the inferior thyroid artery allows for their better dissection and preservation on the right side. Visualization of the vessels with ICG also permits the use of high-energy devices with safety, as we are able to maintain the distance of thermal injury. Repeated doses of ICG may help in the dissection of the gland’s feeding vessel as it is often intertwined with the laryngeal nerve. Preserving the inferior parathyroid gland is especially challenging due to its long pedicle and its close relation with the laryngeal nerve and the branches of the inferior thyroid artery. We perform a careful dissection of the previously identified feeding vessel caudally from the exact point where the branch originates from the inferior thyroid artery, following its path to the inferior gland. After lobectomy is completed, we perform ICG angiography showing no ICG uptake in the superior gland, while the inferior gland shows an intact vascularization and degree of perfusion than before starting dissection, maintaining a score of 2. As stated in our previously published articles, one well-perfused parathyroid gland is enough to predict normal function and therefore normal blood calcium levels. 3 With this technique, we propose a paradigm shift in thyroidectomy by beginning with the identification of the parathyroid glands and their vascular map using ICG before lobectomy. No competing financial interests exist for none of the authors of this abstract. Representation of any instrumentation does not indicate an endorsement of the product and/or company by the publisher, the American Thyroid Association, or the authors. P Moreno Llorente is a KOL for J&J. NO disclosures. Authors have received and archived patient consent for video recording/publication in advance of video recording of the procedure. Runtime of video: 4:11 mins
Background: Normal brain development, mood, and cognitive functions depend on thyroid hormone (TH) action. However, little is known about how TH mediates its actions in the human brain. This is due to limited access to human brains deprived of TH during fetal and early postnatal life, as well as from adults with altered thyroid status. One way to partially bypass these limitations is by using magnetic resonance imaging and spectroscopy, two neuroimaging techniques that provide detailed, noninvasive information on human brain structure and function. Another way is using human-induced pluripotent stem cell (hiPSCs)-derived three-dimensional in vitro systems, known as brain organoids, which allow for the study of fundamental aspects of the early stages of human brain development. Summary: This narrative review focuses on neuroimaging and brain organoid studies. Neuroimaging of human brains performed in individuals with different thyroid conditions provides information on the volume, myelination, blood flow, neural activity, and connectivity of different areas. Such studies show that suboptimal thyroid status can impact human brain development and its normal function throughout life. This is true not only for patients with sporadic congenital hypothyroidism, during pregnancy or early after birth, but also for adult patients with hypo- or hyperthyroidism, patients carrying mutations that manifest as impaired sensitivity to TH, and even for normal individuals during aging. Studies using brain organoids generated from hiPSCs of healthy individuals or patients with thyroid genetic conditions provide insights into how TH can impact the early development of the human cerebral cortex. Conclusions: The developmental alterations in children born to mothers with different degrees of gestational hypothyroidism or who developed hypothyroidism early in life are remarkable, affecting multiple brain regions and pathways, including the cerebral cortex, hippocampus, cerebellum, interhemispheric and corticospinal tracts, and associative nuclei. The data connecting such changes to poor neurological outcomes in adult patients with hypothyroidism represent an objective link between thyroid-specific functional brain alterations and behavior. Growing brain organoids require TH, which is critical for human neurogenesis and oligodendrogenesis. These models have proven useful in screening drugs with potential therapeutic effects for patients with genetic thyroid diseases.
