Cost Effectiveness of Routine Laryngoscopy in the Surgical Treatment of Differentiated Thyroid Cancer.

BACKGROUND: Some surgeons perform flexible fiberoptic laryngoscopy (FFL) in all patients prior to thyroid cancer operations. Given the low likelihood of recurrent laryngeal nerve (RLN) or aerodigestive invasion in clinically low-risk thyroid cancers, the value of routine FFL in this group is controversial. We hypothesized that routine preoperative FFL would not be cost effective in low-risk differentiated thyroid cancer (DTC). METHODS: A decision model was constructed comparing preoperative FFL versus surgery without FFL in a clinical stage T2 N0 DTC patient without voice symptoms. Total thyroidectomy and definitive hemithyroidectomy were both modeled as possible initial surgical approaches. Outcome probabilities and their corresponding utilities were estimated via literature review, and costs were estimated using Medicare reimbursement data. Sensitivity analysis was conducted to examine the uncertainty of cost, probability, and utility estimates in the model. RESULTS: When the initial surgical strategy was total thyroidectomy, routine preoperative FFL produced an incremental cost of $183 and an incremental effectiveness of 0.000126 quality-adjusted life-years (QALYs). The incremental cost-effectiveness ratio (ICER) for routine FFL prior to total thyroidectomy was $1.45 million/QALY, exceeding the $100,000/QALY threshold for cost effectiveness. Routine FFL became cost effective if the preoperative probability of asymptomatic vocal cord paralysis increased from 1.0% to 4.9%, or if the cost of preoperative FFL decreased from $128 to $27. Changing the extent of initial surgery to hemithyroidectomy produced a higher ICER for routine FFL of $1.7 million/QALY. CONCLUSION: Routine preoperative FFL is not cost effective in asymptomatic patients with sonographically low-risk DTC, regardless of the initial planned extent of surgery.

Thyroid cancer is more likely to be detected incidentally on imaging in private hospital patients.

BACKGROUND: The incidence of well-differentiated thyroid cancer (WDTC) is increasing. Patients with higher socioeconomic status have higher rates of WDTC, possibly due to increased imaging and overdiagnosis. We compared methods of WDTC diagnosis in patients treated at a public and an adjacent private university hospital. MATERIALS AND METHODS: Patients with WDTC at the two hospitals between 2004 and 2010 were included. Patients were categorized into having their WDTC discovered on physical examination or on unrelated imaging. Demographic and pathologic data were collected. T-test was used for quantitative variables, and chi-squared test was used for categorical values. Binomial logistic regression was used to asses for confounding. RESULTS: Among 473 patients, 402 (85%) were from the university hospital, and 71 (15%) were from the public hospital. Patients from the university hospital were older (mean age: 49 versus 44, P = 0.02) and had a different racial composition compared to those from the public hospital. The patients at the public hospital had larger tumors (23 versus 18 mm, P = 0.04). Patients from the university hospital were more likely to have WDTC detected by imaging than patients in the public hospital (46% versus 28%, P < 0.01) on univariate analysis. CONCLUSIONS: This study demonstrates that patients with WDTC treated at a university hospital are more likely to have their tumor detected on unrelated imaging than those treated at a public hospital. These data may support the hypothesis that patients with improved insurance are more likely to have WDTC detected by imaging.

NONINVASIVE FOLLICULAR TUMOR WITH PAPILLARY-LIKE NUCLEAR FEATURES: NOT A TEMPEST IN A TEAPOT.

