SHOULD FNA BE PERFORMED IN PATIENTS WITH A MULTINODULAR GOITER AND COMPRESSIVE SYMPTOMS?

OBJECTIVE: In this study, we aimed to determine whether preoperative thyroid fine-needle aspiration (FNA) in patients with multinodular goiter (MNG) and compressive symptoms influences the type of thyroid surgery performed, the incidence of recurrent thyroid cancer, or the need for successive surgery. METHODS: We retrospectively reviewed the charts of 431 patients who underwent thyroidectomy at our institution from 2008 to 2011. Patients who presented with compressive symptoms and no prior FNA at initial presentation were included in this study. RESULTS: Eighty patients met the criteria for our study, of which 46 (57.5%) underwent FNA prior to surgery and 34 (42.5%) were referred to surgery without FNA. The prevalence rates of malignancy (>1 cm) on surgical pathology in the FNA and non-FNA groups were 41% (n = 19) and 38% (n = 13), respectively. There was no statistically significant difference between the rate of total/subtotal thyroidectomies (71.7% in FNA vs. 79.4% in non-FNA, P = .31), lobectomies/partial thyroidectomies (28.3% in FNA vs. 20.5% in non-FNA, P = .43), neck lymph node dissections (P = .89) or subsequent surgeries (P = .72) between the 2 groups. CONCLUSION: Our findings show that preoperative FNA in patients with an MNG and compressive symptoms does not influence the type of surgery performed, short-term outcomes, or the need for subsequent surgeries. Further studies are needed to validate the need for preoperative FNA in such patients. ABBREVIATIONS: FNA = fine-needle aspiration MNG = multinodular goiter WHO = World Health Organization.

UTILITY OF ULTRASOUND VERSUS GENE EXPRESSION CLASSIFIER IN THYROID NODULES WITH ATYPIA OF UNDETERMINED SIGNIFICANCE.

OBJECTIVE: Thyroid nodules with fine-needle aspiration (FNA) cytology categorized as atypia of undetermined significance (AUS) often undergo additional diagnostic analysis with the Afirma Gene Expression Classifier (GEC), which classifies these as either high probability of being benign (GEC-B) or suspicious for malignancy (GEC-S). Our goal was to assess the clinical validity and utility of GEC in the evaluation of AUS cytology and evaluate the performance of ultrasonography (USG) for predicting malignancy in this subset. METHODS: We conducted a study with a retrospective cohort of patients from January 2012 to January 2014 who had FNA of thyroid nodules >1 cm in size with AUS cytology. RESULTS: Cleveland Clinic Florida has an overall prevalence of AUS of 5%. A total of 119 cases with nodules >1 cm in size were reported as AUS. Forty-eight (40.3%) had a GEC performed after the first FNA (AUS-1), and 27 of these were GEC-S. Of those 27, 21 went for surgery and 14 (66.6%) had thyroid cancer on histopathology. The remaining 71 with AUS-1 were sent for a second FNA: 19 nodules were benign and did not undergo further evaluation, while the remaining 52 were reported as AUS for the second consecutive time (AUS-2). AUS-2 samples were sent for GEC. Of these 52 AUS-2, 38 (73.1%) were reported as GEC-S. Thirty-five went for surgery and 32 (91.4%) had confirmed malignancy on histopathology. Positive predictive value (PPV) was 91.4% for AUS-2 and 66.6% for AUS-1. Moreover, AUS-2 nodules that were hypoechoic and solid on USG showed a PPV of 92% for malignancy. CONCLUSION: In our practice, the diagnostic accuracy to predict malignancy with GEC for AUS-1 nodules was poor (PPV, 66.6%). The PPV of GEC testing was markedly higher at 91.4% performed after two consecutive AUS cytologies. AUS-2 nodules that were solid and hypoechoic on USG also had a high probability to be malignant (PPV, 92%). We recommend repeat FNA on AUS-1 nodules rather than proceeding directly to GEC testing. Also, we suggest that among AUS-2 nodules, surgery can be recommended when USG shows solid and hypoechoic features with GEC testing reserved for the remainder. ABBREVIATIONS: AUS = atypia of undetermined significance FNA = fine-needle aspiration GEC = gene expression classifier GEC-B = GEC-benign GEC-S = GEC-suspicious for malignancy NPV = negative predictive value PPV = positive predictive value USG = ultrasonography.

Self-esteem in children and adolescents with and without attention-deficit/hyperactivity disorder: A meta-analytic review.

Meta-analytic methods were used to examine global and domain-specific (i.e., academic, social, behavioral) self-esteem in children and adolescents with and without ADHD. Potential moderators of effect size heterogeneity were also examined via meta-regressions within a three-level approach. Findings from 49 aggregated global self-esteem effect sizes (ADHDN = 2500, TDN = 9448), 12 academic self-esteem effect sizes (ADHDN = 386, TDN = 315), 11 social self-esteem effect sizes (ADHDN = 258, TDN = 254), and 8 behavioral self-esteem effect sizes (ADHDN = 231, TDN = 211) suggest that children and adolescents with ADHD experience moderate global (ES = 0.46, p < .001), academic (ES = 0.60, p = .009), and social (ES = 0.67, p = .001) self-esteem impairments compared to children and adolescents without the disorder. The aggregated behavioral self-esteem effect size (ES = 0.20, p = .54), however, was not significant, and the global self-esteem effect size was markedly smaller compared to effect sizes for the academic and social domains. Further, examination of potential moderators of effect size heterogeneity indicated null effects for medication status, diagnostic complexity, informant, age, sex, comorbid psychopathology, and self-esteem dimension. Collectively, findings suggest that children and adolescents with ADHD do not hold a ubiquitous negative self-perception of difficulties across academic, social, and behavioral domains of functioning, and unexamined domains that are distal to ADHD may serve to bolster global self-esteem.