Background: Although childhood exposure to radioactive iodine-131 (I-131) is an established risk factor for thyroid cancer, evidence for an association with thyroid nodules is less clear. The objective of this study is to evaluate the association between childhood I-131 exposure and prevalence of ultrasound-detected thyroid nodules overall and by nodule histology/cytology (neoplastic/suspicious/non-neoplastic), size (<10 mm/>= 10 mm), and number (single/multiple). Methods: This is a cross-sectional study of radiation dose (mean = 0.53 gray, range: 0.0003-31 gray) and screen-detected thyroid nodules conducted in 1998-2000 (median population age 21.5 years) in a cohort of 13,243 residents of Ukraine who were under 18 years at the time of the Chornobyl accident on April 26, 1986. Excess odds ratios per gray (excess odds ratio [EOR]/Gy) and confidence intervals (CIs) were estimated using logistic regression. Results: Among 13,078 eligible individuals, we identified 358 (2.7%) with at least one thyroid nodule. Significantly increased dose-response associations were found for all nodules and nodule groups with doses <5 Gy except individuals with non-neoplastic nodules. Among individuals with doses <5 Gy, the EOR/Gy for neoplastic nodules (5.35; CI: 2.19-15.5) was significantly higher than for non-neoplastic nodules (0.24; CI: 0.07-0.74), but the EOR/Gy did not vary by nodule size or number. Conclusions: Childhood exposure to I-131 is associated with an increased risk of thyroid nodules detected 12-14 years following exposure, and the risk for neoplastic nodules is higher than for non-neoplastic nodules. Analyses of incident thyroid nodules may help clarify dose-response patterns by nodule characteristics and provide insights into thyroid nodule etiology.
Background: Serum thyroid-stimulating hormone (TSH) measurement is the diagnostic cornerstone for primary thyroid dysfunction. There is high inter-individual but limited intra-individual variation in TSH concentrations, largely due to genetic factors. The currently used wide population-based reference intervals may lead to inappropriate management decisions.Methods: A polygenic score (PGS) including 59 genetic variants was used to calculate genetically determined TSH reference ranges in a thyroid disease-free cohort (n = 6,834). Its effect on reclassification of diagnoses was investigated when compared to using population-based reference ranges. Next, results were validated in a second independent population-based thyroid disease-free cohort (n = 3,800). Potential clinical implications were assessed in a third independent population-based cohort including individuals without thyroid disease (n = 26,321) as well as individuals on levothyroxine (LT4) treatment (n = 1,132).Results: PGS was a much stronger predictor of individual TSH concentrations than FT4 (total variance in TSH concentrations explained 9.2-11.1% vs. 2.4-2.7%, respectively) or any other nongenetic factor (total variance in TSH concentrations explained 0.2-1.8%). Genetically determined TSH reference ranges differed significantly between PGS quartiles in all cohorts, while the differences in FT4 concentrations were absent or only minor. Up to 24.7-30.1% of individuals, previously classified as having subclinical hypo- and hyperthyroidism when using population-based TSH reference ranges, were reclassified as euthyroid when genetically determined TSH reference ranges were applied. Individuals in the higher PGS quartiles had a higher probability of being prescribed LT4 treatment compared to individuals from the lower PGS quartiles (3.3% in Q1 vs. 5.2% in Q4, Pfor trend =1.7 x 10-8).Conclusions: Individual genetic profiles have the potential to personalize TSH reference ranges, with large effects on reclassification of diagnosis and LT4 prescriptions. As the currently used PGS can only predict approximately 10% of inter-individual variation in TSH concentrations, it should be further improved when more genetic variants determining TSH concentrations are identified in future studies.
Background: Diagnostic classification of thyroid malignancy is primarily accomplished through examination of histomorphological features and may be substantiated and clarified by molecular data. Individual molecular drivers show relatively robust and specific associations with histological subtypes of thyroid malignancy, including BRAF sequence variants and kinase gene fusions in papillary thyroid carcinoma, predominantly RAS variants in follicular-patterned neoplasia, and additional "late" mutations affecting TERT promoter, TP53, and the PI3K/AKT/PTEN pathway in high-grade malignancies. Given the oncogenic role of FGFR, particularly FGFR1-3, the goal of this study was to explore the role of FGFR in thyroid carcinoma biology. Methods: We completed a multicenter retrospective observational study for thyroid carcinomas with pathogenic alterations in the FGFR gene family. We performed this study by querying the molecular data accumulated for thyroid carcinomas from each center. Results: Overall, 5030 sequenced thyroid malignancies were reviewed, yielding 17 tumors with FGFR alterations, including 11 where FGFR was the primary molecular driver and 6 where FGFR was a secondary pathogenic alteration, with a subset for which there was available clinical follow-up data. Of the 11 carcinomas with an FGFR driver, 9 were gene fusions involving FGFR2:VCL (4 tumors), TG::FGFR1 (3 tumors), FGFR2::CIT, and FGFR2::SHTN1, and the remaining 2 were driven by FGFR1 amplification. In the 6 tumors where a canonical driver of thyroid neoplasia was present (5 cases) or no clear primary driver was detected (1 case), sequencing detected secondary FGFR2 p.W290C, p.Y375C, and p.N549K, as well as FGFR1 p.N546K in the respective tyrosine kinase domains, some at subclonal variant allele frequencies. Conclusions: This study presents the first description of a collection of thyroid carcinomas grouped by primary driver alterations in FGFR, as well as a cohort of thyroid tumors with secondary alterations that potentially lead to tumor progression or resistance to targeted therapy. Given the availability of small molecular inhibitors targeting oncogenic FGFR, this study emphasizes the significant implications for patients from identification of FGFR alterations as they are currently under-recognized in the literature and, most importantly, have potential novel treatment options.
