BACKGROUND:With the rise in cross-sectional imaging, adrenal incidentalomas are increasingly detected. However, adherence to recommended biochemical evaluation remains low. To improve the evaluation and management of adrenal nodules, we implemented a multicomponent intervention incorporating standardized radiology reporting, an electronic health record-embedded adrenal nodule order set, and a specialized adrenal clinic. This study evaluates early clinical outcomes following implementation. METHODS:Patients referred to a specialized adrenal clinic between June 1, 2024 and October 31, 2025 were evaluated. Referrals were triggered by standardized radiologic identification of an adrenal nodule and reference to an adrenal nodule order set. The order set initiated biochemical testing and clinic referral. The primary outcome was the completion of biochemical evaluation. Secondary outcomes included follow-up, diagnostic evaluation, and surgical intervention. RESULTS:During the study period, 301 patients were referred, and 130 patients completed a clinic visit. Initial biochemical evaluation was completed in 117 patients (90%). Ninety-two patients underwent confirmatory testing, revealing that 72 (73.5%) had nonfunctional adenomas and 20 (20.4%) had hormonally active disease, including primary aldosteronism (11.2%), mild autonomous cortisol secretion (7.1%), and pheochromocytoma (2.0%). Thirteen patients were referred for surgical evaluation, of whom 8 (61.5%) underwent adrenalectomy. CONCLUSION:Implementation of a standardized adrenal incidentaloma evaluation pathway incorporating radiology templating, electronic health record-embedded ordering, and a specialized adrenal clinic was associated with improved completion of biochemical testing and identification of significant disease. Multilevel health-system interventions may bridge the evidence-to-practice gap in the management of adrenal incidentalomas and facilitate the identification of surgically actionable lesions.

BACKGROUND:Alpha-blockade is utilized in the preoperative preparation of patients with pheochromocytomas. Both selective and nonselective alpha-blockade are safe with equivalent clinical outcomes; the goal of this study was to evaluate the comparative costs of selective and nonselective alpha-blockade. PATIENTS AND METHODS:We performed a retrospective cohort study (2004-2022) of patients who underwent adrenalectomy for pheochromocytoma with preoperative alpha-blockade from Optum's deidentified Clinformatics® Data Mart Database. Patients were stratified by treatment with selective (prazosin, doxazosin, terazosin) or nonselective (phenoxybenzamine) alpha-blockade. Primary outcomes were: (1) costs of alpha-blockade in the 30 days prior to surgery (AB) and (2) adjusted standard costs from admission to discharge (AC). Secondary outcomes included length of hospital stay (LOS), intensive care unit (ICU) admission, costs 30 days after discharge (AD), and cumulative costs (CC). RESULTS:In total, 384 patients received selective, and 418 patients received nonselective alpha-blockade. The median age was 58 years (IQR 21 years). Median AB was significantly lower in the selective compared with nonselective alpha-blockade group ($19.73 versus $1033.70, p < 0.001). Median AC ($31,104.47 versus $31,471.90, p = 0.428) and AD ($790.78 versus $715.10, p = 0.074) were not significantly different between selective compared with nonselective alpha-blockade groups. On multivariable regression modeling, higher Elixhauser score (coeff.: $1,801.20, p < 0.001) and longer LOS (coeff.: $1842.33, p < 0.001) were associated with higher CC, while age (coeff.: $- 143.22, p = 0.044) was associated with lower CC. Notably, alpha-blockade strategy was not significantly associated with CC. CONCLUSIONS:When compared with nonselective alpha blockers, selective alpha blockers are associated with lower medication costs but equivalent hospitalization and post-hospitalization costs.