Feature Binding and Working Memory in Children with ADHD: Evidence of Episodic Buffer Impairment.

Previous examinations of working memory impairments in children with attention-deficit/hyperactivity disorder (ADHD) have predominantly focused on discreet visuospatial and phonological subsystem processes, as well as the domain-general central executive. The episodic buffer component of working memory, a neurocognitive process that allows for temporary storage and maintenance of bound episodes/features of information, is understudied in ADHD and initial findings have been equivocal. Heterogeneity in previous findings may reflect between-study methodological variability, floor effects unrelated to episodic buffer processes (i.e., excessive central executive demands), and limitations associated with previous investigations' use of novel paradigms. This study examined ADHD-related episodic buffer processing via an established paradigm (Allen et al., 2006) in well-defined groups of children with attention-deficit/hyperactivity disorder (ADHD) and typically developing peers (TD). Seventy-one children (ADHD n = 34, TD n = 37) aged 8-12 years (M = 9.81, SD = 1.50; 32% female) completed two conditions of a computerized working memory task that presented single feature stimuli (color and shape), and a third condition that presented dual-feature stimuli (color/shape binding). Overall, the ADHD group exhibited a large-magnitude deficit during the color/shape binding condition (d = .77), and both groups evinced worse performance accuracy in the color/shape binding condition compared to the single feature color and shape conditions. Collectively, these findings appear to provide evidence that children with ADHD exhibit large magnitude episodic buffer deficits that are not attributable to visuospatial subsystem or domain-general central executive processes.

Attention-deficit/hyperactivity disorder and risk-taking: A three-level meta-analytic review of behavioral, self-report, and virtual reality metrics.

Meta-analytic methods were used to examine ADHD-related risk-taking in children and adults, and to compare the magnitude of risk taking across behavioral, self-report, and virtual reality metrics. Potential moderators of effect size heterogeneity were also examined via a three-level multi-level approach and a hybrid meta-analytic/systematic review approach. Aggregated effect sizes obtained from 56 behavioral-task studies (82 effect sizes; ADHDN = 2577; TDN = 2606), 51 self-report studies (130 effect sizes; ADHDN = 18,641; TDN = 113,163), and 8 virtual reality studies (16 effect sizes; ADHDN = 382; TDN = 436) suggest that children and adults with ADHD exhibit moderately more risk-taking compared to children and adults without the disorder. Notably, the aggregated effect size obtained from virtual reality simulations (Hedges', g = 0.43) was 30-40% larger than effect sizes obtained from self-report and behavioral task metrics (Hedges' g = 0.31 and 0.27), respectively. Suboptimal Decision Making was the only significant moderator identified via multi-level modeling; however, comparison of subgroup effect sizes revealed potential moderating effects of ADHD presentation and trial-by-trial feedback on behavioral tasks. Collectively, findings suggest that ADHD is reliably associated with small to moderate magnitude greater risk-taking behavior and virtual reality simulations appear be the most sensitive currently available metric.

Smartphone apps for depression and anxiety: a systematic review and meta-analysis of techniques to increase engagement.

Meta-analyses have shown that digital mental health apps can be efficacious in reducing symptoms of depression and anxiety. However, real-world usage of apps is typically not sustained over time, and no studies systematically examine which features increase sustained engagement with apps or the relationship between engagement features and clinical efficacy. We conducted a systematic search of the literature to identify empirical studies that (1) investigate standalone apps for depression and/or anxiety in symptomatic participants and (2) report at least one measure of engagement. Features intended to increase engagement were categorized using the persuasive system design (PSD) framework and principles of behavioral economics. Twenty-five studies with 4159 participants were included in the analysis. PSD features were commonly used, whereas behavioral economics techniques were not. Smartphone apps were efficacious in treating symptoms of anxiety and depression in randomized controlled trials, with overall small-to-medium effects (g = 0.2888, SE = 0.0999, z(15) = 2.89, p = 0.0119, Q(df = 14) = 41.93, p < 0.0001, I2 = 66.6%), and apps that employed a greater number of engagement features as compared to the control condition had larger effect sizes (ß = 0.0450, SE = 0.0164, t(15) = 2.7344, p = 0.0161). We observed an unexpected negative association between PSD features and engagement, as measured by completion rate (ß = -0.0293, SE = 0.0121, t(17) = 02.4142, p = 0.0281). Overall, PSD features show promise for augmenting app efficacy, though engagement, as reflected in study completion, may not be the primary factor driving this association. The results suggest that expanding the use of PSD features in mental health apps may increase clinical benefits and that other techniques, such as those informed by behavioral economics, are employed infrequently.