Background: Long-term management of intermediate- and high-risk differentiated thyroid cancer (DTC) involves thyrotropin (TSH) suppression with thyroid hormone to prevent potential stimulation of TSH receptors on DTC cells, leading to tumor growth. However, the current guidelines recommending TSH suppression are based on low- to moderate-quality evidence. Methods: We performed a systematic review and meta-analysis of studies evaluating the role of TSH suppression in intermediate- and high-risk DTC patients (>= 18 years) treated as per regional guideline-based therapy with a follow-up duration of 5 years (PROSPERO #252396). TSH suppression was defined as "below normal reference range" or, when known, <0.5 mIU/L. Primary outcome measures included (i) composite of progression-free survival (PFS), disease-free survival (DFS), and relapse-free survival (RLFS), and (ii) composite of disease-specific survival (DSS), and overall survival (OS). Secondary outcome included a composite of cardiac or skeletal adverse events. All outcomes and comparisons were represented as TSH suppression versus TSH nonsuppression. Randomized controlled trials, cohort studies, and case-control studies were included for analysis. Pooled hazard ratio (HR) and 95% confidence interval (CI) were calculated using random-effects model. Results: Abstract screening was performed on 6,369 studies. After the exclusion of irrelevant studies and full-text screening, nine studies were selected for the final meta-analysis. Based on seven studies (3,591 patients), the composite outcome of PFS, DFS, and RLFS was not significantly different between TSH suppression and nonsuppression groups (HR: 0.75; 95% CI: 0.48-1.17; I-2 = 76%). Similarly, a DSS and OS composite outcome assessment based on four studies (3,616 patients) did not favor TSH suppression (HR: 0.69; 95% CI: 0.31-1.52; I-2 = 88%). Even after excluding studies of lower quality, the primary outcomes were not significantly different between the TSH suppression and nonsuppression cohorts. The secondary outcome, obtained from two studies (1,294 patients), was significantly higher in the TSH-suppressed groups (HR: 1.82; 95% CI: 1.30-2.55; I-2 = 0%). Significant study heterogeneity was noted for primary outcomes. Conclusion: TSH suppression in intermediate- and high-risk DTC may not improve survival outcomes but may increase the risk of secondary complications. However, the limited evidence and study heterogeneity warrant cautious interpretation of our findings.
Background: The transoral endoscopic thyroidectomy via vestibular approach (TOETVA) is a scarless technique with all incisions hidden within the oral vestibule. However, removal of larger specimens via the middle vestibular incision is challenging, with risks of specimen rupture, chin pain, and wound complications. A hybrid transoral and submental technique (TOaST) for thyroidectomy can obviate these limitations.
