Validating the Modified McGill Thyroid Nodule Score for Assessment of Preoperative Risk of Pediatric Thyroid Malignancy.

OBJECTIVE: The McGill Thyroid Nodule Score (MTNS) is a preoperative tool used to predict the risk for well-differentiated thyroid cancer in adults. It was developed by a multidisciplinary team using established evidence-based risk factors for thyroid cancer. The modified McGill Thyroid Nodule Score (mMTNS) was developed to predict malignancy risk in children. A pilot study suggested the mMTNS was able to assess malignancy risk in children with indeterminate cytology on fine needle aspiration (FNA). This study seeks to validate these findings. METHODS: Retrospective chart review identified subjects who underwent FNA biopsy and subsequent resection. Each patient was assigned a score to compare to final pathology. Statistical analysis was performed with SPSS. All tests were 2-tailed and statistical significance defined p < 0.05. Logistic regression used to determine predictive values of scores. RESULTS: 46 patients ≤21 years of age underwent resection of a thyroid nodule. Female predominance of 85% (n = 39). 78% (n = 36) of patients had palpable nodule. 65% (n = 30) found to have benign pathology and 35% (n = 16) found to have malignancy. Malignant nodules associated with greater mean mMTNS compared to benign [13.63 vs 7.23]. An mMTNS greater >12 had sensitivity of 86.7%, specificity of 90.3%, positive predictive value of 81.3%, and negative predictive value of 93.3%. CONCLUSION: Our data suggests the mMTNS continues to be a useful adjunct in predicting malignancy risk of pediatric thyroid nodules. An mMTNS >12 has a high risk for malignancy, which can aid in counseling and clinical decision making, particularly when there is indeterminate cytology on FNA. LEVEL OF EVIDENCE: IV.

Prediction of Postoperative Surgical Risk: A Needs Assessment for a Medical Student Curriculum.

OBJECTIVE: Medical students' abilities to predict postoperative complications and death are unknown. We hypothesize that medical students will lack confidence in determining surgical risk and will significantly overestimate surgical risk for post-operative morbidities and mortality. DESIGN: Participants were invited to participate in an electronic, anonymous survey to assess their ability to predict surgical risk. The survey presented 7 complex clinical scenarios representative of a diverse general surgery practice. Participants were asked to assess the likelihood of different morbidities and mortality on a 0-100% scale, and predictions were compared to the ACS NSQIP risk calculator. SETTING: Yale School of Medicine, New Haven, Connecticut; Tertiary medical center PARTICIPANTS: Third year medical students on their surgery clerkship as well as general surgery residents were invited to participate. RESULTS: Most students were not confident about predicting postoperative complications (83.3%) or mortality (70.8%). Most students did not feel that the surgery clerkship adequately prepared them to assess surgical risk (69.6%). When compared to surgical residents for most presented cases (57% of cases), students and residents similarly overestimated postoperative morbidities and mortality. Estimates varied significantly, with wide 95% confidence intervals. Only 17% of NSQIP predicted estimates fell within the 95% confidence intervals. CONCLUSIONS: Medical students overestimate morbidity and mortality following surgery in complex patients. Additionally, they lack confidence in their ability to predict surgical complications. A formal curriculum for risk prediction is needed for medical students.

Trainees as Agents of Change in the Opioid Epidemic: Optimizing the Opioid Prescription Practices of Surgical Residents.

OBJECTIVE: Opioid abuse has become an epidemic in the United States, causing nearly 50,000 deaths a year. Postoperative pain is an unavoidable consequence of most surgery, and surgeons must balance the need for sufficient analgesia with the risks of overprescribing. Prescribing narcotics is often the responsibility of surgical residents, yet little is known about their opioid-prescribing habits, influences, and training experience. DESIGN: Anonymous online survey that assessed the amounts of postoperative opioid prescribed by residents, including type of analgesia, dosage, and number of pills, for a series of common general surgery procedures. Additional questions investigated influences on opioid prescription, use of nonnarcotic analgesia, degree of engagement in patient education on opioids, and degree of training received on analgesia and opioid prescription. SETTING: Accreditation Council for Graduate Medical Education accredited general surgery program at a university-based tertiary hospital. PARTICIPANTS: Categorical and preliminary general surgery residents of all postgraduate years. RESULTS: The percentage of residents prescribing opioids postprocedure ranged from 75.5% for incision and drainage to 100% for open hernia repair. Residents report prescribing 166.3 morphine milligram equivalents of opioid for a laparoscopic cholecystectomy, yet believe patients will only need an average of 113.9 morphine milligram equivalents. The most commonly reported influences on opioid-prescribing habits include attending preference (95.2%), concern for patient satisfaction (59.5%), and fear of potential opioid abuse (59.5%). Only 35.8% of residents routinely perform a narcotic risk assessment before prescribing and 6.2% instruct patients how to properly dispose of excess opioids. More than 90% of residents have not had formal training in best practices of pain management or opioid prescription. CONCLUSION AND RELEVANCE: Surgical trainees are relying almost exclusively on opioids for postoperative analgesia, often in excessive amounts. Residents are heavily influenced by their superiors, but are not receiving formal opioid-prescribing education, pointing to a great need for increased resident education on postoperative pain and opioid management to help change prescribing habits.

Quantitative assessment of RASSF1A methylation as a putative molecular marker in papillary thyroid carcinoma.

BACKGROUND: Epigenetic alterations such as DNA methylation are widespread cancer, contributing to tumorigenesis and acting as markers for prognostication. Papillary thyroid cancer (PTC) demonstrates tumor-specific methylation of numerous genes, including RASSF1A. Although the function of RASSF1A in PTC tumorigenesis is still being defined, quantitative evaluation of RASSF1A methylation and its correlation with tumor characteristics has not been performed. METHODS: Analysis of RASSF1A methylation was performed using quantitative polymerase chain reaction after methylation-dependent and -sensitive restriction enzyme digestion in PTC (n = 41) and normal (n = 18) thyroid tissue. Methylation was then evaluated for correlation with tumor size, stage, and multiple histopathologic characteristics. RESULTS: RASSF1A promoter hypermethylation was observed in nearly all PTC cases versus normal thyroid tissue, with mean hypermethylation 4.2 times greater in PTC (P < .05). Hypermethylation was greater in multifocal than unifocal PTC (P < .05). Furthermore, tumor methylation was inversely correlated with extracapsular invasion (P < .05). CONCLUSION: RASSF1A methylation differs in PTC compared with normal thyroid, is associated with multifocality, and is inversely correlated with extracapsular invasion. The ease of evaluating methylation status with minute amounts of DNA suggests a potential role for RASSF1A as a molecular marker for characterization of PTC histopathology.