Social Determinants of Health and Quality of Life in Endocrine Surgery Patients.

INTRODUCTION: Quality of life (QoL) of endocrine surgery patients is an important patient outcome but the role of social determinants of health (SDH) on preoperative QoL is understudied. METHODS: This study used preoperative data of 233 endocrine surgery patients participating in a longitudinal QoL study to examine the influence of SDH (patient-level and environmental) on preoperative QoL. Patient-level SDH was assessed with structured survey questions and environmental SDH with the Social Vulnerability Index. Multiple domains of QoL were assessed with the Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29). RESULTS: The average age of the sample was 52.9 y and 76.8% were female, 10% were Hispanic, 55.8% were White, 32.6% were Black, 6.9% were Other, and 4.7% were Asian. Patients with patient-level SDH were more likely to have worse preoperative QoL in multiple PROMIS domains. Patients who lived in the most socially vulnerable areas had the same or better QoL scores in the PROMIS-29 domains than those living in less vulnerable areas. Minority race patients were more likely to have patient-level SDH and to live in the most vulnerable areas. CONCLUSIONS: This study is the first to our knowledge to examine the role of patient-level and environmental SDH on preoperative QoL among endocrine surgery patients. The results identified specific patient-level factors that could be used as the basis for interventions aimed to improve patients' QoL. Future studies that evaluate the role of preoperative SDH on long-term QoL and clinical outcomes would further enhance our understanding of the impact of SDH on patient wellbeing.

Differentiated thyroid cancer and Hashimoto thyroiditis: Utility of the Afirma gene expression classifier.

BACKGROUND AND OBJECTIVES: The Afirma gene expression classifier (AGEC) has not been tested or validated in a high-risk group, such as patients with Hashimoto's thyroiditis (HT). We hypothesized that AGEC would perform worse in patients with HT. METHODS: A retrospective review of patient charts in a single academic institution who underwent thyroidectomy between 2012 and 2017 was conducted. Patients with HT who underwent AGEC were identified to calculate sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). RESULTS: We identified 69 patients with HT and atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) on cytology who underwent AGEC analysis. The mean age of AGEC cohort was 50 years (range, 26-77 years) with 90% female. The median nodule size was 1.9 cm (interquartile range [IQR], 1.2-2.7 cm). Of the 69 patients, 62 showed suspicious AGEC of which 26 showed TC on surgical pathology. Of the seven benign AGEC, two showed TC on surgical pathology. The sensitivity, specificity, PPV, and NPV were 93%, 12%, 42%, and 71%, respectively. Of the entire AGEC cohort, 17 (43%) showed multicentric disease. CONCLUSIONS: We observed a lower NPV for AGEC to rule out thyroid cancer in patients with HT, which reduces the utility of the test for this population.

Safety of Thyroid Surgery in the Elderly: A Propensity Score Matched Cohort Study.

BACKGROUND: Thyroid surgery is becoming more common in the elderly as elderly population continues to grow. We aim to evaluate the relative risk of morbidity from thyroidectomy in patients greater than 75 y of age. METHODS: A retrospective analysis was performed for patients who were undergoing thyroidectomy between 2001 and 2018 in a multihospital network. A matched control group was selected with use of a propensity score, which was based on gender, ethnicity, type of surgery, insurance status, and comorbidities. The Charlson Comorbidity Index was used to quantify comorbidities. Total complications included both thyroid-specific and systemic complications. RESULTS: We identified 313 patients over the age of 75 y with a propensity score matched group of 313 patients. There was no difference between the percent female (73% versus 73%, P = 0.92), race composition (P = 0.91), insurance status (P = 0.99), percent undergoing total thyroidectomy (84% versus 84%, P = 0.91), and Charlson Index (2.6 versus 2.69, P = 0.70) of the two groups. Overall complications (4.8% versus 1.9%, P = 0.05) and thrombotic events (1.2 versus 0%, P = 0.04) were significantly higher but there was no statistically significant difference between postoperative emergency room visits (7% versus 6%, P = 0.61), readmissions (11.5% versus 8.6%, P = 0.18), cardiovascular (1.3 versus 0.6%, P = 0.61), pulmonary (3.2 versus 0.9%, P = 0.07), or neurologic complications (1.0 versus 0.3%, P = 0.34). No reoperations were noted in either group. Elder patients did have a longer length of stay (2.64 versus 1.29 d, P < 0.01). CONCLUSIONS: Elderly patients did have a longer length of stay when compared to a matched younger population. Although there was a trend with higher complication rates in the elderly, those differences did not reach statistical significance.