Injury to the laryngeal nerves is a possible complication of thyroid thermal ablation techniques. Existing ablation guidelines recommend checking a patient's voice intermittently during ablation procedures to assess for hoarseness. However, this is a similar scenario to the use of intermittent neuromonitoring during thyroid surgery, a technique that relies on surgeon-driven nerve stimulation at sporadic timepoints. The primary issue with these intermittent techniques is that changes occurring between proceduralist-driven checks are unable to be detected. This is in contrast to continuous intraoperative neuromonitoring where the laryngeal nerves are stimulated throughout the procedure, thereby providing real-time information about nerve functional integrity. After neck endocrine surgeries, voice changes can be masked by two main effects: 1. Endotracheal intubation frequently creates some mild edema of the vocal folds that can mask symptoms of an immobile vocal fold in the first few days. The patient may still note some change in their voice, but it is not severe enough for them to complain. 2. Surgery is performed under general anesthesia and thus audible voice change at the time of nerve injury cannot be assessed. Over ensuing weeks until the first postoperative review, the contralateral vocal cord has some ability to compensate for the ipsilateral weakness by hyperadducting and the paralyzed vocal cord can assume a medialized position. This can mask externally perceived hoarseness and, if the larynx is not directly examined, miss a paralyzed cord. As compared with surgery under general anesthesia, thyroid ablation is generally performed with the patient awake using local anesthesia. This allows the proceduralist to actually hear, in real-time, any voice change occurring as a result of laryngeal nerve thermal injury. There is no endotracheal tube-induced vocal fold edema to falsely and transiently compensate for incomplete vocal fold closure caused by vocal fold paresis or paralysis, and there is no masking effect from delayed ability to assess the voice. Continuous Auditory Voice Assessment (CAVA) refers to the use of continuous voicing during thermal ablation of danger zones. CAVA can be safely performed during ablation without significant motion in the ultrasound image provided patients are asked to vocalize without large pitch inflections, thereby enabling continuous auditory feedback on vocal integrity. This video introduces the concept of CAVA and demonstrates how it can be safely and effectively performed during thermal ablation of thyroid nodules. CAVA potentially lessens the risk of laryngeal nerve injury by allowing for immediate procedure cessation and remedial actions if voice change is heard. Further studies are necessary to better determine its utility in preventing recurrent laryngeal nerve injuries; however, its simplicity to perform and potential benefit make it a valuable addition to the current armamentarium of safety techniques in thermal ablation. No competing financial interests exist for information contained within this video. Runtime of video: 9 mins 1 sec
Introduction: Intraoperative neuromonitoring in thyroid surgery has several different techniques that can be used with a goal to prevent nerve injury and predict postoperative recurrent laryngeal nerve function. This video aims to compare traditional intermittent neuromonitoring with continuous monitoring, specifically laryngeal adductor reflex monitoring. Methods: Both neuromonitoring techniques were captured for standard thyroidectomy cases, performed by the first and senior authors. Video was captured intraoperatively to illustrate the techniques described. Results: Intermittent and continuous laryngeal adductor reflex neuromonitoring techniques are directly compared using specific examples of their applications. The advantages and disadvantages of both techniques are explored to illustrate how they can be used in various surgical situations. Specifically, the neurophysiology behind each technique is discussed and how this impacts its utilization and interpretation. Conclusions: Intermittent and continuous neuromonitoring have complementary applications and ideally can be used in conjunction to provide the best patient outcomes.1 No competing financial interests exist. Runtime of video: 9 mins 12 secs