Primary aldosteronism (PA) is an under-diagnosed cause of resistant hypertension. In this study, we validated a PA risk stratification model in an independent cohort.Patients screened for PA were identified and risk scores were calculated for each patient. The predicted and observed proportions of PA-positive patients at each risk score were assessed and performance, accuracy, and cut-point analyses were calculated.Among 652 patients screened, 13% were positive for PA. Rates of PA increased significantly (p < 0.001) with increase in risk score and varied from 0% (1 point) to 29% (9 points). The optimal cut-point was 6. The model showed moderate performance at predicting the risk of PA, with AUC of 0.66 (95% CI 0.60-0.72), sensitivity of 0.57, and Brier statistic of 0.29.A novel scoring system was moderately accurate at predicting the risk of PA in an independent validation cohort and may be clinically useful in identifying patients at elevated risk.

ABSTRACT Background and Objectives Serious mental illness and dementia‐related disorders are associated with worse postoperative outcomes. We evaluated the impact of pre‐existing neuropsychiatric disorders on post‐parathyroidectomy healthcare utilization. Methods Adult patients who underwent parathyroidectomy for primary hyperparathyroidism were identified in the Healthcare Cost and Utilization Project State Inpatient and Ambulatory Surgery Databases (2016–2021). Neuropsychiatric disorders were classified. The primary outcome was 30‐day readmission. Secondary outcomes were length of stay and costs (2021USD). Balancing weights were used for covariate adjustment. Subgroup analyses were performed in serious mental illness and dementia‐related disorder groups. Results Of 10,733 parathyroidectomy patients, 1,249 (11.6%) had neuropsychiatric disorders: 60.5% mood, 58.8% anxiety, 5.1% dementia‐related, and 1.8% schizophrenia‐type disorders. Patients with neuropsychiatric disorders were younger and more likely to undergo emergent/urgent parathyroidectomy ( p < 0.001). There was no difference in adjusted odds of readmission between patients with and without neuropsychiatric disorders (0.91[95%CI 0.55, 1.49], p = 0.710). Adjusted length of stay was 0.20 days longer among patients with neuropsychiatric disorders ([95%CI: + 0.11, + 0.30]; p < 0.001). Adjusted encounter costs were similar between groups (median[IQI]: neuropsychiatric disorder $6767[5290,8589] vs. no neuropsychiatric disorder $6511[5259, 8550]; p = 0.080). Subgroup analyses showed similar results. Conclusions Patients with neuropsychiatric disorders have similar parathyroidectomy readmission and cost. They have slightly longer length of stay that may ameliorate the risk of readmission.

Primary aldosteronism (PA) can be treated surgically or medically depending on disease lateralization and surgical candidacy. There is a dearth of data directly comparing antihypertensive medication trajectories and costs between these strategies. We performed a retrospective cohort study of patients with new PA diagnoses and adrenal vein sampling to assess antihypertensive medication outcomes and treatment costs using Optum’s de-identified Clinformatics® Data Mart Database (2004–2022). Patients were stratified by receipt of adrenalectomy versus medical management alone. The index time point was defined as adrenal vein sampling (AVS) for medically managed and adrenalectomy for surgically managed patients. Outcomes were assessed using regression models. Of 911 patients, 52

OBJECTIVE:Primary hyperparathyroidism (PHPT) affects 1% of adults, but fewer than one-third of screen-eligible patients are tested. We developed and evaluated two new non-interruptive, clinician-facing alerts to increase appropriate PHPT screening. MATERIALS AND METHODS:We designed process changes to facilitate guideline-informed patient identification via electronic phenotyping, laboratory test ordering, result interpretation, and follow-up. The computable phenotype was retrospectively validated. Clinician-facing alerts were built atop existing workflows for health maintenance (HM) and pended orders (PO) and evaluated in separate primary care clinics. RESULTS:Screening laboratory orders were more frequent in PO (81%; n = 30/37; p < 0.001) and HM (57%; n = 51/90; p < 0.001) than in control (19%; n = 373/1945) clinics. Increased screening appeared to yield higher detection of likely PHPT in PO (43%; 16/37; p < 0.001) and HM (8%; 7/90; p = 0.01) than in control (2%; 48/1945) clinics. CONCLUSION:Non-interruptive alerts demonstrate potential to substantially increase PHPT screening among appropriate patients.