Understanding delays to parathyroidectomy: A mixed-methods approach.

BACKGROUND: Patients from ethnic and racial minority groups with primary hyperparathyroidism may have greater time delays to curative parathyroidectomy. Contributing factors are unclear. METHODS: This was a sequential mixed-methods study. The quantitative phase was a retrospective chart review of adults with primary hyperparathyroidism who underwent parathyroidectomy between 2015 and 2020, collecting demographic and clinical data. Social vulnerability of the patients' residential area, measured with the Social Vulnerability Index, and relevant clinical time intervals were calculated. A multivariable analysis of factors associated with greater time intervals was performed. The qualitative phase involved semistructured interviews with endocrinologists, analyzed inductively for themes. RESULTS: On chart review of 1,083 patients, the median age was determined to be 61 years and 856 (79%) were female. Six hundred twenty-eight (57.9%) were non-Hispanic White and 456 (42.1%) were Hispanic ethnicity or Asian, Pacific Islander, Black, Native American, Other or Unknown race. Patients of Hispanic ethnicity, or Asian or Pacific Islander, Black, Native American, Other or Unknown race were more likely than non-Hispanic White patients to live in the most socially vulnerable areas (19.3% vs 5.9%, P < .01) and had greater time intervals than non-Hispanic White patients between index hypercalcemia and first parathyroid hormone level, surgical referral, or parathyroidectomy (all P < .05). On multivariable analysis, age (coefficient 7.9, 95% CI 2.8-13.0) and living in the most socially vulnerable areas (coefficient 297.9, 95% CI 87-508.7) were associated with greater days between index hypercalcemia and parathyroidectomy. In the study's qualitative phase, identified themes for reasons for care delays included socioeconomic, nonsocioeconomic patient, and nonsocioeconomic nonpatient factors. CONCLUSION: Care delays are driven by a combination of socioeconomic and nonsocioeconomic factors.

Gender Disparity in Earliest Phase of Academic Surgical Training: An Area for Intervention.

BACKGROUND: To overcome persistent gender disparities in academic surgery, it is critical to examine the earliest phase of surgical training. This national study sought to assess whether gender disparities also existed among surgical interns, as a proxy for medical school research experience in both quantity and quality. STUDY DESIGN: Using the 2021 to 2022 public information of 1,493 US-graduated categorical general surgery interns, a bibliometric evaluation was conducted to assess medical school research experience. Multivariable linear regressions with response log-transformed were performed to evaluate the impact of intern gender on (1) total number of peer-reviewed publications, (2) total impact factor (TIF), and (3) adjusted TIF based on authorship placement (aTIF). Back-transformed estimates were presented. RESULTS: Of these interns, 52.3% were female. Significant differences were observed in TIF (male 6.4 vs female 5.3, p = 0.029), aTIF (male 10.8 vs female 8.7, p = 0.035), gender concordance with senior authors (male 79.9% vs female 34.1%, p < 0.001), Hirsch index (male 21.0 vs female 18.0, p = 0.026), and the geographic region of their medical schools (p = 0.036). Multivariable linear regressions revealed that female interns were associated with lower TIF (0.858, p = 0.033) and aTIF (0.851, p = 0.044). Due to a significant gender-by-region interaction, adjusted pairwise comparisons showed that male interns in the Northeast had approximately 70% higher TIF (1.708, p = 0.003) and aTIF (1.697, p = 0.013) than female interns in the South. CONCLUSIONS: Gender disparities existed in the quality of research experience in the earliest phase of surgical training. These timely results call for additional interventions by the stakeholders of graduate medical education.

Endocrine Patients' Views on Transoral Endoscopic Thyroidectomy via Vestibular Approach (TOETVA).

