Don't chase the adenoma: A probabilistic approach to imaging before parathyroidectomy.

BACKGROUND: Preoperative imaging before parathyroidectomy can localize adenomas and reduce unnecessary bilateral neck explorations. We hypothesized that (1) the utility of preoperative imaging varies substantially depending on the preoperative probability of having adenoma(s) and (2) that a selective imaging approach based on this probability could avoid unnecessary patient costs and radiation. METHODS: We analyzed 3,577 patients who underwent parathyroidectomy for primary hyperparathyroidism from 2001 to 2022. The predicted probability of patients having single or double adenoma versus hyperplasia was estimated using logistic regression. We then estimated the relationship between the predicted probability of single/double adenoma and the likelihood that sestamibi or 4-dimensional computed tomography was helpful for operative planning. Current Medicare costs and published data on radiation dosing were used to calculate costs and radiation exposure from non-helpful imaging. RESULTS: The mean age was 62 ± 13 years; 78% were women. Adenomas were associated with higher mean calcium (11.2 ± 0.74 mg/dL) and parathyroid hormone levels (140.6 ± 94 pg/mL) than hyperplasia (9.8 ± 0.52 mg/dL and 81.4 ± 66 pg/mL). The probability that imaging helped with operative planning increased from 12% to 65%, as the predicted probability of adenoma increased from 30% to 90%. For every 10,000 patients, a selective approach to imaging that considered the preoperative probability of having adenomas could save patients up to $3.4 million and >239,000 millisieverts of radiation. CONCLUSION: Rather than imaging all patients with primary hyperparathyroidism, a selective strategy that considers the probability of having adenomas could reduce costs and avoid excess radiation exposure.

Academic global surgical competencies: A modified Delphi consensus study.

Academic global surgery is a rapidly growing field that aims to improve access to safe surgical care worldwide. However, no universally accepted competencies exist to inform this developing field. A consensus-based approach, with input from a diverse group of experts, is needed to identify essential competencies that will lead to standardization in this field. A task force was set up using snowball sampling to recruit a broad group of content and context experts in global surgical and perioperative care. A draft set of competencies was revised through the modified Delphi process with two rounds of anonymous input. A threshold of 80% consensus was used to determine whether a competency or sub-competency learning objective was relevant to the skillset needed within academic global surgery and perioperative care. A diverse task force recruited experts from 22 countries to participate in both rounds of the Delphi process. Of the n = 59 respondents completing both rounds of iterative polling, 63% were from low- or middle-income countries. After two rounds of anonymous feedback, participants reached consensus on nine core competencies and 31 sub-competency objectives. The greatest consensus pertained to competency in ethics and professionalism in global surgery (100%) with emphasis on justice, equity, and decolonization across multiple competencies. This Delphi process, with input from experts worldwide, identified nine competencies which can be used to develop standardized academic global surgery and perioperative care curricula worldwide. Further work needs to be done to validate these competencies and establish assessments to ensure that they are taught effectively.

Validation of the Psychosocial Assessment Tool Sibling Module Follow-Up Version.

OBJECTIVE: Psychosocial screening is recommended to connect siblings of youth with cancer to psychosocial services, but the lack of validated sibling-specific screening tools is a barrier to routine screening. The current study aimed to validate and establish a clinical cutoff for the recently developed Psychosocial Assessment Tool (PAT) Sibling Module follow-up version to address this barrier. METHODS: Parents (N = 246) completed the PAT Sibling Module follow-up version for all siblings within their families ages 0-17 years (N = 458) at three time points between 6- and 24-month post-cancer diagnosis. For one target sibling within each family aged 8-17 years, parents also completed the Strengths and Difficulties Questionnaire, and the target sibling completed the Child PTSD Symptom Scale. Cross-sectional and longitudinal analyses examined internal consistency and convergent and predictive validity. Receiver operator characteristic analyses were used to establish a maximally sensitive and specific clinical cutoff. RESULTS: Internal consistency was acceptable for all age versions (Kuder-Richardson 20s ≥ 0.79), except for the ages 0-2 version, which had low internal consistency at 18 months post-diagnosis (Kuder-Richardson 20 = 0.57). Convergent (r values >0.7, p values <.001) and predictive (r values >0.6, p values <.001) validity were strong at each time point. An optimal clinical cutoff of 0.32 was identified (range: 0.00-1.00). CONCLUSIONS: The PAT Sibling Module follow-up version is a reliable and valid screener for sibling psychosocial risk following cancer diagnosis. Validation of a sibling-specific screener and establishment of a clinical cutoff are necessary first steps to addressing siblings' unmet psychosocial needs and improving trajectories of sibling functioning.