Introduction The need for thyroid hormone therapy (levothyroxine [LT4]) after partial thyroidectomy varies with clinical factors, including the preoperative thyroid stimulating hormone (TSH) level and diagnosis. The goal of this study was to develop an easy-to-use clinical risk score to predict the need for LT4 after partial thyroidectomy. Methods This is a retrospective cohort study of patients who underwent partial thyroidectomy between 2013 and 2020 at a single institution. The primary outcome was postoperative LT4 therapy. Univariable and multivariable logistic regression evaluated the relationship between covariates and LT4 therapy. Covariates selected by lasso regression as significantly associated with LT4 therapy were incorporated into a weighted risk score. Performance characteristics for the risk score were assessed. Results Of 425 patients, the median preoperative TSH was 1.4 uIU/mL interquartile range: 0.9-2.0), and 101 patients (23.8%) had a diagnosis of hypothyroidism. In total, 41.9% (n = 178) of patients required LT4 supplement after partial thyroidectomy. On multivariable logistic regression, non-Black race (odds ratio [OR]: 3.40, P < 0.001), preoperative TSH ≥1.59 (OR: 3.51, P < 0.001), and cancer diagnosis (OR: 2.08, P < 0.001) remained significantly associated with LT4 therapy and were incorporated into a clinical risk score. Rates of LT4 use increased with risk score points (0-2: 14%; 3-4: 34%; 5-6: 58%, 7-8: 75%). The model had a negative predictive value of 75% for LT4 therapy. Conclusions This simple risk score can be easily derived from data in the health record and can be used to counsel patients about likelihood of needing LT4 after partial thyroidectomy and guide clinical discussions about the extent of surgery in patients with thyroid nodules.

BackgroundTolerance of enteral nutrition following percutaneous endoscopic gastrostomy is a barrier to discharge. This study investigated the impact of an expedited feeding protocol following percutaneous endoscopic gastrostomy on postprocedure length of stay (LOS). MethodsWe performed a before-and-after cohort study on hospitalized adults in whom percutaneous endoscopic gastrostomy was placed by surgeons following the implementation of a standardized feeding protocol in which enteral feeds were resumed at the preoperative rate 6 h later. ResultsEnteral feeding resumed within 6 h postoperatively in 93% of patients after protocol initiation. The mean +/- SD time to the goal enteral rate after percutaneous endoscopic gastrostomy was significantly shorter following protocol implementation (15 +/- 10 vs 50 +/- 26 h, P <= 0.0001). Compared with the preprotocol cohort, there was no change in postoperative aspiration at 1 week (6% vs 4%, P = 0.531) or rates of tube dislodgement (10% vs 9%, P = 0.89), return to the operating room (10% vs 6%, P = 0.36), and surgical-site infection (9% vs 8%, P = 0.92) at 1 month in the protocol implementation cohort. On multivariable regression, an expedited feeding protocol generated a significantly shorter postprocedure LOS for patients remaining in the hospital for <= 1 week (beta = -2.14, 95% CI, -2.98 to -1.30; P < 0.001). ConclusionAn expedited feeding protocol following percutaneous endoscopic gastrostomy placement had a high degree of provider uptake without any significant change in safety outcomes. Beginning enteral nutrition within 6 h postoperatively at the preoperative rate reduced LOS by >2 days, suggesting that these protocols can address common delays to discharge.

