Psychometric properties of EQ-5D-5L for use in patients with Graves' disease.

BACKGROUND: The EQ-5D-5 L is a commonly used generic measure of health. This study aimed to evaluate the psychometric properties of the EQ-5D-5 L in patients with Graves' disease (GD). METHODS: A prospective cohort of patients with GD recruited at three public hospitals in Hong Kong completed the EQ-5D-5 L and ThyPRO-39 questionnaires at baseline, 1-month, and 6-month follow-ups. Convergent validity was tested by examining the Spearman correlation between EQ-5D-5 L and ThyPRO-39 scores at baseline. 1-month test-retest reliability was assessed by Intraclass Correlation Coefficient (ICC), Gwet's Agreement Coefficient 2 (AC2), and percentage agreement. Responsiveness of EQ-5D-5 L index and EQ-VAS scores was assessed using effect size statistics (standardized effect size [SES] and standardized response mean [SRM]). RESULTS: Of 125 recruited patients, 101 (80.8%) and 100 (80.0%) patients were followed up at 1- and 6-month, respectively. For convergent validity, there was a moderate negative correlation between EQ-5D-5 L index or EQ-VAS score and ThyPRO-39 overall QoL-impact score (-0.350, -0.451), between EQ-VAS score and composite score (-0.483), and strong negative correlation between EQ-5D-5 L index score and composite score (-0.567). The Gwet's AC2 and percentage agreement were the highest in self-care (0.964 and 0.967), followed by mobility (0.952 and 0.962), usual activities (0.934 and 0.948), pain/discomfort (0.801 and 0.887), and anxiety/depression (0.788 and 0.882). The ICC for the EQ-5D-5 L index and the EQ-VAS was 0.707 and 0.700. For patients who reported having 'worsened' health at 6-month follow-up, the SES and SRM were - 0.66 and - 0.42 for EQ-5D-5 L index and - 1.15 and - 1.00 for EQ-VAS, respectively. CONCLUSIONS: The EQ-5D-5 L demonstrated convergent validity, test-retest reliability, and responsiveness to worsened health status among patients with GD.

Discharge of postoperative patients with an opioid prescription is associated with increased persistent opioid use, healthcare expenditures and mortality: a retrospective cohort study.

BACKGROUND: The risk factors for persistent opioid use after surgical discharge and the association between opioid prescription at discharge and postoperative emergency department visits, readmission, and mortality are unclear. METHODS: This population-based retrospective cohort study involved opioid-naive patients who underwent surgical procedures from January 1, 2000 to November 30, 2020. The data source was Hong Kong Hospital Authority Clinical Management System electronic health record. The primary outcome was the incidence of new persistent opioid use. Other study outcomes included 30-day emergency department visits, 30-day readmission, and 30-day all-cause mortality. Multivariable logistic regression models were used to estimate the association between opioid prescription at discharge and persistent opioid use, emergency department visits, readmission, and all-cause mortality. RESULTS: Over a median follow-up of 1 month with 36 104 person-years, 438 128 patients (opioid prescription: 32 932, no opioid prescription: 405 196) who underwent surgical procedures were analysed, of whom 15 112 (3.45%) had persistent opioid use after discharge. Prescribing opioids on discharge was associated with increased risks of developing persistent opioid use (odds ratio [OR]: 2.30, 95% confidence interval [CI]: 2.19-2.40, P<0.001), 30-day emergency department visits (OR: 1.28, 95% CI: 1.23-1.33, P<0.001), 30-day readmission (OR: 1.17, 95% CI: 1.13-1.20, P<0.001), and 30-day all-cause mortality (OR: 1.68, 95% CI: 1.53-1.86, P<0.001). CONCLUSIONS: In this large cohort of patients undergoing surgery, an opioid prescription on discharge was associated with a higher chance of persistent opioid use and increased risks of postoperative emergency department visits, readmission, and mortality. Minimising opioid prescriptions on discharge could improve perioperative patient outcomes.

A prospective study evaluating the use of low-dose intravenous sedation and analgesia during radiofrequency ablation of symptomatic, benign thyroid nodules.

BACKGROUND: We compared post-treatment pain, quality of recovery and complications between those who did not receive (Group I) and received (Group II) intravenous low-dose Midazolam (<0.05 mg/kg) and Pethidine (<0.5 mg/kg) during radiofrequency ablation (RFA) of benign thyroid nodules. METHODS: Both groups received local anesthesia. Post-treatment pain was rated by a 0-10 numerical rating scale (NRS). The Quality-of-Recovery-9 (QoR9) questionnaire was completed upon discharge. RESULTS: Each group included 25 patients. Baseline characteristics were comparable (p > 0.05). Group II had lower pain NRS than group I both immediately (0 (0-3.5) vs. 4 (3-5), p = 0.002) and 4 h after RFA (2 (0.5-4) vs 3.5 (2-5), p = 0.031). There were no differences in complications and QoR9 score (Group I: 15 (13-17) vs Group II: 16 (14-18), p = 0.254). Both groups were discharged within the same day. CONCLUSION: Low dose intravenous sedation improved pain control without affecting recovery or safety in thyroid RFA.

