Development of a binational thyroid cancer clinical quality registry: a protocol paper.

INTRODUCTION: The occurrence of thyroid cancer is increasing throughout the developed world and since the 1990s has become the fastest increasing malignancy. In 2014, a total of 2693 Australians and 302 New Zealanders were diagnosed with thyroid cancer, with this number projected to rise to 3650 in 2018. The purpose of this protocol is to establish a binational population-based clinical quality registry with the aim of monitoring and improving the quality of care provided to patients diagnosed with thyroid cancer in Australia and New Zealand. METHODS AND ANALYSIS: The Australian and New Zealand Thyroid Cancer Registry (ANZTCR) aims to capture clinical data for all patients over the age of 16 years with thyroid cancer, confirmed by histopathology report, who have been diagnosed, assessed or treated at a contributing hospital. A multidisciplinary steering committee was formed which, with operational support from Monash University, established the ANZTCR in early 2017. The pilot phase of the registry is currently operating in Victoria, New South Wales, Queensland, Western Australia and South Australia, with over 20 sites expected to come on board across Australia in 2018. A modified Delphi process was undertaken to determine the clinical quality indicators to be reported by the registry, and a minimum data set was developed comprising information regarding thyroid cancer diagnosis, pathology, surgery and 90-day follow-up. FUTURE PLANS: The establishment of the ANZTCR provides the opportunity for Australia and New Zealand to further understand current practice in the treatment of thyroid cancer and identify variation in outcomes. The engagement of endocrine surgeons in supporting this initiative is crucial. While the pilot registry has a focus on early clinical outcomes, it is anticipated that future collection of longer term outcome data particularly for patients with poor prognostic disease will add significant further value to the registry.

Primary hyperparathyroidism during pregnancy: management by minimally invasive surgery based on ultrasound localization.

BACKGROUND: Primary hyperparathyroidism in pregnancy has the potential to seriously impact the mother and foetus. Management may be difficult because the condition is usually diagnosed during pregnancy necessitating a rapid decision to proceed with surgery. Minimally invasive surgery is appealing due to shorter operative times and lower risk of complications. METHOD: We present a consecutive series of eight women diagnosed with hyperparathyroidism during pregnancy. RESULTS: All eight women were treated successfully by parathyroidectomy during pregnancy with no maternal or foetal complications. Seven of these 8 women were treated with minimally invasive parathyroidectomy based on ultrasound localization. CONCLUSION: Where ultrasound localization is performed by experienced endocrine surgeons, minimally invasive parathyroidectomy is a feasible and safe approach in the pregnant patient with primary hyperparathyroidism.

Oncoplastic multidisciplinary meetings: a necessity or luxury?

Although there is scant evidence to support multidisciplinary meetings in any cancer specialty, they are now regarded as best practice. We believe the oncoplastic multidisciplinary meeting plays a similarly important role, consolidating oncoplastic multidisciplinary working and allowing transparent decision making, standardisation of care and recording of results. This may drive oncoplastic surgery to an evidence-based position from which oncoplastic excellence can be achieved.

Undergraduate child psychiatry teaching in Melbourne, Australia.

OBJECTIVE: The teaching of child psychiatry in Australian medical schools is under review: the content, the placement of the field within medical curricula, and the appropriate teaching and learning methods are all contested. The authors developed a 1-day program in the 9-week child and adolescent health course conducted in the final two semesters of the medical degree at the University of Melbourne and conducted a systematic evaluation of learning outcomes. The program facilitates a group process that draws students to reflect on the role of the doctor and his or her relationship with the patient-child, adolescent, family, and peers. METHODS: Questionnaires were administered before and after the program to assess students' learning, and end-of-day and end-of-term questionnaires were used to obtain feedback from students. RESULTS: The assessment of students' knowledge of key topics in child psychiatry immediately prior to and following the teaching day showed notable improvement on most measures. The surveys showed that the majority of students considered the day a worthwhile and useful part of their course, including a positive response to the role plays. CONCLUSION: The sound pedagogical base and successful iterative development of the program has been confirmed by the immediate improvement in students' knowledge. The findings are relevant to academic psychiatrists, medical course designers, and medical educators seeking insights into teaching undergraduate child psychiatry.