OBJECTIVE: Encapsulated non-invasive follicular variant papillary thyroid cancer (ENIFVPTC) has recently been retermed noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP). This designation specifically omits the word "cancer" to encourage conservative treatment since patients with NIFTP tumors have been shown to derive no benefit from completion thyroidectomy or adjuvant radio-active iodine (RAI) therapy. METHODS: This was a retrospective study of consecutive cases of tumors from 2007 to 2015 that met pathologic criteria for NIFTP. The conservative management (CM) group included patients managed with lobectomy alone or appropriately indicated total thyroidectomy. Those included in the aggressive management (AM) group received either completion thyroidectomy or RAI or both. RESULTS: From 100 consecutive cases of ENIFVPTC reviewed, 40 NIFTP were included for the final analysis. Of these, 10 (27%) patients treated with initial lobectomy received completion thyroidectomy and 6 of 40 (16%) also received postsurgical adjuvant RAI. The mean per-patient cost of care in the AM group was $17,629 ± 2,865, nearly twice the $8,637 ± 309 costs in the CM group, and was largely driven by the cost of completion thyroidectomy and RAI. CONCLUSION: The term NIFTP has been recently promulgated to identify a type of thyroid neoplasm, formerly identified as a low-grade cancer, for which initial surgery represents adequate treatment. We believe that since the new NIFTP nomenclature intentionally omits the word "cancer," the clinical indolence of these tumors will be better appreciated, and cost savings will result from more conservative and appropriate clinical management. ABBREVIATIONS: AM = aggressive management CM = conservative management ENIFVPTC = encapsulated noninvasive form of FVPTC FVPTC = follicular variant of papillary thyroid carcinoma NIFTP = noninvasive follicular thyroid neoplasm with papillary-like nuclear features PTC = papillary thyroid carcinoma PTMC = papillary thyroid microcarcinoma RAI = radio-active iodine US = ultrasound.

Surgical approach and outcomes in patients with lithium-associated hyperparathyroidism.

BACKGROUND: Patients receiving lithium therapy are at elevated risk of developing hyperparathyroidism. In lithium-associated hyperparathyroidism (LAH), the incidence of multiglandular disease (MGD) is unclear, and the need for routine bilateral cervical exploration remains controversial. Therefore, in LAH patients, surgical approaches, pathologic findings, cure rates, and factors associated with persistent or recurrent disease were investigated. METHODS: Retrospective analysis of 27 patients with LAH undergoing parathyroidectomy with the intraoperative parathyroid hormone (PTH) assay. RESULTS: The median postoperative follow-up was 7 months; 17 patients had >6 months follow-up. Cervical exploration was unilateral in 9, bilateral in 18 (3 were converted from unilateral). Sixteen patients (62%) had MGD, 12 with four-gland hyperplasia and 4 with double adenomas. Ten patients (38%) had a single adenoma. Twenty-five (93%) of 27 patients had initially successful surgery. Of the 17 patients with >6 months follow-up, two had persistent disease and two experienced recurrent disease. All patients with a single adenoma remain free of disease. Three (75%) of four patients with persistent/recurrent disease had MGD and were receiving lithium at the time of surgery. Patients with persistent/recurrent disease were older (p = 0.01) and had experienced a longer duration of hypercalcemia (p = 0.04). CONCLUSIONS: LAH patients have a high incidence of MGD, and bilateral exploration is frequently necessary. With access to the intraoperative PTH assay, it is reasonable to initiate a unilateral approach because many patients will harbor single adenomas and can be reliably rendered normocalcemic. Patients with MGD remain at higher risk of persistent/recurrent disease.

Dentists' treatment of underserved populations following participation in community-based clinical rotations as dental students.

OBJECTIVE: The purpose of this study was to identify which underserved populations are being treated by dentists after participation in community-based clinical rotations as dental students and to determine which predictor variables are associated with dentists' treatment of these populations. METHODS: A 25-item written survey was developed and mailed to University of Iowa College of Dentistry alumni (1992-2002; N = 745) to assess what percentage of their current total patient population was composed of each of the twelve identified populations. Separate statistical analyses (descriptive, bivariate, and generalized logistic regression) were performed for each underserved population. RESULTS: Three-hundred seventy-two dentists responded for an adjusted response rate of 50 percent. Respondents were most likely to treat "other ethnic groups" and low income populations. In contrast, 70 percent or more of all respondents said they never treat the homebound, homeless, and incarcerated. Additionally, over 40 percent of respondents said they never treat HIV+/AIDS patients and Medicaid patients. Logistic regression models showed that comfort in treating a population, treating more than seven populations, and having the total percentage of underserved populations treated within a practice total more than 50 percent were the most frequently associated (P < 0.05) and strongest predictors of treating the listed underserved populations. CONCLUSIONS: Although respondents reported treating most populations, community leaders and dentists should identify at-risk populations and develop protocols to help ensure that these populations are able to obtain, at a minimum, emergency care. Additionally, dental schools should develop educational curricula to help increase students' comfort in treating underserved populations.