TOETVA's adoption has been slow in the Western hemisphere. Our study aimed to evaluate how endocrine patients in the United States perceive the risks and benefits of TOETVA. This was a cross-sectional study where a de novo survey was sent via email to patients seen from 2018 to 2020. The survey asked how each of TOETVA's risks and benefits affect their choice between traditional thyroidectomy (TT) and TOETVA on a scale from 1 (favors TT) to 10 (favors TOETVA). Statistical significance was determined at p < 0.05. Of 422 patients (3.2% response rate), 76.0% were female, 28.9% were non-Whites, 58.3% possessing graduate/professional degrees, and 34.1% were diagnosed with thyroid cancer. Significant differences were found between groups of age, race, educational attainment, thyroid cancer diagnosis, and history of thyroid or parathyroid surgery with respect to their preference for thyroidectomy between TT and TOETVA. In multivariate analysis, attitudes towards longer operative time (estimate 0.130, 95% CI 0.026-0.235, p = 0.002), limited outcome data (estimate 0.142, 95% CI 0.029-0.254, p = 0.024), having less pain (estimate 0.108, 95% CI 0.004-0.212, p = 0.042), travel to seek care (estimate 0.166, 95% CI 0.042-0.290, p = 0.009), as well as African American race (estimate 0.714, 95% CI 0.093-1.334, p = 0.024), and history of surgery (estimate - 0.843, 95% CI - 1.364- - 0.323, p = 0.002) were independently predictive of overall preferences. TOETVA's risks and benefits may carry varying degrees of significance in patients' decision-making process, which helps tailor the discussion to choose the right procedure for patients.

The role of preoperative neck ultrasounds to assess lymph nodes in patients with suspicious or indeterminate thyroid nodules.

BACKGROUND AND OBJECTIVES: Currently there are no recommendations for obtaining a preoperative neck ultrasound for patients with suspicious or indeterminate thyroid nodules. Because a preoperative surgical ultrasound can detect suspicious lymph nodes that could result in ultimately altering surgical management, we chose to study which variables were predictive of this change. METHODS: Medical records of 173 patients who presented between January 2006 and December 2010 with suspicious or indeterminate thyroid cytology were retrospectively reviewed. Clinicopathological variables were analyzed to determine factors predictive of malignancy and a change in operative approach. RESULTS: One hundred thirty-four of 173 patients were evaluable. Seventeen of 134 (12.6%) of the preoperative ultrasounds were suspicious. Seven of 134 (5.2%) patients underwent a formal lymph node dissection based on ultrasound findings. Size of tumor, Bethesda FNAB category, and male gender were associated with malignancy while thyroid nodule microcalcifications and category of FNAB were associated with performing lymph node dissections. CONCLUSION: Thyroid nodule microcalcifications on ultrasound and category of FNAB appear to be the best predictors of metastatic disease. Because the surgical approach was altered in only a few patients, further analysis is needed to delineate whether performing cervical ultrasound for suspicious/indeterminate nodules is cost effective.

Comparing the rate and extent of malignancy in surgically excised thyroid nodules across race and ethnicity.

BACKGROUND: Few studies have compared the features of thyroid cancer among races and ethnicities. We hypothesized that race and ethnicity may influence the frequency and features of thyroid malignancy in thyroid nodules. METHOD: This was a retrospective chart review of patients between 2013 and 2020 who underwent thyroidectomy. RESULTS: In the analysis of 2737 patients, thyroid cancer was less prevalent among Blacks (24.0% vs Whites 52.1%, Hispanics 58.7%, Asians 71.7%, and Others 57.9%, p < 0.001). Thyroid cancer in Blacks was less likely to have extrathyroidal extension (9.7% vs Whites 18.6%, Hispanics 25.8%, Asians 18.2%, and Others 17.8%, p = 0.01), overall nodal involvement (12.4% vs Whites 31.1%, Hispanics 37.5%, Asians 36.3%, and Others 30.1%, p < 0.01), and lateral neck metastasis (4.4% vs Whites 10.8%, Hispanics 6.3%, Asians 13.2%, and Others 9.6%, p = 0.02). CONCLUSIONS: Race and ethnicity may play important roles in the risk of malignancy as well as in the extent of thyroid cancer.

The death of an Indian Rhinoceros.