Metabolic and bariatric surgery (MBS) is an effective treatment for obesity and metabolic syndrome. Evidence regarding the impact of MBS on hypertension outcomes is limited by short-term follow-up. Thus, this retrospective cohort study was designed to compare blood pressure (BP) control, number of antihypertensive medications (AHMs), development of apparent treatment resistant hypertension (ATRH), and remission of hypertension between patients treated with and without MBS. Adults with BMI ≥ 35 kg/m2 and a new diagnosis of hypertension receiving care within the Veterans Health Administration system from 2000–2019 were included. Generalized estimating equations and time-updated Cox models with inverse probability of treatment weighting to address time-updated confounding were used. Over a median follow-up of 5.1 years, 183702 patients with BMI ≥ 35 kg/m2 and hypertension were managed medically and 3965 were managed surgically. At baseline, those who underwent MBS were more likely to be women than men (22 vs. 10%). Patients treated surgically demonstrated significantly better BP control over time, with an average 5.4 mm Hg (95% CI 4.9–5.9) lower systolic BP and 1.8 mm Hg (95% CI 1.5–2.1) lower diastolic BP. Compared to patients treated medically, those who received MBS had 32% higher likelihood of complete AHM discontinuation (95% CI 1.23–1.42). Patients treated with MBS were 14% less likely to develop ATRH (95% CI 0.78–0.95). Overall, among patients with obesity and hypertension, treatment with MBS was associated with durably improved BP control compared to medical management, including lower systolic and diastolic BPs, higher AHM cessation, and lower rates of ATRH.

Incidental adrenal cysts are quite rare and thus can present a diagnostic conundrum for even experienced clinicians. Here, we present the case of a patient with an incidentally identified 5 cm adrenal mass. Her evaluation was notable for evidence of mild autonomous cortisol secretion and imaging findings concerning for malignancy with possible invasion of the inferior vena cava. Adrenalectomy was performed; pathology ultimately demonstrated an adrenal cortical pseudocyst without evidence of malignancy. All patients with solid, high-density, or large adrenal tumors require further imaging for characterization and biochemical testing for hormone secretion. While simple, low-density adrenal adenomas and cysts do not require further imaging evaluation beyond non-contrast CT, mixed cystic and solid lesions or pseudocystic lesions should be evaluated similarly to solid tumors, with the caveat that pseudocysts cannot always be well-differentiated from benign cysts on imaging. All adrenal incidentalomas should be evaluated with a biochemical work-up to assess hormonal activity. Tumors suspicious for malignancy require surgical excision. Patients with benign, hormonally active tumors should be managed surgically or medically, according to their primary pathology.

BACKGROUND:Primary aldosteronism (PA) is the most common cause of secondary hypertension, yet screening remains startlingly infrequent. We describe (1) PA screening practices in a large, diverse health system, (2) the development of a computable phenotype for PA screening, and (3) the design and pilot deployment of an electronic health record (EHR)-based active choice nudge to recommend PA screening. STUDY DESIGN:A multidisciplinary team developed a multipronged intervention to improve PA screening informed by guidelines, expertise, and multivariable analyses of factors associated with screening. The intervention included EHR-based tools to automatically identify screen-eligible patients, an active choice nudge recommending screening for these patients, and screening result interpretation. The intervention was piloted across 2 primary care practices for 7 months. Screening frequencies were compared with clinics not receiving the intervention. RESULTS:The baseline frequency of screening of eligible patients within 1 year was 1.4%. Higher mean systolic blood pressure (odds ratio [OR] 1.4; p < 0.001), more antihypertensive medications (OR 1.3; p = 0.002), lower minimum serum potassium (OR 2.0; p = 0.001), specialist care (OR 3.0; p < 0.001), and Black race (OR 1.5; p = 0.001) were associated with a higher likelihood of screening. The refined computable phenotype identified a subcohort with a higher frequency of positive screening (8.6% vs 4.1%; p = 0.03). In a pilot study of an active choice nudge, a greater proportion of eligible patients were screened in the intervention clinics (16.4%) than in the nonintervention clinics (1.8%; p < 0.001). CONCLUSIONS:PA screening rates are low. This pilot study suggests an EHR-based nudge leveraging a precise computable phenotype can dramatically increase appropriate PA screening.