Introduction: Many patients with anaplastic thyroid cancer (ATC) present with vocal cord paralysis. Patients with BRAF-mutated ATC have been shown to have rapid and dramatic responses to BRAF/MEK inhibitor with immunotherapy.1–5 These rapid and dramatic responses have been associated with recovery of vocal cord function, as has been recently reported in a multi-institutional case series in the literature.6 Herein we demonstrate pre- and post-treatment positron emission tomography (PET) scans and video laryngoscopies in a series of patients with BRAF-mutated ATC who had recovery of nerve function after treatment with BRAF/MEK inhibitor and immunotherapy. Methods: We present a case series of five patients with BRAF-mutated ATC who presented with either unilateral (four patients) or bilateral (one patient) vocal cord paralysis/paresis. Pre-treatment and post-treatment video laryngoscopies, and pre-treatment and post-treatment PET scans were performed for each patient. Results: All five patients presented with significantly locoregionally advanced ATC, as demonstrated by pre-treatment PET scans. Pre-treatment videostroboscopy was performed on all patients, displaying two with right vocal cord paralysis, two with left vocal cord paralysis, and one with bilateral vocal cord paresis. All patients underwent BRAF/MEK inhibitor with immunotherapy, with 3 (range 2–22) months median duration of therapy, followed by post-treatment PET imaging and video laryngoscopy. All five post-treatment PET scans showed complete or near-complete resolution of PET avid disease in the neck. Postneoadjuvant therapy video laryngoscopy demonstrated return of vocal cord function in all patients. All five patients proceeded to surgery after neoadjuvant therapy, wherein all patients had significant desmoplasia and fibrosis partially encasing the recurrent laryngeal nerve(s). Of the six nerves that were initially paretic and recovered function after neoadjuvant therapy, all were anatomically preserved during surgery. Intraoperative intermittent neural integrity monitoring (NIM) of these six nerves revealed the following: two nerves initially stimulated but lost stimulation during dissection, whereas four nerves did not ever stimulate at any time during the procedure. Flexible laryngoscopy of the six affected vocal cords postsurgery revealed the following: five vocal cords were mobile and one remained pending evaluation. Conclusions: Given that ATC represents an extremely fast-growing malignancy, and initial nerve paralysis/paresis may be reversible with rapid initiation of therapy with rapid disease response. With BRAF-mutated ATC, BRAF/MEK inhibitors with immunotherapy have been demonstrated to induce these rapid and dramatic responses in many patients. This allows for the possibility of nerve recovery in some patients if nerve compression and/or early nerve invasion is quickly reversed. IRB approval: This research was conducted after MD Anderson Cancer Center IRB approval and patient consent was waived. M.E.C. receives Bayer, Exelixis, Lilly advisory board/consulting fees and grant funding from Merck, Genentech:. K.H. has funding from the PCORI, NIH/NIDCR, NIH/NCI, Atos Medical, Charles and Daneen Stiefel Fund, DOD, and MD Anderson Institutional Research Grant Program. C.B. has funding from MD Anderson Internal Research Grant and NIH/NCI. R.D. has research support from Exelixis, Eisai, Merck, AstraZeneca; consulting fees from Exelixis, Bayer. N.L.B. has research funding from Novartis; is on ad board of Eisai; and consultant of Exelixis. M.E.Z. has clinical trial research funding to MD Anderson Cancer Center from Merck and Eli Lilly. E.E.H., S.H.S., P.C.I., J.R.W., and A.M. have no disclosures. One of these five patients in this case series was recently published as a Letter to the Editor in Thyroid (reference included herein) as part of a multi-institutional case series (six patients total). This recently published Letter to the Editor did not include pre-/post-treatment video laryngoscopies or pre-/post-treatment PET scans. This current case series submitted to VideoEndocrinology includes an additional four patients, plus one patient included in the aforementioned multi-institutional case series. We could not include three other patients from MDACC who were included in the recent multi-institutional series, as they did not have pre- and post-treatment video laryngoscopies, which we feel is essential for this video article. Runtime of video: 7 mins 43 secs
Introduction: In neck endocrine surgeries, the recurrent laryngeal nerve (RLN) is at risk of injury, requiring reliable monitoring methodologies.1 This video explains the integration of intermittent and continuous nerve monitoring, focusing on the laryngeal adductor reflex (LAR),2 a noninvasive technique to assess RLN, vagus nerve, and superior laryngeal nerve integrity during surgery.3 Materials and Methods: Two main forms of nerve monitoring—intermittent and continuous (CIONM)—are currently employed. The noninvasive tube-based LAR technique offers real-time feedback without operative exposure or additional devices. A specialized endotracheal tube (NIM EMG ® Medtronic Xomed Inc., Jacksonville, FL, USA) is used for LAR stimulation and recording. For LAR elicitation, one pair of