PHEEM 'downunder'.

BACKGROUND: The use of the Postgraduate Hospital Education Environment Measure (PHEEM) has been previously described in this journal. AIMS: We established a nine-hospital project to test the acceptability of the PHEEM in Australia. METHOD: We adapted the language of some items in the PHEEM in order to localize the terminology (such as 'beeped'/'paged') and adjusted the demographics section to facilitate tracking of individual hospitals in the project. RESULTS: Over two years, more than 400 PHEEMs were returned. Eight of the nine hospitals have an educational environment that is 'more positive than negative but with room for improvement'. One has an 'excellent' environment. None are in the two lowest scoring categories. The lowest scoring items in the collaborative project related to 'feedback', 'information and support', 'infrastructure' and 'interruptions'. The highest scoring items related to 'teachers', 'personal security' and 'working together'. CONCLUSION: The PHEEM is valuable for systematically collecting information about the educational environment of hospitals. It has brought particular attention to problems associated with protected training time for first year trainees, inappropriate paging and lack of feedback.

Simulated parents: developing paediatric trainees' skills in giving bad news.

AIM: In curriculum documents for medicine in undergraduate, post-graduate and continuing professional development, there is now a focus on communication skills. The challenges are to place communication skills in the crowded curriculum and then to construct and sustain a programme that uses an evidence-based approach to the teaching and learning of communication skills. For 6 years, we have conducted a programme that involves simulated parents supporting junior medical staff to refine their skills in communication, particularly in giving parents bad news. The aim of our study was to obtain a better understanding of the trainees' experiences of the programme. METHODS: Nine junior residents individually worked through two scenarios and received feedback from the simulated parent. They gave bad news to a simulated parent/actor who then gave feedback. A recording of the simulation was provided for discussion with a designated colleague at an arranged time. The tapes were then separately appraised by two independent raters - another actor and a paediatrician. Brief written reports and conducted semi-structured interviews provided more insights into the trainees' experience of the simulation. Other participating medical/medical education staff were interviewed about the simulation programme. RESULTS: Five themes emerged from the qualitative data: timeliness, emotional safety, the complexity of communication, practical usefulness and the challenge of effecting change. In addition, the ratings of the videos helped to clarify those 'parent-centred' communication skills that trainees may neglect in difficult conversations: 'ask about support', 'encourage the parent to ask questions' and 'repeat key messages'. CONCLUSION: The evaluation highlighted the value of an early-career experiential programme to highlight the importance of communication skills in post-graduate paediatrics practice.

Clinical communication: Innovative education for graduate nurses in paediatrics.

The Royal Children's Hospital (RCH) is a specialist paediatric centre in Melbourne, Australia. RCH provides a full range of clinical services including tertiary care and health promotion and prevention for children and adolescents. RCH has 250 beds and treats approximately 32,000 in-patients a year. A total of 280,000 children are seen by this centre annually. The graduate nurse programme (GNP) at RCH has been established for over 20 years, as a twelve-month internship following a three-year bachelor degree in nursing. The aim of our GNP is to support each newly qualified registered nurse through their experience of transition from student to registered nurse. After initial orientation, the programme requires attendance at ten development days. The graduate nurses are supported by preceptors in the clinical environment whose role is to enable the application of new knowledge and skills. The Programme philosophy is that through a combination of reflective practice and individual goal setting, the graduate will fulfil the scope of their practice as set out in their Hospital job description.

Thyroid incidentaloma: an evidence-based assessment of management strategy.

BACKGROUND: Palpable thyroid nodules are present in 4-7% of the population and their prevalence increases with age. Thyroid incidentalomas-impalpable nodules detected fortuitously during a radiological investigation-may be found in up to 50% of patients. Although numerous guidelines exist that indicate the appropriate management of palpable thyroid nodules, there are no accepted guidelines for the increasingly common thyroid incidentaloma. Presently no level I or II evidence exists on this topic. METHODS: Systematic review of the literature using evidence-based criteria was performed. RESULTS: Thyroid incidentalomas are common and are mostly benign lesions. A small proportion is malignant, mainly papillary thyroid microcarcinomas (PTMC). Lesions <5 mm in diameter, even if PTMC, exceptionally metastasize and can be safely left. Lesions between 5 mm and 9 mm without sinister radiological features need not be investigated. The appropriate follow-up is controversial. CONCLUSION: It is unlikely that a trial of sufficient power to demonstrate or refute the beneficial effects of presymptomatic investigation of thyroid nodules will take place. We propose a pragmatic approach based on current evidence that balances the benefit of early diagnosis and treatment with the cost to the patient and the healthcare system associated with unnecessary investigations and surgery.

