Evaluating Patients' Health Literacy to Improve Thyroid Pathology Reports.

INTRODUCTION: As our growing population demonstrates a significant increase in the incidence of thyroid cancer, so does patient access to their medical records. Poor health literacy and understanding of disease severity, underscores the importance of effective and accessible patient-doctor communication. No previous studies on patient understanding of thyroid pathology reports exist; therefore, we sought to characterize health literacy in this population. METHODS: Using a modified Delphi technique, a 12-question multiple-choice survey regarding common pathology terms with possible definitions for each term was synthesized and administered to patients in a high-volume endocrine surgery clinic. Survey results, patient demographics, history of prior thyroid procedure (biopsy or surgery), and self-reported health literacy were collected. Data analysis included t tests, chi-squared, and multivariable linear regression using R. RESULTS: The survey was completed by 54 patients (response rate: 69.8%). On univariate analysis, White race, previous thyroid procedure, and at least a high school level education were all more likely to score higher on the survey than their counterparts (P < 0.05). On multivariable logistic regression for predicting a higher survey score, only race (est: 2.48 [95% confidence interval: 1.01-3.96]) and higher educational attainment (est: 3.98 [95% confidence interval: 2.32-5.64]) remained predictive (P < 0.05). The remaining demographic groups (age, health literacy confidence, and previous thyroid procedure) did not show a statistically significant difference. CONCLUSIONS: Overall, terms on a thyroid pathology report are poorly understood by patients. This is exacerbated by non-White race and low educational attainment. There is a need for patient-facing pathology education.

Does Graves' Disease Truly Increase the Risk of Complications After Total Thyroidectomy?

INTRODUCTION: Total thyroidectomy (TTx) has been reported to be more challenging in patients with Graves' disease, especially in those who are hyperthyroid at the time of surgery. Our aim was to compare outcomes in patients undergoing TTx for Graves' disease compared to other thyroid diseases at a large academic institution with high-volume fellowship-trained endocrine surgeons. METHODS: In our retrospective analysis from December 2015 to May 2023, patients undergoing TTx for Graves' disease were compared to those undergoing TTx for all other indications excluding advanced malignancy (poorly differentiated thyroid cancer and concomitant neck dissections). Patient demographics, biochemical values, and postoperative outcomes were compared. A subgroup analysis was performed comparing hyperthyroid to euthyroid patients at the time of surgery. RESULTS: There were 589 patients who underwent TTx, of which 227 (38.5%) had Graves' disease compared to 362 (61.5%) without. Intraoperatively in Graves' patients, nerve monitoring was used more frequently (65.6% versus 57.1%; P = 0.04) and there was a higher rate of parathyroid autotransplantation (32.0% versus 14.4%; P < 0.01). Postoperatively, transient voice hoarseness occurred less frequently (4.8% versus 13.6%; P < 0.01) and there was no difference in temporary hypocalcemia rates or hematoma rates. In our subgroup analysis, 83 (36%) of Graves' patients were hyperthyroid (thyroid-stimulating hormone < 0.45 and free T4 > 1.64) at the time of surgery and there were no differences in postoperative complications compared to those who were euthyroid. CONCLUSIONS: At a high-volume endocrine surgery center, TTx for Graves' disease can be performed safely without significant differences in postoperative outcomes. Hyperthyroid patients demonstrated no differences in postoperative outcomes.

When I Don't see me, Am I seen? Race and student perception of the surgery clerkship.