stainless-steel wire electrodes integrated in the tube are connected to the stimulating box delivering a single or short train of electrical pulses up to 25 mA intensity, 0.5–1 ms duration at 0.4 Hz rate. For LAR recording, the contralateral pair of wire electrodes are connected to the amplifier box. To optimize our recordings, one bipolar and two monopolar derivations were utilized (i.e., V+/V−; V+/Reference; V−/Reference). Direct nerve stimulation with a hand-held probe (mapping) at 0.5–0.8 mA intensity (0.2 ms duration) at 4 Hz rate aids in nerve localization, identification, and integrity. All electrophysiologic LAR stimulation and recordings were made using a Medtronic Eclipse® system (Medtronic Xomed, Inc.). The institutional review board of the Icahn School of Medicine at Mount Sinai Hospital approved this study (STUDY-23-01728). Results: The video illustrates the intubation process under video laryngoscope observation (GlideScope, Verathon Inc., Seattle, WA, USA), emphasizing the importance of maintaining optimal electrode contact with laryngeal structures. The setup, positioning, and tube fixation procedures (Anchor-Fast™, Libertyville, IL, USA) are detailed. The characteristics of the LAR recordings are described. LAR preskin incision opening baselines provide reference values crucial for monitoring during surgery. Surgical approaches are discussed, emphasizing constant communication between surgeons and neurophysiologists during RLN localization and dissection. The LAR technique aids surgeons in timely corrective actions when intraoperative changes in nerve signals occur. Previous studies have shown that the LAR methodology presents high specificity, presenting no false negatives.4–9 Therefore, if the LAR is stable as the surgery is advanced, the surgeon can be confident that the RLN's integrity and function are preserved. While adding costs by the neurophysiologist participation, the potential benefits in enhancing patient safety justify this approach. Conclusions: This study emphasizes the advantage of combining intermittent mapping with LAR-CIONM over mapping alone in challenging scenarios, such as revision surgery. LAR-CIONM offers continuous real-time assessment of laryngeal nerve function without operative nerve exposure, but its success depends on optimal endotracheal tube positioning and expert neurophysiologist support. The study discusses prospects, anticipating improved monitoring with dedicated advanced EMG endotracheal tubes, and dedicated machine programming. No authors have conflicts of interest in connection with the video. Runtime of video: 11 mins 00 secs
Introduction: Standards for intraoperative nerve monitoring (IONM) during thyroid and parathyroid surgery are well established.1,2 Most monitoring systems use endotracheal tube-based electrodes. Applications of nerve monitoring include intraoperative neural identification and mapping, neural dissection, identification of impending neurologic injury, and neural prognostication at the conclusion of surgery, among others. Intermittent IONM (I-IONM) assesses the nerve at surgeon-directed specific timepoints using a hand-held probe. Continuous IONM (C-IONM) assesses the functional status of the nerve every few seconds without surgeon input required. C-IONM may be associated with lower early and permanent postoperative vocal fold paralysis compared with I-IONM.3 Materials and Methods: This 10-minute 49-second video summarizes the role of IONM for thyroid and parathyroid surgeries. Particular attention is paid to the differences between C-IONM and I-IONM. An instructional case demonstrating the use of C-IONM is included. Results: A baseline electromyographic (EMG) signal should be obtained to confirm a working monitoring system and an intact nerve. An adequate baseline includes an amplitude of at least 500 μV at a 1 to 2 mA stimulus, as well as a detectable laryngeal twitch. A severe combined event, marking impending neuropraxia, is defined as a concurrent decrease in EMG amplitude by at least 50% from baseline, and an increase in latency of at least 10%. C-IONM allows for real-time tracking of amplitude and latency changes, which can help direct the surgeon to avoid or cease maneuvers that precipitate adverse EMG changes. C-IONM does not lend itself to nerve mapping and identification, which are features of I-IONM. I-IONM and C-IONM are complementary in their functions. Conclusions: C-IONM has the ability to provide real-time feedback, potentially allowing avoidance of a slowly evolving nerve injury. The use of C-IONM with a vagal electrode is demonstrated in this video. G.W.R. receives research institutional grants from Eisai, Fluoptics, and Medtronic. He is also a Medtronic consultant. All other authors have no relevant disclosures. Runtime of video: 10 mins 49 secs