Academic Global Surgery: Creating Opportunities, Equity, and Diversity.

A workforce trained in the development and delivery of equitable surgical care is critical in reducing the global burden of surgical disease. Academic global surgery aims to address the present inequities through collaborative partnerships that foster research, education, advocacy and training to support and increase the surgical capacity in settings with limited resources. Barriers include a deficiency of resources, personnel, equipment, and funding, a lack of communication, and geographical challenges. Multi-level partnerships remain fundamental; these types of partnerships include a wide range of trainees, professionals, institutions, and nations, yet care must be taken to avoid falling into the trap of surgical "voluntourism" and undermining the expertise and practice of long-standing frontline providers. Academic global surgery has the benefit of developing a community of surgeons who possess the tools needed to collaborate on individual, institutional, and international levels to address inequities in surgery that are spread variously across the globe. However, challenges for surgeons pursuing a career in global surgery include balancing clinical responsibilities while integrating global surgery as a career during training. This is due in part to the lack of mentorship, research time, grant funding, support to attend conferences, and a limitation of resources, all of which are significantly more pronounced for surgeons from low-resource countries.

Initial validation of a new psychosocial screener for siblings of youth with cancer: The Psychosocial Assessment Tool Sibling Modules.

OBJECTIVE: Psychosocial screening can facilitate the identification of families who have difficulty adjusting to and managing serious pediatric illness. Despite siblings' roles within the family and increased psychosocial risk, a systematic approach to screening siblings of youth with cancer remains rare. One barrier to systematic sibling screening is the lack of a validated screener. We aimed to establish initial validity of the new parent-reported Psychosocial Assessment Tool (PAT) Sibling Modules for siblings ages 0-2, 3-4, 5-9, and 10+. METHODS: Families (N = 64) completed the PAT Sibling Modules and the Strengths and Difficulties Questionnaire (SDQ) regarding siblings' functioning at cancer diagnosis (13-23 items, depending on age version) and 6 months later (17-42 items). Cross-sectional and longitudinal analyses examined internal consistency and convergent and predictive validity of the PAT Sibling Modules. RESULTS: Baseline and follow-up versions of the modules have strong internal consistency (Kuder-Richardson 20 range: 0.82-0.93) and convergent validity at diagnosis (r-values ≥0.4, p-values <0.01) and follow-up (r-values >0.4, p-values <0.05). Predictive validity was supported by significant correlations between baseline PAT Sibling Module scores and 6 month SDQ scores (r = 0.86, p < 0.001). CONCLUSIONS: Findings provide initial evidence that the PAT Sibling Modules are valid measures of sibling psychosocial risk. Availability of a validated screener is a first step toward addressing siblings' unmet psychosocial needs.

Academic Global Surgery Curricula: Current Status and a Call for a More Equitable Approach.

INTRODUCTION: We aimed to search the literature for global surgical curricula, assess if published resources align with existing competency frameworks in global health and surgical education, and determine if there is consensus around a fundamental set of competencies for the developing field of academic global surgery. METHODS: We reviewed SciVerse SCOPUS, PubMed, African Medicus Index, African Journals Online (AJOL), SciELO, Latin American and Caribbean Health Sciences Literature (LILACS) and Bioline for manuscripts on global surgery curricula and evaluated the results using existing competency frameworks in global health and surgical education from Consortium of the Universities for Global Health (CUGH) and Accreditation Council for Graduate Medical Education (ACGME) professional competencies. RESULTS: Our search generated 250 publications, of which 18 were eligible: (1) a total of 10 reported existing competency-based curricula that were concurrent with international experiences, (2) two reported existing pre-departure competency-based curricula, (3) six proposed theoretical competency-based curricula for future global surgery education. All, but one, were based in high-income countries (HICs) and focused on the needs of HIC trainees. None met all 17 competencies, none cited the CUGH competency on "Health Equity and Social Justice" and only one mentioned "Social and Environmental Determinants of Health." Only 22% (n = 4) were available as open-access. CONCLUSION: Currently, there is no universally accepted set of competencies on the fundamentals of academic global surgery. Existing literature are predominantly by and for HIC institutions and trainees. Current frameworks are inadequate for this emerging academic field. The field needs competencies with explicit input from LMIC experts to ensure creation of educational resources that are accessible and relevant to trainees from around the world.