Preoperative parathyroid scintigraphic lesion localization: accuracy of various types of readings.

PURPOSE: To retrospectively compare the accuracy of various parathyroid scintigraphy readings for single-gland disease (SGD) and multigland disease (MGD) in patients with primary hyperparathyroidism, with histologic analysis as the reference standard. MATERIALS AND METHODS: Institutional review board approval was obtained for this HIPAA-compliant study. Records of 462 patients with primary hyperparathyroidism who underwent preoperative imaging with a technetium 99m ((99m)Tc) sestamibi and (99m)TcO4- protocol that consisted of early and late pinhole (99m)Tc sestamibi, pinhole thyroid imaging, image subtraction, and single photon emission computed tomography (SPECT) were retrospectively reviewed. An experienced nuclear medicine physician without knowledge of other test results or of the final diagnoses graded images on a scale from 0 (definitely normal) to 4 (definitely abnormal). Early pinhole (99m)Tc sestamibi images, late pinhole (99m)Tc sestamibi images, subtraction images, SPECT images, early and late pinhole (99m)Tc sestamibi images, all planar images, and all images--including SPECT images--were read in seven sessions. Receiver operating characteristic curves were generated for each session and were used to calculate sensitivity, specificity, and accuracy. RESULTS: A total of 534 parathyroid lesions were excised. Of the 462 patients, 409 had one lesion, whereas 53 had multiple lesions. Reading all images together was more accurate (89%, P = .001) than was reading early (79%), late (85%), subtraction (86%), and SPECT (83%) images separately; however, it was not significantly more accurate than reading planar images (88%) or early and late images together (87%). Reading all images was significantly less sensitive in the detection of lesions with a median weight of 600 mg or less than in the detection of lesions with a median weight of more than 600 mg (86% vs 94%, P = .004). Per-lesion sensitivity for reading all images was significantly higher for SGD than for MGD (90% vs 66%, P < .001). Sensitivity of reading all images together in the identification of patients with MGD was 62%. CONCLUSION: Reviewing early, late, and subtraction pinhole images together with SPECT images maximizes parathyroid lesion detection accuracy. Test sensitivity is adversely affected by decreasing lesion weight and MGD.

Dentists' comfort in treating underserved populations after participating in community-based clinical experiences as a student.

The purpose of this project was to determine new dentists' comfort levels in treating traditionally underserved populations after participating in two consecutive five-week community-based clinical experiences while in dental school. A written survey was mailed to all known University of Iowa alumni (1992-2002; N=745). Respondents were asked to rank their comfort levels in treating twelve underserved populations on a five-point Likert type scale (5=no problem; 1=will not). Bivariate and logistic regression model analyses were performed to examine associations (p<0.05) among comfort and six predictor variables. Alumni (n=372) were most comfortable treating other ethnic, low-income, non-English-speaking, and HIV+/AIDS populations and least comfortable treating incarcerated and homebound populations. The following variables were significantly associated with comfort: 1) perception that the community experiences had great/much value; 2) practice located in larger communities; 3) non-solo practitioners; and 4) dentist's gender. As more dental schools utilize community-based clinical experiences to increase students' exposure to underserved populations, it is important that these experiences provide exposure to a variety of populations. Additionally, dental schools should continuously monitor the short- and long-term value of these programs for their students and recent graduates.

Coordinating operations in a multi-foundation health care system.

When Sid Mallory took the helm in 2005 as executive vice president for philanthropy at Allina Hospitals & Clinics, he immediately recognized a key challenge. Although fundraising across the 11-hospital system was solid, there were substantive differences in strategies, reporting and day-to-day operations that were making it difficult to leverage best practices and individual foundation successes within the system as a whole. With ambitious fundraising goals set for the next several years, Mallory knew that change was needed, and soon. If you are fundraising for a hospital that is part of a broader system, this conundrum may sound familiar. If you raise funds for an independent health care organization, the lessons shared by your system peers can improve your own practices as well.