Introduction: The management of recurrent pancreatic neuroendocrine tumors has changed with improvements in both systemic and locoregional therapies. This study aims to describe the patterns of recurrence and respective treatments and evaluate the changes in multimodality treatment. Methods: This is a single-institution retrospective study of patients diagnosed with a pancreatic neuroendocrine tumor from 2004 to 2022. The primary outcome was time to recurrence. Secondary outcomes included overall survival and therapeutic modality. Time to event probabilities were calculated using the Kaplan-Meier method; probabilities were compared using log-rank tests. Cox proportional hazards multivariable modeling with competing risks yielded subdistribution hazard ratios. Results: Of 284 patients with a primary pancreatic neuroendocrine tumor, 189 underwent upfront surgical resection and were included in the analysis. Of the 182 patients with a well-differentiated G1 or G2 tumor, 44 patients (24%) experienced a recurrence. Mean time to recurrence was 57 months, with the liver as the most common site (77%, 34/44). On adjusted Cox proportional hazards modeling, only nodal positivity (subdistribution hazard ratio, 4.06; 95% confidence interval, 1.31-12.03, P 1/4 .013) was associated with a greater risk of recurrence. There was an increase in adoption of newer liver-directed and systemic therapies in the latter half of the study period, with increased use of therapies such as liver embolization and peptide receptor radionucleotide therapy for recurrences occurring after 2010. Conclusions: Of the patients with well-differentiated pancreatic neuroendocrine tumors managed with upfront surgical resection, one quarter developed recurrent disease. Nodal positivity was the most significant risk factor for recurrence. The majority of patients received multimodality therapies for recurrent disease. (c) 2024 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

The diagnosis of amyloidosis requires high clinical suspicion and is often made only after significant clinical symptoms arise. Here, we present a case of amyloidosis diagnosed in a patient with an enlarging incidental adrenal cyst. Imaging and biochemical evaluation suggested that the cyst was benign and non-functional. Adrenalectomy was performed to treat symptoms of mass effect, and surgical pathology led to the diagnosis of leukocyte cell-derived chemotaxin 2 (ALECT2) associated adrenal amyloidosis. Patients with ALECT2 amyloidosis may have subclinical involvement of the adrenal glands, subcutaneous fat, and other tissues before developing the more common manifestation of renal amyloidosis. Early identification of patients with ALECT2 amyloidosis can assist in prevention of renal morbidity. Prevention of chronic kidney disease (CKD) should be among the main goals of managing patients with ALECT2 amyloidosis.

Hypocalcemia is common after cervical procedures. Patients who have undergone Roux-en-Y gastric bypass (RYGB) experience increased risk for post-thyroidectomy hypocalcemia. This association has not been elucidated for nonbariatric operations that bypass the duodenum. A multi-institutional retrospective cohort study included patients who underwent parathyroidectomy and/or thyroidectomy with prior sleeve gastrectomy (SG), bariatric RYGB, or nonbariatric gastrojejunostomy (GJ). The primary outcomes were early (≤6 months) and late (>6 months) postoperative hypocalcemia. The secondary outcomes were prolonged length of stay (>24 hours) and 30-day readmission. A total of 241 patients had prior SG (39

BackgroundMetastasectomy is a useful adjunct in the management of metastatic cancer. Widespread adoption of novel targeted and immunotherapies has improved the survival profiles of multiple malignancies, which has potentially altered the role of metastasectomy. This study aimed to characterize trends in metastasectomy across five primary cancers eligible for these therapies.MethodsThe National Inpatient Sample was used to identify patients who underwent metastasectomy in the United States (2016-2021). Patients with procedure codes for resection of the lung, liver, adrenal gland, brain, or small bowel and concurrent diagnosis codes for secondary malignant neoplasm of that site were included. Subjects were subcategorized by primary malignancy: colorectal cancer, lung cancer, breast cancer, melanoma, or renal cancer. Sample weights were used to produce national estimates, which were incidence adjusted by primary malignancy. Trends in utilization were calculated with average annual percent change (AAPC) and linear regression coefficients.ResultsColorectal cancer was the most frequent indication for metastasectomy (n = 57,644 cases), followed by lung cancer (n = 55,090 cases), breast cancer (n = 12,616 cases), renal cancer (n = 8427 cases), and melanoma (n = 5658 cases). Utilization of metastasectomy increased over the study period for breast cancer (AAPC, +10.6%; p = .013) and melanoma (AAPC, +8.3%; p = .040) but did not change for lung cancer (AAPC, -1.6%; p = .26), colorectal cancer (AAPC, +0.3%; p = .83), or renal cancer (AAPC, +2.3%; p = .36).ConclusionsBetween 2016 and 2021, utilization of metastasectomy increased significantly for melanoma and breast cancer. The role of metastasectomy will likely continue to develop as new treatment protocols improve survival profiles for patients with metastatic disease.