In 1834, the London Zoological Society purchased a male Indian Rhinoceros, Rhinoceros unicornis, at the request of the anatomist, Richard Owen. Fifteen years later, the rhinoceros died from traumatic injuries, and the necropsy performed by Owen led to the very first discovery of parathyroid glands. Around this time, Richard Owen and Charles Darwin vehemently disagreed with one another about the theory of natural selection. Their public feud sparked the public's interest in Darwin and his theory while Owen became less popular despite his many accomplishments in the scientific world. Not until decades after Owen's death was his contribution to the identification of parathyroid glands discovered. Because his discovery is considered pivotal to the history of endocrine surgery, we sought to investigate the circumstances surrounding the rhinoceros' death, its dissection, and Owen's initial discovery.

Randomized control trial of opioid- versus nonopioid-based analgesia after thyroidectomy.

BACKGROUND: Opioid-based analgesia is the most common method for pain control in the postoperative period. Limited data exist to compare the adequacy of pain control in the post thyroidectomy period with nonopioid-based analgesia. We aimed to evaluate the efficacy of nonopioid-based, postoperative analgesia. METHODS: After institutional review board approval, patients were randomized to 1 of 2 pain control regimens. Sample size was calculated to assess for a pain score difference of 1 based on a visual analog scale. The control group received opioid-based, postoperative analgesia, whereas the study group received nonopioid-based analgesia of acetaminophen and ibuprofen. Pain scores (measured on visual analog scale) and opioid use (converted to morphine equivalent dose) were measured after completion of the operation. RESULTS: The sample sizes for the study and control groups were 49 and 46 patients, respectively. The pain score for the study and control groups 1 hour after the operation (3.3 vs 3.9, P = .35), 6 hours after the operation (2.8 vs 3.0, P = .08), on postoperative day 1 (1.6 vs 2.4, P = .08) and on the first office visit (0.2 vs 0.1, P = .82) did not have a statistically significant difference. Morphine equivalent opioid requirement for pain control in the postoperative period was 0.8 vs 6.9 mg (P < .01), respectively. CONCLUSION: In a randomized control trial, we showed that patients treated with nonopioid analgesia had similar pain scores to those treated with opioids, with the benefit of having lower opioid exposure in the perioperative period.

Evaluation of Thyroid Hormone Replacement Dosing in Overweight and Obese Patients After a Thyroidectomy.

Background: Initiation of thyroid hormone replacement (THR) after a total thyroidectomy has traditionally relied on the weight of the patient, regardless of the patient's body mass index (BMI). Current literature suggests that THR in obese patients differs from nonobese patients. This can lead to overdosing of levothyroxine (LT4) and delay in achievement of euthyroid state. Methods: We retrospectively identified patients on THR after total thyroidectomy with a benign postoperative diagnosis. Patients who achieved euthyroidism with THR were included in the analysis. Patient demographic and THR dosing information was collected. Regression analysis was performed to identify appropriate THR dosing at varying BMIs. This study aimed to evaluate the appropriate dosing of THR in overweight and obese patients. Results: Our cohort consisted of 114 patients achieving euthyroidism while on THR. Mean age was 55 years (range 28-77 years) with 84% females. Of the 114 patients, the number of patients with a BMI less than 25, 25-29, 30-34, 35-39, and greater than 40 were 26 (23%), 33 (29%), 23 (20%), 19 (17%), and 13 (11%), respectively. Of the entire cohort, a mean of 50 weeks elapsed after surgery to achieve euthyroidism, with no significant difference between the BMI categories (p = 0.58). In obese patients (BMI >30), 35% were overdosed with LT4 on initial dosing. The cohort lost a mean of 3 kg until euthyroidism was achieved, with no significant difference in the weight loss based on BMI category (p = 0.61). Patients with a higher BMI did require a higher dose (mcg) of LT4 to achieve euthyroidism (p < 0.01), but the dose was significantly lower in relation to their weight (mcg/kg) (p < 0.01). The LT4 dose required to achieve euthyroidism based on the previously mentioned BMI categories were 1.76, 1.47, 1.42, 1.27, and 1.28 mcg/kg. Conclusion: The current weight-based dosing of THR inappropriately overdoses overweight and obese patients. A more appropriate formula for THR titration should consider both the weight and BMI of the patient.