INTRODUCTION: Increasing interest in general surgery from students who are Under-Represented in Medicine (URiM) is imperative to advancing diversity, equity, and inclusion efforts. We examined medical student third year surgery clerkship evaluations quantitatively and qualitatively to understand the experiences of URiM and non-URiM learners at our institution. METHODS: Evaluations from 235 graduated medical students between the years of 2019 and 2021 were analyzed. T-tests were used to compare numerical data. Free-text comments were qualitatively analyzed using inductive thematic analysis by two independent reviewers with conflicts resolved by a third. RESULTS: Evaluations were completed by 214 non-URiM students (91.1 â€‹%) and 21 (8.9 â€‹%) URiM students. There were no significant differences between URiM and non-URiM students in ratings of faculty and resident teaching. When asked whether residents were positive role models for patient care, non-URiM students were more likely than URiM students to agree (3.284 vs. 2.864, p â€‹= â€‹0.040). When asked whether they considered faculty to be positive role models, non- URM students were also more likely to answer affirmatively than URiM students (3.394 vs. 2.909 p â€‹= â€‹0.013). Qualitative comments were similar between the two groups. When asked what the strengths of the clerkship were, the most commonly evoked theme was "interactions with team" with subthemes of "team integration" "feeling valued" and positive "faculty" or "resident" interactions. "Operative experience" was the second most commonly evoked strength of the clerkship. The most common criticisms of the clerkship involved "negative interactions with team" with subthemes of "not prioritized above other learners" and "ignored." Negative "academic experience" was the next most commonly evoked weakness, with an affiliated theme of "lack of teaching." CONCLUSIONS: URiM students are less likely than non-URiM students to see surgical residents and faculty as positive role models. Integrating medical students into the team, taking time to teach, and allowing students to feel valued in their roles improves the clerkship experience for trainees and can contribute to recruitment efforts.

Somatostatin Receptor Type 2 and Thyroid-Stimulating Hormone Receptor Expression in Oncocytic Thyroid Neoplasms: Implications for Prognosis and Treatment.

Somatostatin receptor type 2 (SSTR2) and thyroid-stimulating hormone receptor (TSHR) display variable expression in primary thyroid tumors and have been implicated as theranostic targets. This study was designed to explore the differential expression of SSTR2 and TSHR in oncocytic (Hurthle cell) carcinoma (OC) vs oncocytic adenoma (OA). We performed a retrospective review for oncocytic neoplasms treated at our institution from 2012 to 2019. Formalin-fixed paraffin-embedded tissue blocks were used for tissue microarray construction. Tissue microarray blocks were cut into 5-µm sections and stained with anti-SSTR2 and anti-TSHR antibodies. Immunostains were analyzed by 3 independent pathologists. χ2 and logistic regression analysis were used to analyze clinical and pathologic variables. Sixty-seven specimens were analyzed with 15 OA and 52 OC. The mean age was 57 years, 61.2% were women, and 70% were White. SSTR2 positivity was noted in 2 OA (13%) and 15 OC (28%; 10 primary, 4 recurrent, and 1 metastatic) (P = .22). TSHR positivity was noted in 11 OA (73%) and 32 OC (62%; 31 primary and 1 metastatic) (P = .40). Those who presented with or developed clinical recurrence/metastasis were more likely to be SSTR2-positive (50% vs 21%; P = .04) and TSHR-negative (64.3% vs 28.9%; P = .02) than primary OC patients. Widely invasive OC was more likely to be SSTR2-positive compared to all other OC subtypes (minimally invasive and angioinvasive) (P = .003). For all patients with OC, TSHR positivity was inversely correlated with SSTR2 positivity (odds ratio, 0.12; CI, 0.03-0.43; P = .006). This relationship was not seen in the patients with OA (odds ratio, 0.30; CI, 0.01-9.14; P = .440). Our results show that recurrent/metastatic OC was more likely to be SSTR2-positive and TSHR-negative than primary OC. Patients with OC displayed a significant inverse relationship between SSTR2 and TSHR expression that was not seen in patients with OA. This may be a key relationship that can be used to prognosticate and treat OCs.

Thresholds for surgical referral in primary hyperparathyroidism: A conjoint analysis.

BACKGROUND: Primary hyperparathyroidism (PHPT) can be cured through surgery, but referral for treatment is often provider dependent. A conjoint analysis was performed to identify factors influencing referral for surgery. METHODS: Online survey assessed endocrinologists and other physicians who reviewed 10 patient scenarios. They decided whether to refer for surgery or medical management based on clinical (age, comorbidities, etc) and biochemical factors (mild or classic disease). RESULTS: Classic PHPT, age below 50, absence of comorbidities, presence of osteoporosis, and seeing a surgical provider significantly increased the likelihood of surgery referral (p < 0.001). Physician characteristics such as gender, practice duration, and setting did not have a significant influence. CONCLUSION: Despite published benefits of surgery, non-surgical physicians were less likely to refer PHPT patients for surgical treatment if patients were older (age ≥ 50), had comorbid conditions, or had mild disease. More education and advocacy are needed for improved access to surgery.