Online Information for Treatment for Low-Risk Thyroid Cancer: Assessment of Timeliness, Content, Quality, and Readability.

The Internet is a key source of health information, yet little is known about resources for low-risk thyroid cancer treatment. We examined the timeliness, content, quality, readability, and reference to the 2015 American Thyroid Association (ATA) guidelines in websites about thyroid cancer treatment. We identified the top 60 websites using Google, Bing, and Yahoo for "thyroid cancer." Timeliness and content analysis identified updates in the ATA guidelines (n = 6) and engaged a group of stakeholders to develop essential items (n = 29) for making treatment decisions. Website quality and readability analysis used 4 validated measures: DISCERN; Journal of the American Medical Association (JAMA) benchmark criteria; Health on the Net Foundation certification (HONcode); and the Suitability Assessment of Materials (SAM) method. Of the 60 websites, 22 were unique and investigated. Content analysis revealed zero websites contained all updates from the ATA guidelines and rarely (18.2%) referenced them. Only 31.8% discussed all 3 treatment options: total thyroidectomy, lobectomy, and active surveillance. Websites discussed 28.2% of the 29 essential items for making treatment decisions. Quality analysis with DISCERN showed "fair" scores overall. Only 29.9% of the JAMA benchmarks were satisfied, and 40.9% were HONcode certified. Readability analysis with the SAM method found adequate readability, yet 90.9% scored unsuitable in literacy demand. The overall timeliness, content, quality, and readability of websites about low-risk thyroid cancer treatment is fair and needs improvement. Most websites lack updates from the 2015 ATA guidelines and information about treatment options that are necessary to make informed decisions.

Developing Research Potential and Building Partnerships: A Report of the Fundamentals of Surgical Research Course at the College of Surgeons of East, Central, and Southern Africa.

BACKGROUND: Approximately a decade after the inaugural Fundamentals of Surgical Research Course (FSRC) at the West African College of Surgeons meeting (2008), the Association for Academic Surgery expanded the course offering to the annual meeting of the College of Surgeons of East, Central and Southern Africa (COSECSA). After the second annual offering of the course in 2019, participants were surveyed to assess the impact of the course. METHODS: A survey was distributed to the attendees of the 2019 second COSECSA FSRC course, held in December 2019 in Kampala, Uganda. Approximately 80 people attended at least a portion of the full-day course. Forty-nine participants completed the voluntary survey questionnaire distributed to assess each session of the course at course completion. RESULTS: Ten different countries were represented among the attendees. Of the 49 evaluations, 35 respondents were male and six were female. Eight respondents did not identify a gender. Surgical residents comprised 19 of the 49 attendees, and one of the 49 attendees was a medical student. Thirty-five respondents indicated that their views of surgical research had changed after attending the course. CONCLUSIONS: The second annual FSRC at COSECSA confirmed significant interest in building research skills and partnerships in sub-Saharan Africa. A wide variety of learners attended the course, and a majority of the sessions received overwhelmingly positive feedback. Multiple conference attendees expressed interest in serving as faculty for the course moving forward, highlighting a viable path for sustainability as the Association for Academic Surgery develops an international research education platform.

Sleep Education and Training among Practicing Clinical Psychologists in the United States and Canada.