Four-year cost-utility analyses of sealed and nonsealed first permanent molars in Iowa Medicaid-enrolled children.

OBJECTIVES: Dental sealants, by their ability to prevent caries and maintain teeth in better health, have some inherent utility to individuals, programs, or society. This study assessed the 4-year incremental cost utility of sealing first permanent molars of 6-year-old Iowa Medicaid enrollees from a societal perspective and identified the group of teeth or children in whom sealants are most cost effective. METHODS: Dental services for first permanent molars were assessed using claims and encounter data for a group of continuously enrolled Medicaid enrollees who turned 6 between 1996 and 1999. Previously published utilities were used to weight the different health states. The weighted sum of outcomes [Quality-Adjusted Tooth-Years (QATYs)] was the measure of effectiveness. Costs and QATYs were discounted to the time of the child's sixth birthday. RESULTS: For all first molars, the cost of treatment associated with sealed teeth was higher but the utility was also slightly higher over the 4-year period. The relative incremental cost per 0.19 QATY ratio [changing the health state from a restored tooth (utility= 0.81) to a nonrestored tooth (utility = 1)] by sealing the molar ranged from $36.7 to $83.5 per 0.19 QATY. The incremental cost/QATY ratio was lower for sealing lower utilizers and for mandibular versus maxillary molars. CONCLUSIONS: Sealants improved overall utility of first permanent molars after 4 years. The 4-year cost/QATY ratio of sealing the first permanent molar varied by arch and type of utilizers. Sealing first permanent molars in lower dental utilizers is the most cost-effective approach for prioritizing limited resources.

Students' opinions about treating vulnerable populations immediately after completing community-based clinical experiences.

The purpose of this study was to analyze students' perceptions of comfort and anticipated willingness to treat selected special needs and traditionally underserved populations immediately upon completion of community-based clinical assignments. The sample consisted of University of Iowa senior dental students who completed a questionnaire that asked, in part, about student comfort with and future willingness to treat twelve vulnerable population groups. With student comfort and future willingness to treat each group as dependent variables, logistic models were developed to determine whether there were significant associations between dependent variables and gender, graduation year, and students' prior experience with these groups. Regression models indicate students' prior experience is most often associated with comfort in treating the associated population group. Likewise, experience and comfort add different dimensions to perceived future willingness to treat almost all of the twelve groups. Student gender, graduation year from dental school, and community assignments influence only a few of these targeted population groups. This study provides empirical evidence concerning students' perceptions about comfort with various vulnerable populations after completing their extramural rotations. Students were more comfortable treating certain population groups as well as more willing to consider including these groups in their future practices.

Warthin-like tumor of the thyroid gland: an uncommon variant of papillary thyroid cancer.

Several variants of papillary thyroid cancer have been described, including, most recently, Warthin-like tumor of the thyroid gland. To bring attention to this uncommon variant, we review previous reports on this entity and we add 5 new cases to the literature. We retrospectively reviewed the records of all patients who had undergone thyroidectomy at our institution during a 7-year period. Among these cases, we identified 5 patients who had had a Warthin-like tumor of the thyroid. From their charts, we compiled data on age, sex, lymphadenopathy, distant spread, and treatment. Pathologic specimens were reviewed for tumor size, capsular invasion, and vascular invasion. All 5 patients were women (mean age: 51.6 yr). Tumor size ranged from 0.9 to 2.0 cm. Multifocality was seen in 1 of the 5 patients; this patient was also the only one who experienced capsular and vascular invasion. No patient had lymph node spread or distant metastasis. Because the follow-up period among these patients was still short, we were unable to analyze long-term survival data.

Method of Detection of Well-Differentiated Thyroid Cancers in Obese and Non-Obese Patients.