Surgical Treatment of Hyperthyroidism Can Be Performed Safely Before a Euthyroid State is Achieved.

Background: The 2016 American Thyroid Association guidelines recommend that hyperthyroid patients should be euthyroid before thyroidectomy. This recommendation is based on low-quality evidence. In this retrospective cohort study, we compare peri- and post-operative outcomes of patients with hyperthyroidism who were controlled versus uncontrolled at the time of thyroidectomy. Methods: A retrospective cohort study was performed on 275 hyperthyroidism patients at a single institution from December 2015 to November 2022. Patients were defined as hyperthyroid if they had a diagnosis of hyperthyroidism with at least one suppressed thyrotropin (TSH). Patients were considered uncontrolled if triiodothyronine or thyroxine (T4) was elevated immediately before surgery. Patient demographics, perioperative data, and postoperative outcomes were compared with Chi-square and Wilcoxon Rank Sum tests, as appropriate. Results: Of the 275 patients, 84.3% were women and 51.3% were uncontrolled at time of surgery. Controlled patients had higher median [interquartile range] TSH (0.4 [0.0, 2.4] mIU/L vs. 0.0 [0.0, 0.0] mIU/L, p < 0.001) and lower free T4 (fT4) (0.9 [0.7, 1.1] ng/dL vs. 3.1 [1.9, 4.4] ng/dL, p < 0.001), respectively. Uncontrolled patients were more likely to be diagnosed with Grave's disease (85.1% vs. 67.9%, p < 0.001) and to undergo surgery due to medication intolerance (12.1% vs. 6%) or history of thyroid storm (6.4% vs. 1.5%) (p = 0.008). Uncontrolled patients were also more likely to take a larger number of preoperative medications (2.3 vs. 1.4, p < 0.001). No patient in either group experienced thyroid storm precipitated by surgery. Controlled patients had shorter operative times (7.3% vs. 19.8% <1 hour, p < 0.014) and decreased median estimated blood loss (15.0 [5.0, 30.0] mL vs. 20.0 [10.0, 50.0] mL, p = 0.002). Both groups experienced similar, low rates of postoperative complications, apart from an increase in temporary hypocalcemia in the uncontrolled group (13.4% vs. 4.7%, p = 0.013). Conclusion: Our study is the largest to date examining the postoperative outcomes of patients with uncontrolled hyperthyroidism who undergo thyroidectomy. Our results affirm that thyroidectomy in actively thyrotoxic patients is safe and will not precipitate thyroid storm.

Reclassification of CKD in living kidney donors with the refitted race-free eGFR formula.

BACKGROUND: Chronic Kidney Disease (CKD) Epidemiology Collaboration eGFR 2021 formula removed Black race from the 2009 equation. Unintended consequences may lead to reclassifying Black living kidney donors as having more advanced CKD, exacerbating racial disparities in living donation. METHODS: We used national data to quantify CKD stage reclassification based on eGFR for Black living donors both pre- and post-donation. RESULTS: Among 6365 Black living donors, 17.7% were reclassified as having a higher CKD stage pre-donation with the 2021 formula. Among 4149 Black living donors with at least 2 creatinine measurements post-donation, 25.5% were reclassified as having a higher CKD stage post-donation with the 2021 formula. CONCLUSION: Eliminating race in the formula may inappropriately label Black potential donors with CKD. These data highlight the need for a validated eGFR formula for donors, use of measured and not eGFR, and education of non-transplant providers regarding interpretation of CKD staging in living donation.

Impact of refitted race-free eGFR formula on obesity pharmacotherapy options.