Total thyroidectomy for amiodarone-associated thyrotoxicosis in patients with severe cardiac disease.

BACKGROUND: Surgical treatment of amiodarone-associated thyrotoxicosis (AAT) is effective although fewer than 100 cases have been reported world wide. MATERIALS AND METHODS: We reviewed 14 patients treated with total thyroidectomy by a single surgeon from 1998 to 2005. RESULTS: There were 11 male and 3 female patients who ranged in age from 26 to 82 years (average 50.5). Nine patients refractory to medical management and 5 in whom amiodarone needed to be continued were treated surgically. Ten patients developed thyrotoxicosis while being treated with amiodarone, but 4 became thyrotoxic after ceasing amiodarone 2, 2, 6 and 13 months previously. One patient recently had a cardiac transplant, and 4 were on the active cardiac transplant waiting list. Cardiac ejection fractions ranged from 15% to 50% (average 39%). Four patients had serious complications from medication used to control thyrotoxicosis, including one case of agranulocytosis from carbimazole. Total thyroidectomy was performed under general anaesthesia with no significant intraoperative complications and no deaths. There were no recurrent laryngeal nerve injuries. Two patients required short-term calcium supplementation. All patients had rapid resolution of their symptoms and were euthyroid on thyroxine postoperatively. Two patients had such improvement they were removed from the cardiac transplant list. CONCLUSIONS: Despite severe cardiac disease, total thyroidectomy can be performed successfully under general anaesthesia. Surgery should be considered early in the treatment plan. Surgery is particularly appropriate where it is considered necessary to continue amiodarone, when there are complications from the medications used to treat thyrotoxicosis and to facilitate fitness for or defer the need for cardiac transplantation.

The role of cranial expansion for craniocephalic disproportion.

The appropriate treatment for craniocephalic disproportion, such as caused by slit ventricle syndrome, is uncertain. We have reviewed the treatment and outcomes of 4 children who underwent cranial expansion over a period of 5 years. The ages at cranial expansion were 16 months, 3 years 6 months and 2 at 6 years. Two children had slit ventricle syndrome and were treated with bilateral parietal expansions. Two children had non-syndromic craniosynostosis, one of these having vitamin D-resistant rickets. The latter 2 were treated with posterior cranial vault expansion, and one also had a craniocervical junction decompression performed. Post-operatively, symptoms of raised intracranial pressure resolved in all cases, and there was radiological evidence of re-establishment of normal CSF pathways. Although a rare condition, cranial expansion operations can be successful in appropriately selected cases of craniocephalic disproportion.

Protein losing enteropathy in critically ill adult patients with burns: a preliminary report.

OBJECTIVE: Few data have been published regarding protein losing enteropathy in adult patients with burns. This study characterised the presence of protein-losing enteropathy in adults with burns and examined the relationship between the magnitude of burn size and the severity of protein loss. METHODS: Twenty adult patients with burns (BSA 31+/-25%, range 2-80%) were studied. Fluid resuscitation was based on the Parkland's formula. Protein loss into the gastrointestinal tract was measured using faecal alpha1-antitrypsin (FA-1-AT) concentrations. Serial measurements of serum protein and albumin concentrations were performed. RESULTS: Fourteen patients demonstrated elevations in FA-1-AT levels. The mean peak FA-1-AT level was 3.6+/-4.2 mg/g dry weight of stool. Two patients demonstrated elevated FA-1-AT excretion 1.5 months and 3 months after the burns. There was a good correlation between burn size and FA-1-AT excretion (R2=0.40). CONCLUSIONS: Protein losing enteropathy was demonstrable in patients with major burns. The magnitude of this phenomenon appears to be proportional to the burns size.