BACKGROUND: The incidence of well-differentiated thyroid cancer (WDTC) is increasing rapidly. Many authors feel that this increase is due to over-diagnosis and that one of the contributing factors is the increasing use of various imaging studies. The rate of obesity has also been increasing in the United States. It has been suggested that patients with an increased body mass index (BMI kg/m2) have a higher incidence of WDTC than patients with normal BMI. One might hypothesize that thyroid nodules are more difficult to palpate in obese patients and that as more cancers are detected by imaging the apparent rate of increase in WDTC in obese patients would appear to be greater than in non-obese patients. This study was undertaken to evaluate this hypothesis by determining if there is any difference in the way thyroid cancers are initially detected in obese and non-obese patients. METHODS: The medical records of all 519 patients with a postoperative diagnosis of WDTC who underwent thyroidectomy at NYU Langone Medical Center from January 1, 2007 through August 31, 2010 by the three members of NYU Endocrine Surgery Associates were reviewed. Patients were divided into Non-obese (BMI<30 kg/m2) and Obese (BMI≥30 kg/m2) groups. Patients were also divided by the initial method of detection of their tumor into Palpation, Imaging, and Incidental groups. RESULTS: The final study group contained 270 patients, 181(67%) of whom were in the Non-obese Group and 89(33%) were in the Obese Group. In the Non-obese group, 81(45%) of tumors were found by palpation, 72(40%) were found by imaging, and 28(16%) were found incidentally. In the Obese group, 40(45%) were found by palpation, 38(43%) were found by imaging, and 11(12%) were found incidentally. These differences were not statistically significant (p-value 0.769). CONCLUSION: We show that BMI does not play a role in the method of initial detection in patients with WDTC. This suggests that the prevalence of WDTC detected by imaging is not an artifact caused by an increasingly obese population and that any association of WDTC and obesity is not related to the way in which these tumors are detected.

Persistently elevated parathyroid hormone levels after parathyroid surgery.

BACKGROUND: Persistent elevation of serum parathyroid hormone (PTH), despite normocalcemia, occurs in 8% to 40% of patients after parathyroidectomy. Explanations have included hypocalcemia owing to vitamin D deficiency or bone remineralization, and persistent hyperparathyroidism. METHODS: A retrospective chart review of 816 consecutive patients who underwent surgery for primary hyperparathyroidism was conducted. RESULTS: One hundred fourteen patients (15%) had persistently elevated PTH levels (PPTH). Patients with PPTH had higher preoperative PTH levels than those with normal PTH levels postoperatively. They also had lower postoperative Ca(++) and vitamin D levels. Multiple gland enlargement was identified in fewer patients with PPTH than in those with normal postoperative PTH levels. In patients with PPTH and a postoperative Ca(++) less than 9.6 mg/dL (group I), there was a greater decrease in IOPTH, a higher initial postoperative PTH level, and a lower postoperative vitamin D level than in PPTH patients whose postoperative Ca(++) was > or =9.6 mg/dL (group II). Postoperative Ca(++) and vitamin D levels were also lower in patients whose PPTH did not ultimately resolve. Three patients in group II had recurrent disease. CONCLUSIONS: Persistent elevation of postoperative serum PTH levels in normocalcemic patients is associated with mild hypocalcemia, probably owing to vitamin D deficiency. In some patients it may also be indicative of mild persistent hyperparathyroidism.

A comparison of dental services received by Medicaid and privately insured adult populations.

BACKGROUND: Few studies have compared differences in dental care utilization rates between a publicly and a privately insured adult population in the same geographic area. The authors conducted this study to compare the demographic characteristics and use of dental services for enrollees in the Iowa Medicaid program and in the Delta Dental Plan of Iowa. The focus was on the overall use of dental services, with an emphasis on the use of tertiary care services such as endodontic therapy and tooth extraction services. METHODS: The authors used insurance claims data for adults aged 21 to 64 years who were enrolled in Delta Dental of Iowa and the Iowa Medicaid program for fiscal year 1998. They calculated utilization of dental services rates by type of dental procedure. RESULTS: In fiscal year 1998, 69.3 percent of Delta Dental enrollees and 27.2 percent of Medicaid enrollees had a dental visit. More than 90 percent of those in both populations with a dental visit had used preventive dental services during the year. Medicaid users were nearly twice as likely as Delta Dental enrollees to receive endodontic therapy (9.9 percent versus 5.0 percent, respectively) and nearly four times as likely to have had a tooth extracted (27.4 percent versus 7.1 percent, respectively). CONCLUSIONS: Privately insured enrollees were more likely to use dental services that were Medicaid enrollees. The greater use of tertiary care services by the Medicaid population than by the privately insured population is indicative of a lower oral health status for this group at the time they sought care, even though it was a much younger group of adults. PRACTICE IMPLICATIONS: The oral health status of low-income adults enrolled in Medicaid could benefit greatly from higher use of routine preventive dental services and earlier treatment of oral diseases to prevent the substantial need for preventable tertiary care services.