Paediatric thyroidectomy: When and why? A 25-year institutional experience.

OBJECTIVE: Thyroidectomy in paediatric patients is relatively uncommon. In this study, we reviewed our experience of thyroidectomy in children and identified risk factors associated with postoperative complications. METHODS: We performed a retrospective analysis of paediatric patients who had thyroidectomy in our institution between April 1995 and January 2021. Demographic data, preoperative cytological findings, indications of surgery, surgical complications and histological results were analysed. RESULTS: A total of 87 paediatric patients with 92 thyroidectomy were identified. The indications for surgery were Graves' disease refractory to medical treatments (40.2%), benign thyroid nodules or multinodular goitre (26.4%), thyroid carcinoma (23.0%) and multiple endocrine neoplasm type 2A syndrome (10.3%). Patients presented with thyroid nodules or cervical lymph nodes had a 43.9% risk of malignancy. 66 total thyroidectomy were done with median operation time of 134 min(102-170), while 26 hemi-thyroidectomy were performed (Right side 12/92, Left side 14/92) with median operation time of 65 min(49-102). The median postoperative hospital stay was 2 days(1-4). Intraoperative neck dissection (p = 0.003), drain insertion (p = 0.001) and hypocalcaemia requiring medical treatment (p = 0.004) were associated with longer hospital stay. The median follow-up was 11.3 years (3.0-16.8). 32% patients had immediate postoperative hypocalcaemia and 8% patients had permanent hypoparathyroidism. Transient vocal cord palsy was found in 3 patients(3%) and all resolved within 5-month time upon reassessment direct laryngoscopy. The use of intraoperative recurrent laryngeal nerve monitoring was associated with less vocal cord palsy (p = 0.022). The median disease-free survival was 13.7 years(7.4-17.7) for patients operated for well-differentiated thyroid carcinoma(WDTC). amongst the 9 patients who had prophylactic total thyroidectomy for MEN2A syndrome, 44% were found to have medullary thyroid microcarcinomas on pathology. CONCLUSIONS: Surgical management of paediatric thyroid disease can be complex. Postoperative hypocalcaemia and vocal cord palsy were usually transient after total thyroidectomy. The use of intraoperative recurrent laryngeal nerve monitoring had resulted in less vocal cord palsy. Long-term disease-free survival of patients with thyroid cancer had been achieved with multi-disciplinary management in our centre. LEVEL OF EVIDENCE: Retrospective Comparative Study; Level III.

High intensity focused ultrasound (HIFU) ablation of benign thyroid nodule is safe and efficacious in patients who continue taking an anti-coagulation or anti-platelet agent in the treatment period.

BACKGROUND: High intensity focused ultrasound (HIFU) ablation is a promising treatment for benign thyroid nodules but because bleeding complications can occur following any intervention to the thyroid gland, the safety and efficacy of HIFU ablation were evaluated in patients who continued taking an anti-coagulation or anti-platelet agent during treatment. METHODS: From 2015 to 2017, 303 patients who underwent a single-session ablation for a benign thyroid nodule were analyzed. The primary study endpoint was thyroid bleeding, intra-lesional or peri-thyroidal hematoma or neck bruising diagnosed within 4 days of the treatment. Other endpoints included treatment-related complications, extent of nodule shrinkage and symptom score. Nodule volume was estimated by ultrasound. Extent of nodule shrinkage (by volume reduction ratio) (VRR)= [Baseline volume - volume at 6-month]/[Baseline volume] × 100. Obstructive symptom score (by 0- 10 visual analog scale, VAS) was evaluated after treatment. RESULTS: Twelve patients continued taking an anti-coagulation or anti-platelet agent while the other 291 patients did not during treatment. No patients in either group suffered active thyroid bleeding, intralesional/pericapsular hematoma or subcutaneous neck bruising in the first 4 days of treatment. Complication rate and the 6-month VRR were comparable between the two groups (0.0% vs. 1.7%, p = 1.000 and 55.96% vs. 61.29%, respectively, p = .073). CONCLUSIONS: HIFU ablation is a feasible treatment in patients who continue to take an anti-coagulation or anti-platelet agent during treatment and might be preferable in patients who continuously require an anti-coagulation or anti-platelet agent for one reason or another during treatment.

The significance of unrecognized histological high-risk features on response to therapy in papillary thyroid carcinoma measuring 1-4 cm: implications for completion thyroidectomy following lobectomy.