OBJECTIVE: Recent changes to the Chronic Kidney Disease Epidemiology Collaboration estimated glomerular filtration rate (eGFR) formula (2021 CKD-EPI) removed race from the 2009 formula, increasing the number of Black people classified as having CKD, but these changes may impact eligibility and/or dosing for antiobesity medications. This study estimated the number of people with obesity nationwide who might have pharmacotherapy options impacted by the new formula. METHODS: Using National Health and Nutrition Examination Survey (NHANES) cohort study data, the number of people eligible for antiobesity medication was estimated, and the number who would require a dosage reduction or would no longer be eligible for specific medications based on the new eGFR formula was also estimated. RESULTS: Among 16,412,571 Black and 109,654,751 non-Black people eligible for antiobesity medication, 911,336 (6.1%) Black and 6,925,492 (6.6%) non-Black people had ≥CKD stage 3 by the 2009 CKD-EPI formula. Applying the 2021 CKD-EPI formula, 1,260,969 (8.5%) Black people and 4,989,919 (4.7%) non-Black people had ≥CKD stage 3. For medications requiring renal adjustment, the number of Black people who would require a lower dose or be precluded from using a medication increased by 24.7% to 50.2%. CONCLUSIONS: These findings highlight the importance of measuring-rather than estimating-GFR in Black people with CKD when considering many antiobesity pharmacotherapy options.

Socioeconomic and demographic considerations of pediatric concussion recovery.

The objective of this study was to investigate predictors of concussion recovery in children (5-12) versus adolescents (13-18) while identifying economic and demographic disparities in post-concussion care at a tertiary referral concussion clinic versus emergency department (ED). Race and insurance status were recorded for patients presenting to the concussion clinic (724) and ED (1,160) with an ICD-10 concussion diagnosis between 2018 and 2019. Secondly, a subset of patients from the concussion clinic group were included for retrospective cohort review based on documented recovery data. Overall, the concussion clinic saw more Caucasian patients (66.7%) than the ED (56.8%). Concussion clinic patients were more likely to have Private insurance than ED patients (67.2% vs. 55.3%) and less likely to have Medicaid and Self pay (p < 0.001). Children were more likely to be hospitalized after concussion diagnosis than adolescents (40.8% vs. 24.4%, p = 0.006). Attending public school was associated with a 1.8 times greater hazard ratio (HR) for shorter time to recovery compared to attending private school. Additionally, presence of a diagnosed psychiatric disorder was associated with a HR of 0.5, indicating a longer time to recovery (p < 0.001) than patients without a disorder. The present findings may support limitations on contact sports participation in young children given their higher hospitalization rate after concussion. Additionally, the study highlights potential barriers to care amongst youth concussion patients with those seen in specialized concussion clinics more likely to be White and have private insurance.

Concurrent Validity Evidence for Entrustable Professional Activities in General Surgery Residents.

BACKGROUND: A subset of Entrustable Professional Activities (EPAs) has been developed for general surgery. We aim to contribute validity evidence for EPAs as an assessment framework for general surgery residents, including concurrent validity compared to ACGME milestones, the current gold standard for evaluating competency. STUDY DESIGN: This is a cross-sectional study in a general surgery training program within a tertiary academic medical center. EPA assessments were submitted using a mobile app and scored on a numerical scale, mirroring milestones. EPA score distribution was analyzed with respect to post-graduate year (PGY) level and phase of care. Proportional odds logistic regression identified significant predictors. Spearman rank and Wilcoxon rank tests were used for comparisons with milestone ratings. RESULTS: From August 2018 to December 2019, 320 assessments were collected. EPA scores increased by PGY level. Operative phase EPA scores were significantly lower than nonoperative phase scores. PGY level, operative phase, and case difficulty significantly influenced entrustment scoring. EPA scores demonstrated strong correlation with nonoperative milestones patient care-1, medical knowledge-1, interpersonal and communication skills-2, interpersonal and communication skills-3, professionalism-1, professionalism-3, and practice-based learning and improvement-2 (ρ > 0.5, p < 0.05) and a weaker correlation with operative milestones patient care-3 and medical knowledge-2 (ρ < 0.5, p < 0.05). CONCLUSIONS: The influence of PGY level and operative phase on entrustment scoring supports the validity of EPAs as a formative evaluation framework for general surgery resident performance. In addition, evident correlations between EPA scores and respective milestone ratings provide concurrent validity evidence.