Natural history of treatment outcomes of permanent first molars: a study of sealant effectiveness.

BACKGROUND: Few studies have used insurance claims data to retrospectively assess the natural history--a natural process or flow of events without any special interventions--and treatment outcomes of teeth with dental sealants. METHODS: The authors constructed treatment outcome trees (TOTs) from the Iowa Medicaid claims and eligibility data (1996-2000) of continuously enrolled 6-year-old children who routinely used Medicaid dental services. The authors used the TOTs to compare the restorative treatments of sealed permanent first molars with those of nonsealed permanent first molars. RESULTS: Forty percent of routine utilizers received a sealant during the four-year period. Overall, 25 percent of molars received at least one restoration. Sealed molars were less likely to receive further restorative treatment than were nonsealed molars (13 versus 29 percent). Sealed molars had fewer extensive restorative treatments (crowns, endodontic therapy and extractions) than did nonsealed molars. The median time to restorative treatment of the sealed molars also was greater than that of the nonsealed molars. All four first molars had comparatively similar patterns of subsequent care. CONCLUSIONS: Permanent first molars with sealants received less subsequent restorative treatment than did those without sealants. TOTs are useful tools for identifying necessary outcome information needed for program evaluations. CLINICAL IMPLICATIONS: Greater use of sealants could reduce the need for subsequent treatment and prolong the time until treatment may be necessary for permanent first molars.

Overview of the evidence for clinical interventions in pediatric dentistry.

PURPOSE: The purpose of this report was to describe the quantity of published literature and types of studies supporting the use of 4 pediatric dentistry procedures: (1) ferric sulfate pulpotomy; (2) stainless steel crowns; (3) space maintainers; and (4) atraumatic restorative technique (ART). METHODS: When available, titles and abstracts of reports written in English and published over a 36-year period (1966-2002) concerning these procedures were retrieved from MEDLINE. They were classified using a modified classification scheme that, in addition to the study designs, also considered the 4 dimensions of measuring dental outcomes. RESULTS: The quantity of available literature concerning each dental procedure varied considerably. Even though many reports were published on treatments, only a small proportion of the published literature for each procedure was found to evaluate outcomes, regardless of outcome dimension. Besides outcomes evaluations, studies on techniques, material properties, and review articles comprised a large proportion of the literature. Clinical dimension of outcomes was most commonly studied. Case series and case reports were the most frequently used study designs to report outcomes. CONCLUSIONS: The outcomes-related literature to support some of the commonly performed treatments is limited both in quantity and study types. More reports are needed to develop the evidence base to support the commonly performed procedures in pediatric dental practice. Additional analyses reporting of the literature are also needed to assess internal and external validity of the studies.

Ethical dilemmas reported by fourth-year dental students.

Ethics education in dentistry is a requirement for accreditation. Despite universal adoption of ethics courses, there is ongoing discussion about the appropriate content of these courses and about methods to engage students. Faculty who teach ethics must select a limited set of topics from the broad fields of professional ethics, bioethics, and the humanities. The purpose of this article is to describe the ethical issues reported by fourth-year dental students during community-based extramural clinical experiences. Senior dental students (n=123) wrote essays describing an ethical issue they encountered during one of two extramural rotations. Ethical issues were categorized and coded by consensus between two faculty authors. Students most often reported perceived dilemmas related to patients' limited resources (25 percent), conflict between professionals (19 percent), clinic policy or procedures (15 percent), and decision making by patients' surrogates (13 percent). One student (<1 percent) reported encountering no ethical issues. Students' perceptions of ethical issues in clinical practice offer faculty a foundation for designing a dental ethics curriculum that is practical and immediately relevant to the experience of a dental student. Students' reports may also yield a method for systematic assessment of students' abilities to apply classroom ethics instruction to clinical practice.