BACKGROUND: Although lobectomy is an alternative to total thyroidectomy (TT) for 1-4 cm papillary thyroid carcinoma (PTC) without high-risk features (HRFs) such as aggressive histology, vascular invasion, lymphovascular invasion (LVI), microscopic extrathyroidal extension, positive margin, nodal metastasis >5 mm and multifocality, these HRFs are not recognized until after surgery. Therefore, the chance of completion TT being required following lobectomy might be high. We evaluated the frequency of unrecognized HRFs and how they affected the response to therapy following TT and radioiodine (RAI). METHODS: Altogether, 1513 patients were analysed. Only 1-4 cm PTCs without recognizable HRFs were included. For response-to-therapy evaluation, only patients who had TT and post-RAI-stimulated thyroglobulin were analysed. Patients without an excellent response were defined as having 'incomplete response'. A multivariate analysis for incomplete response was performed. RESULTS: Of the 600 patients eligible for lobectomy, 257 (42·8%) had ≥1 unrecognized histological HRF before surgery. The prevalence of unrecognized HRFs was similar between 1-2 cm and >2-4 cm PTCs (P = 0·393). Of the 330 patients eligible for response-to-therapy evaluation, 260 (78·8%) had an excellent response while 70 (21·2%) had an incomplete response. LVI was the only independent unrecognized HRF for incomplete response (P = 0·021). CONCLUSIONS: The prevalence of unrecognized histological HRFs under the current recommendations is relatively high among 1-4 cm PTCs. Among the unrecognized histological HRFs, LVI was the only one which independently associated with an incomplete response (i.e. posing an increased risk of persistent/recurrent disease after curative surgery). These findings may have implications for patients who undergo lobectomy for 1-4 cm PTCs with no clinically recognizable HRFs under the current recommendations.

Impact of microscopic extra-nodal extension (ENE) on locoregional recurrence following curative surgery for papillary thyroid carcinoma.

BACKGROUND: The presence of microscopic extra-nodal extension (ENE) may increase locoregional recurrence (LRR) in papillary thyroid carcinoma (PTC). We aimed to evaluate the association between microscopic ENE, response to initial therapy and LRR risk following total thyroidectomy, therapeutic neck dissection, and radioactive iodine (RAI) ablation in PTC. METHODS: Of the 369 eligible PTC patients, 264 (71.5%) did not have microscopic ENE (group I) while 105 (28.5%) did (group II). All presented with clinical nodal metastasis (cN1) and underwent therapeutic neck dissection and RAI ablation. Biochemical incompleteness meant post-ablation stimulated thyroglobulin (sTg) >10 ng/ml. Multivariate analyses were conducted to identify independent factors for LRR. RESULTS: Biochemical incompleteness was significantly more common group II (43.8% vs. 17.4%, P < 0.05). The 10-year locoregional free-survival was significantly worse in group II than I (52.0% vs. 86.2%, P = 0.005). After adjusting for other significant factors, age <45 (P < 0.05), multifocality (P < 0.05), presence of ENE (P = 0.027) were independent risk factors of LRR. The number and size of positive lymph nodes were not independent factors. CONCLUSIONS: Patients with microscopic ENE were significantly more likely to have biochemical incompleteness after initial therapy. After adjusting for other significant primary and nodal characteristics, microscopic ENE was an independent factor for LRR in patients with cN1. J. Surg. Oncol. 2016;113:526-531. © 2016 Wiley Periodicals, Inc.

Assessing perioperative body weight changes in patients thyroidectomized for a benign nontoxic nodular goitre.

BACKGROUND: Following thyroidectomy, patients often complain of weight gain. Our study aimed to evaluate the extent of weight change in patients thyroidectomized for a nontoxic benign goitre after adjusting for patient demographics and pre-operative weight changes. METHODS: Three different patient groups were studied. The first comprised 898 patients who underwent thyroidectomy for benign nontoxic nodular goitre (group I). The second comprised 179 patients who had benign nontoxic goitre but did not undergo thyroidectomy (group II), and the third comprised 80 patients who underwent a simple excision of a parathyroid adenoma (group III). All patients were weighed 12 months preceding baseline, at baseline and 6 months after baseline. RESULTS: Baseline characteristics were comparable between groups. Patients in Group I who gained the least weight in the year leading to surgery gained the most weight 12 months after surgery (P = 0·030). After adjusting for demographics and pre-operative weight changes, Group I gained significantly more weight at post 6 and 12 months (0·71 (95% CI=0·46-0·95) kg and 1·21 (95% CI = 0·96-1·46) kg, respectively). Weight gain at post 12 months appeared similar between hemithyroidectomy and total thyroidectomy (1·32 vs 1·16 kg, P = 0·197). Younger age (ß coefficient -0·100, 95% CI = -0·030 to 0·003, P = 0·015) and higher baseline thyroid stimulating hormone (ß coefficient -0·315, 95% CI = -1·468 to 0·134, P = 0·020) were significant factors for weight gain at post 12 months. CONCLUSIONS: Compared to nonthyroidectomized patients, thyroidectomized patients experienced significant weight increases at post 6 and 12 months. The extent of thyroidectomy did not affect the extent of weight gain. Younger age and higher baseline thyroid stimulating hormone were significant factors of weight gain at post 12 months.