Efficacy of outpatient infusion therapy in pediatric patients with postconcussive headaches.

PURPOSE: To determine the relative efficacy of intravenous therapy for postconcussive headaches in a pediatric population, as compared to oral therapy. METHODS: Pediatric patients treated for postconcussive headaches at an outpatient infusion clinic from 2016 to 2018 were selected for inclusion in the study. Of the 95 patients who were treated in clinic, 53 patients were selected for a retrospective chart review. Clinic visits before and after infusions were reviewed to determine changes in headache score (HA), symptom severity score (SSS), and self-reported symptom relief. An age-matched and SSS-matched group served as a control. The control group received only oral therapy for their headaches. The infusion consisted of parenteral ketorolac, compazine, diphenhydramine, and a normal saline bolus (20 mg/kg). RESULTS: Following infusion therapy, overall mean HA and SSS scores were both reduced (p < 0.0001). Oral therapy demonstrated a similar mean overall reduction in HA and SS scores (p < 0.0001). While both groups achieved a reduction in HA and SS scores, there was not a statistically significant difference in reduction of symptoms scores between the oral and infusion groups. CONCLUSION: Infusion therapy is as effective at reducing HA and SSS as established oral therapies. Infusion therapy may have a shorter time to headache abortion than oral therapy based on pharmacokinetics. Further, some physicians are unwilling to allow an athlete to return to play while taking suppressive medication. Future studies may show that an infusion could allow a more rapid return to play and resolution of symptoms.

Hepatic macrosteatosis in the US pediatric deceased liver donor population.

INTRODUCTION: The pediatric obesity epidemic is associated with early development of hepatic macrosteatosis, a hallmark of non-alcoholic fatty LI disease, which is thought to be more rapidly progressive in children than adults. Macrosteatosis in adult allografts is associated with allograft loss, but this has not been examined in pediatric donors. METHODS: We studied all pediatric potential whole LI donors (2005-2018) who had a LI biopsy in the SRTR (n = 862) and whose LI was transplanted (n = 862). Macrosteatosis was abstracted from biopsy reports and compared to values in the SRTR standard analytic file. Recipients of macrosteatotic pediatric allografts were matched 1:1 to recipients of non-macrosteatotic pediatric allografts by propensity score matching on donor/recipient variables. All-cause allograft loss was estimated via Kaplan-Meier analysis and Cox proportional hazards model. RESULTS: From 2005 to 2018, the proportion of pediatric donors (age ≥2 years) with obesity increased (14.8% to 21.7%; p < .001), as did the proportion of pediatric deceased whole LI-only donor allografts with macrosteatosis (n = 10 648; 1.8% to 3.9%; p < .001). The median degree of macrosteatosis among macrosteatotic donors was 10% (IQR 5-30). There were no significant differences in all-cause allograft loss between recipients of pediatric LI allografts with and without macrosteatosis at 90 days (p = .11) or 1 year (p = .14) post-transplant in Kaplan-Meier analysis or a Cox proportional hazards model (p > .05). CONCLUSION: Obese pediatric LI donors have increased over time and were more likely to have hepatic macrosteatosis; however, pediatric macrosteatosis did not appear to adversely affect recipient outcomes.

Survival following simultaneous liver-lung versus liver alone transplantation: Results of the US national experience.

BACKGROUND: There are little data to compare the post-transplant survival between lung-liver transplant (LLT) and liver-alone recipients. This study was undertaken to compare survival between LLT and liver-alone transplant. METHODS: UNOS data for patients undergoing LLT from 2002 to 2017 was analyzed. LLT recipients (n = 81) were matched 1:4 to liver-alone recipients (n = 324) by propensity score and patient survival was compared in the matched cohorts. RESULTS: Unadjusted 1, 3, and 5-year patient survival in the matched cohort was significantly worse in the LLT (82.5%, 72.2%, and 62.2%) versus liver-alone (92.2%, 82.8%, and 80.9%; p = 0.005). This difference persisted after adjusting for covariates with residual imbalance (HR 2.05, 95% CI 1.37-3.08; p = 0.001). CONCLUSION: LLT has significantly worse survival than liver-alone transplant. With an increasing organ shortage, medical necessity criteria such as those developed for simultaneous liver-kidney transplantation should be developed for simultaneous lung-liver transplants to assure liver allografts are only allocated when truly needed.