Introduction: Clinical psychologists often treat patients with a sleep disorder. Cognitive-behavioral treatments can independently, or in combination with medical interventions, effectively improve sleep health outcomes. No studies have examined sleep education and training among practicing clinical psychologists.Method: Actively practicing clinical psychologists were recruited through psychological associations' e-mail listservs across the United States and Canada. Respondents (N = 200) provided information about: 1) duration and format of formal sleep education and training; 2) perceived self-efficacy to evaluate and treat sleep disorders; and 3) interest in further sleep training.Results: Clinical psychologists reported a median of 10.0 hours of didactic sleep training (range 0-130 hours) across their training or career. Ninety-five percent reported no clinical sleep training during graduate school, internship, or post-doctoral fellowship. In terms of evaluation and treatment, 63.2% reported feeling at least "Moderately Prepared" to evaluate a patient's sleep and 59.5% felt at least "Moderately Prepared" to treat a common sleep disorder (insomnia disorder). However, most endorsed using insomnia disorder treatment approaches inconsistent with empirically supported guidelines. The vast majority (99.3%) desired additional sleep training across a variety of delivery formats.Discussion: Many clinical psychologists engaged in active patient care have received minimal formal sleep training. Despite this, they felt prepared to evaluate and treat sleep disorders. Their treatment recommendations were not aligned with evidence-based standards. This may result in a delay to, or absence of, effective treatment for patients, underscoring the critical need for sleep training among clinical psychologists. It is essential to improve sleep competencies for the field.

Pediatric Psychosocial Standards of Care in action: Research that bridges the gap from need to implementation.

OBJECTIVE: To describe innovative models of psychosocial care delivery that align with published Standards of Psychosocial Care of Children with Cancer and their Families, in efforts to bridge the divide between research and practice. METHODS: The Mattie Miracle Cancer Foundation, in partnership with the American Psychosocial Oncology Society reviewed 22 letters of intent and 13 full grants and awarded small grants to researchers with high quality projects that aimed to implement any of the published 15 Standards of Care. For three of the highest rated funded research projects, we describe the Standard implemented, the novel research design and implementation strategies, and how the research findings might inform the development, implementation, and dissemination of effective solutions for bridging Standard-to-practice gaps. RESULTS: The first study presented is an innovative eHealth intervention for parents of children with cancer designed to improve family functioning and decrease symptoms of acute distress, anxiety, and posttraumatic stress. The second study addresses the acceptability and feasibility of using daily text message assessments of oral chemotherapy adherence in adolescents and young adults with leukemia, and the third creates a blueprint for providing psychosocial services to siblings, including ways to overcome common implementation barriers. CONCLUSIONS: Several themes emerged from the studies presented, including (1) attention to barriers to previous attempts at implementation; (2) technology's role in delivering care; (3) the need for stakeholder involvement; and (4) consideration for multi-pronged solutions that address heterogeneity in care settings. Next steps for integrating the Standards of Psychosocial Care into clinical practice are discussed.

Optimizing Levothyroxine Dose Adjustment After Thyroidectomy With a Decision Tree.

BACKGROUND: After thyroidectomy, patients require Levothyroxine (LT4). It may take years of dose adjustments to achieve euthyroidism. During this time, patients encounter undesirable symptoms associated with hypo- or hyper-thyroidism. Currently, providers adjust LT4 dose by clinical estimation, and no algorithm exists. The objective of this study was to build a decision tree that could estimate LT4 dose adjustments and reduce the time to euthyroidism. METHODS: We performed a retrospective cohort analysis on 320 patients who underwent total or completion thyroidectomy at our institution. All patients required one or more LT4 dose adjustments from their initial postoperative dose before attaining euthyroidism. Using the Classification and Regression Tree algorithm, we built various decision trees from patient characteristics, estimating the dose adjustment to reach euthyroidism. RESULTS: The most accurate decision tree used thyroid-stimulating hormone values at first dose adjustment (mean absolute error = 13.0 µg). In comparison, the expert provider and naïve system had a mean absolute error of 11.7 µg and 17.2 µg, respectively. In the evaluation dataset, the decision tree correctly predicted the dose adjustment within the smallest LT4 dose increment (12.5 µg) 79 of 106 times (75%, confidence interval = 65%-82%). In comparison, expert provider estimation correctly predicted the dose adjustment 76 of 106 times (72%, confidence interval = 62%-80%). CONCLUSIONS: A decision tree predicts the correct LT4 dose adjustment with an accuracy exceeding that of a completely naïve system and comparable to that of an expert provider. It can assist providers inexperienced with LT4 dose adjustment.

Disparities Based on Race, Ethnicity, and Socioeconomic Status Over the Transition to Adulthood Among Adolescents and Young Adults on the Autism Spectrum: a Systematic Review.