Importance:Adverse patient events are inevitable in surgical practice. Objectives:To characterize the impact of adverse patient events on surgeons and trainees, identify coping mechanisms, and assess whether current forms of support are sufficient. Design, Setting, and Participants:In this mixed-methods study, a validated survey instrument was adapted and distributed to surgical trainees from 7 programs, and qualitative interviews were conducted with faculty from 4 surgical departments in an urban academic health system. Main Outcomes and Measures:The personal impact of adverse patient events, current coping mechanisms, and desired forms of support. Results:Of 216 invited trainees, 93 (43.1%) completed the survey (49 [52.7%] male; 60 [64.5%] in third postgraduate year or higher; 23 [24.7%] Asian or Pacific Islander, 6 [6.5%] Black, 51 [54.8%] White, and 8 [8.6%] other race; 13 [14.0%] Hispanic or Latinx ethnicity). Twenty-three of 29 (79.3%) invited faculty completed interviews (13 [56.5%] male; median [IQR] years in practice, 11.0 [7.5-20.0]). Of the trainees, 77 (82.8%) endorsed involvement in at least 1 recent adverse event. Most reported embarrassment (67 of 79 trainees [84.8%]), rumination (64 of 78 trainees [82.1%]), and fear of attempting future procedures (51 of 78 trainees [65.4%]); 28 of 78 trainees (35.9%) had considered quitting. Female trainees and trainees who identified as having a race and/or ethnicity other than non-Hispanic White consistently reported more negative consequences compared with male and White trainees. The most desired form of support was the opportunity to discuss the incident with an attending physician (76 of 78 respondents [97.4%]). Similarly, faculty described feelings of guilt and shame, loss of confidence, and distraction after adverse events. Most described the utility of confiding in peers and senior colleagues, although some expressed unwillingness to reach out. Several suggested designating a departmental point person for event debriefing. Conclusions and Relevance:In this mixed-methods study of the personal impact of adverse events on surgeons and trainees, these events were nearly universally experienced and caused significant distress. Providing formal support mechanisms for both surgical trainees and faculty may decrease stigma and restore confidence, particularly for underrepresented groups.

Introduction Primary aldosteronism affects 20% of patients with resistant hypertension and may be due to unilateral or bilateral causes. Patients with a unilateral source of aldosterone secretion are potentially curable with adrenalectomy. Adrenal vein sampling (AVS) is the definitive test for subtype differentiation but may not be accessible outside tertiary centers. The goal of this study was to determine whether clinical characteristics can predict a unilateral source of aldosterone on AVS. Methods Patients with a biochemical diagnosis of primary aldosteronism who underwent AVS between 1998 and 2019 were identified from a prospectively maintained database. Unilateral aldosterone secretion was defined as lateralization index ≥4. Univariate and multivariate logistic regression were used to assess the correlation between clinical characteristics and unilateral aldosterone secretion. A risk score was developed to predict a unilateral source of aldosterone. Results Of 461 patients, 61% were male and 39% female. The mean age was 54 ± 11 y, and median duration of hypertension was 10 (interquartile range: 5-20) y. A total of 324 patients had unilateral aldosterone secretion. On multivariate logistic regression analysis, non-Black race, lower body mass index, shorter duration of hypertension, and nonincidental diagnoses were significantly associated with a unilateral source of aldosterone. Neither age nor an adrenal adenoma on imaging was predictive of a unilateral aldosterone source. The clinical risk score had an 86% positive predictive value for a unilateral source of aldosterone. Conclusions Clinical characteristics imperfectly predict subtype differentiation. However, high clinical risk scores have a strong positive predictive value for a unilateral source of aldosterone.