Students' comfort level in treating vulnerable populations and future willingness to treat: results prior to extramural participation.

This study analyzed senior dental students' perceptions prior to extramural rotations for comfort and future willingness to treat patients with special needs and other vulnerable groups. The sample included 690 University of Iowa senior dental students who graduated from 1992 through 2004. These students completed a questionnaire concerning twelve vulnerable population groups. Logistic regression models were performed, using student comfort and future willingness to treat each group as the dependent variable. There was a wide percentage of range of comfort with these groups, yet there was no individual group that more than 60 percent of these students were willing to treat in their future practices. Generally, prior experience with the group had a positive impact on comfort level. When gender was included in the regression models, male students were more likely to express comfort. In all instances except one, experience had a positive influence on perceived future willingness to treat the associated group. However, younger graduates had a greater willingness to treat. When controlling for other variables within the future willingness to treat models, comfort was statistically significant only for HIV+/AIDS and non-English speaking groups. This study provides insight about comfort with and perceived future willingness to treat special needs and other vulnerable patient groups.

Management of recurrent/persistent nodal disease in patients with differentiated thyroid cancer: a critical review of the risks and benefits of surgical intervention versus active surveillance.

BACKGROUND: The primary goals of this interdisciplinary consensus statement are to define the eligibility criteria for management of recurrent and persistent cervical nodal disease in patients with differentiated thyroid cancer (DTC) and to review the risks and benefits of surgical intervention versus active surveillance. METHODS: A writing group was convened by the Surgical Affairs Committee of the American Thyroid Association and was tasked with identifying the important clinical elements to consider when managing recurrent/persistent nodal disease in patients with DTC based on the available evidence in the literature and the group's collective experience. SUMMARY: The decision on how best to manage individual patients with suspected recurrent/persistent nodal disease is challenging and requires the consideration of a significant number of variables outlined by the members of the interdisciplinary team. Here we report on the consensus opinions that were reached by the writing group regarding the technical and clinical issues encountered in this patient population. CONCLUSIONS: Identification of recurrent/persistent disease requires a team decision-making process that includes the patient and physicians as to what, if any, intervention should be performed to best control the disease while minimizing morbidity. Several management principles and variables involved in the decision making for surgery versus active surveillance were developed that should be taken into account when deciding how best to manage a patient with DTC and suspected recurrent or persistent cervical nodal disease.

The clinical significance and anatomic distribution of parathyroid double adenomas.

BACKGROUND: Parathyroid double adenomas are reported to occur in 3% to 12% of cases of primary hyperparathyroidism, but the very existence of double adenomas has been controversial. This study was undertaken to evaluate the clinical significance and anatomic distribution of parathyroid double adenomas. STUDY DESIGN: The medical records of 384 consecutive patients who underwent operation for primary hyperparathyroidism were reviewed. RESULTS: A total of 27 patients (7%) were found to have double parathyroid adenomas. Intraoperative parathyroid hormone (PTH) levels were measured in each case. Two enlarged hypercellular parathyroid glands were identified in 6 possible configurations: 10 both superior, 3 both inferior, 5 both right, 3 both left, 5 right superior and left inferior, and 1 left superior and right inferior. There was preferential distribution to the bilateral superior position (p = 0.008). In all patients intraoperative PTH levels dropped by at least 50% from baseline and into the normal range after removal of both abnormal parathyroid glands. All patients remain normocalcemic 1 to 26 months postoperatively. Two patients have persistently elevated PTH values with normal serum calcium levels. CONCLUSIONS: The drop in intraoperative PTH levels and maintenance of normocalcemia postoperatively confirm previous reports that double adenomas do exist and are not simply missed cases of four-gland hyperplasia. Their incidence is more than would be expected by chance alone. The preferential occurrence of bilateral superior double adenomas suggests the possibility that these may represent hyperplasia of parathyroids arising from the fourth branchial pouch rather than isolated neoplastic events.