Indications and extent of central neck dissection for papillary thyroid cancer: An American Head and Neck Society Consensus Statement.

BACKGROUND: The primary purposes of this interdisciplinary consensus statement were to review the relevant indications for central neck dissection (CND) in patients with papillary thyroid cancer (PTC) and to outline the appropriate extent and relevant techniques required to accomplish a safe and effective CND. METHODS: A writing group convened by the American Head and Neck Society (AHNS) Endocrine Committee was tasked with identifying the important clinical elements to consider when managing the central neck compartment in patients with PTC based on available evidence in the literature, and the group's collective experience. The position statement paper was then submitted to the full Endocrine Committee, Education Committee, and AHNS Council. RESULTS: This consensus statement was developed to inform the clinical decision-making process when managing the central neck compartment in patients with PTC from the AHNS. This document is intended to provide clarity through definitions as well as a basic guideline from which to manage the central neck. It is our hope that this improves the quality and reduces variation in management of the central neck, facilitates communication, and furthers research for patients with thyroid cancer. CONCLUSION: This represents, in our opinion, contemporary optimal surgical care for this patient population and is endorsed by the American Head and Neck Society. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1269-1279, 2017.

Spinal metastases due to thyroid carcinoma: an analysis of 202 patients.

BACKGROUND: Spinal metastases (SMs) due to thyroid cancer (TC) are associated with significantly reduced quality of life. The goal of this study is to analyze the clinical manifestations, presentation, and treatments of TC SMs, and to describe specific features of SMs associated with different TC types. PATIENTS AND METHODS: A retrospective analysis of 202 TC SM patients treated at Medstar Washington Hospital Center (37) and collected from the literature (165) was performed. RESULTS: The mean age of patients with SMs was 56.9±14.7 years, and the female-to-male ratio was 2.1:1. Of all patients, 29% (28% of follicular thyroid cancer [FTC] and 37% of papillary thyroid cancer [PTC]) had SMs only. Twenty-nine percent of all patients and 54% of patients with single-site SMs had neither bone non-SMs nor solid organ metastases at the time of presentation. Thirty-five percent of patients had SMs as an initial presentation of TC. TC patients presenting with SMs had a lower rate of other bone and visceral involvement compared with patients whose SMs were diagnosed at the time of thyroid surgery or during follow-up (p<0.05). SMs were more often the initial manifestation of FTC (41% vs. 24%), while PTC SMs were more commonly diagnosed after TC diagnosis (76% vs. 59%; p<0.05). PTC SMs were more frequently diagnosed as synchronous (63% vs. 36% in FTC) versus FTC SMs that developed as metachronous metastases (64% vs. 37% in PTC; p<0.01). All FTC SMs developed within 82 (0-372) months and all PTC SMs within 35 (0-144) months (p<0.01). In FTC SMs as TC manifestation, solid organ metastases involvement was less common than in FTC SMs that were found after TC diagnosis (34% vs. 67%; p<0.01); multisite FTC SMs compared to solitary FTC SMs were associated with the development of other bone nonspinal metastases (82% vs. 30%; p<0.01) and solitary organ metastases (65% vs. 41%; p<0.01). These correlations were not observed in PTC SMs. FTC patients often had neural structure compression (myelopathy/radiculopathy; 72% vs. 36% in PTC), while PTC patients frequently were asymptomatic (38% vs. 5% in FTC; p<0.01). FTC SMs more commonly were (131)I-avid (p<0.01). FTC patients required surgery more frequently (72% vs. 55% in PTC; p<0.05). CONCLUSIONS: Our study reveals that a significant part of TC SMs patients have solitary spinal involvement at the time of presentation and may be considered for aggressive treatment with the intention to improve quality of life and survival. FTC SMs and PTC SMs appear to have distinct presentations, behavior, and treatment modalities, and should be categorized separately for treatment and follow-up planning.

Primary hyperparathyroidism.

Primary hyperparathyroidism is the most common cause of hypercalcemia in the outpatient setting. Phenotypically, it has evolved from a disease of overt symptomatology to one of vague complaints and biochemical diagnosis. Preoperative localization and intraoperative parathyroid hormone have revolutionized the surgical management of these patients. Minimally invasive operations are now common worldwide with low morbidity and high patient satisfaction.