Mechanical or chemical and mechanical pleurodesis for spontaneous pneumothorax: what is the most effective approach in preventing recurrence? A systematic review and meta-analysis.

OBJECTIVES: Surgical management of spontaneous pneumothorax typically involves wedge resection and mechanical pleurodesis. It is unclear whether combining mechanical and chemical pleurodesis can further reduce the recurrence rate. We have performed a meta-analysis of studies comparing the combined approach with mechanical pleurodesis alone. METHODS: A comprehensive search of the existing literature was performed using PubMed, EMBASE and Web of Science for all types of studies that compared combined pleurodesis to a single approach. We used the Cochrane Risk of Bias Tool and Strengthening The Reporting of OBservational Studies in Epidemiology (STROBE) to assess the quality of the studies. Relative risk of pneumothorax recurrence was calculated, and the differences between the studies were examined. The primary outcome was the recurrence of pneumothorax. RESULTS: Of 2301 eligible studies, 5 studies were included. Five hundred sixty-one patients who received combined pleurodesis were compared to 286 patients who received mechanical pleurodesis only. Patients treated with combined intervention had a 63% lower risk of developing a recurrent pneumothorax compared to single intervention [relative risk 0.37, 95% confidence interval (CI) 0.18-0.76; P = 0.006]. There were no statistically significant differences in the length of stay (standardized mean difference -0.17, 95% CI -0.39 to 0.05, P = 0.138), the duration of postoperative air leak (standardized mean difference 0.17, 95% CI -1.14 to 1.47, P = 0.804) or the duration of postoperative chest tube drainage (standardized mean difference -0.07, 95% CI -0.27 to 0.12, P = 0.471). CONCLUSIONS: This meta-analysis demonstrated that combined intervention with mechanical and chemical pleurodesis for spontaneous pneumothorax may be more effective in preventing recurrence than mechanical pleurodesis alone. These findings will provide some guidance to surgeons in the decision-making process.

Patient Experiences and Clinician Views on the Role of Radiation Therapy for Ductal Carcinoma In Situ.

PURPOSE: To evaluate patient experiences with decisions regarding radiation therapy (RT) for ductal carcinoma in situ (DCIS), and to assess clinician views on the role of RT for DCIS with favorable features in the present era. METHODS AND MATERIALS: A sample of women with newly diagnosed breast cancer from the population-based Georgia and Los Angeles County Surveillance, Epidemiology, and End Results (SEER) registries were sent surveys approximately 2 months after undergoing breast-conserving surgery (BCS), with a 70% response rate. The analytic sample was limited to 538 respondents with unilateral DCIS. We also surveyed 761 surgeons and radiation oncologists treating breast cancer in those regions, of whom, 539 responded (71%). RESULTS: After BCS, 23% of patients omitted RT, with twice the rate of omission in Los Angeles County relative to Georgia (31% vs 16%; P < .001). The most common reasons for omitting RT were advice from a clinician that it was not needed (62%) and concern about side effects (24%). Cost and transportation were not reported as influential considerations. After covariate adjustment, low- and intermediate-grade disease (odds ratio [OR] 5.5, 95% confidence interval [CI] 2.5-12; and OR 3.2, 95% CI 1.7-6.1, respectively) and Los Angeles County SEER site (OR 4.3, 95% CI 2.3-8.2) were significantly associated with greater RT omission. Of the responding clinicians, 62% would discuss RT omission for a patient with DCIS with favorable features. Clinicians in Los Angeles County were more likely to discuss RT omission than were those in Georgia (67% vs 56%; P = .01). Approximately one third of clinicians would obtain the Oncotype DX DCIS score. CONCLUSIONS: The heterogeneity in RT omission after BCS for DCIS continues to be substantial, with systematic differences in provider opinions across the 2 regions we studied. Enhanced precision of recurrence estimates, guidance from professional organizations, and better communication are needed to improve the consistency of treatment in this controversial area.