PURPOSE OF REVIEW: Few studies have examined disparities in autism services and functional outcomes over the life course. Transition to adulthood is an especially important developmental period, as it sets up trajectories of adult functioning. This systematic review summarizes patterns of service use and transition outcomes according to race, ethnicity, and socioeconomic characteristics over the transition to adulthood. RECENT FINDINGS: Forty studies were included. Low-income and racial/ethnic minority youth on the autism spectrum were less likely to participate in transition planning meetings, enroll in postsecondary education, find competitive employment after high school, live independently, participate in social activities, and receive health care transition services than their White and higher income peers on the autism spectrum. Racial/ethnic minority and low-income youth on the autism spectrum were more likely to be disconnected from educational, occupational, and social activities upon entering adulthood. Future research should explore the mechanisms underlying these disparities as a first step to addressing them.

Improving Surgical Outreach in Palestine: Assessing Goals of Local and Visiting Surgeons.

BACKGROUND: Short-term surgical outreach is often criticized for lack of sustainability and partnership with local collaborators. As global surgical capability increases, there is increased focus on educating local providers. We sought to assess and compare the educational goals of local surgeons in the Palestinian territories with goals of visiting volunteer providers. METHODS: Electronic surveys were sent to Palestinian surgeons and compared with evaluation data collected from Palestine Children's Relief Fund volunteer providers. RESULTS: The response rate was 52% from Palestinian surgeons and 100% from volunteer providers, giving a combined response rate of 83%. Ninety-two percent of Palestinian surgeons desired protected time during each mission trip for formal didactic teaching and 92% learn new techniques best by performing skills on patients with expert surgeons observing and providing feedback. Most respondents requested the addition of case reviews or debriefing sessions after completion of surgical cases. Volunteer providers indicate that 86% of prior mission trips involved training of local surgeons and 100% plan to volunteer with the organization again in the future. CONCLUSIONS: Surgical education is a vital component of any successful outreach program. Adult learning theory emphasizes the necessity of understanding the specific educational needs of participants to foster the most successful learning environment. This survey highlights the value of tailoring surgical specialty outreach to the explicit needs of local providers and patient populations, while also clearly demonstrating the importance of collaboration, feedback, and protected educational didactics as a critical focus of future surgical humanitarian endeavors.

Implementation of a low-cost laparoscopic skills curriculum in a third-world setting.

BACKGROUND: Training outside the operating room has become a mainstay of surgical education. Laparoscopic training often takes place in a simulation setting. Advanced laparoscopic procedures are now commonplace, even in third-world countries with minimal hospital resources. We sought to implement a low-cost laparoscopic skills curriculum in a general surgery residency program in East Africa. STUDY DESIGN: The laparoscopic skills curriculum created and validated at the University of Kentucky was presented to the 10 general surgery residents at Tenwek Hospital. The curriculum and all materials were purchased for approximately $50 (USD). The residents in Kenya had access to laparoscopic trainer boxes and personal laptops to perform the simulations. Residents were timed on their performance at the initiation of the project and after 3 weeks of practice. RESULTS: Residents were tested on 3 separate tasks (cannulation drill, peg board, and rope pass). At the initiation of the project, residents were unable to complete the 3 tasks chosen for timing without a critical error (i.e., dropping a peg out of view). After 3 weeks of independent practice, residents were able to successfully complete the tasks, nearing the time limits established in the curriculum manual. Additional practice and testing sessions are scheduled for the remainder of the year. CONCLUSIONS: Implementation of a low-cost laparoscopic skills curriculum in a third-world setting is feasible. This approach offers much-needed exposure and opportunities for residents with extremely limited resources and promises to be a vital aspect of the growing surgical residency training in third-world settings.

Brief report: A pilot study of a web-based resource for families of children with cancer.

OBJECTIVE: To develop a Web-based resource for families of children newly diagnosed with cancer and examine the viability of this modality of providing support. METHODS: Twenty-one children (8-17 years) newly diagnosed with cancer and their families were enrolled. Quantitative data on Web site utilization and frequency of accessing specific sections and qualitative data on participant satisfaction are reported. RESULTS: Twenty-one families comprising 51 participants (children with cancer, parents, and siblings) had access to the Web site. Utilization was lower than anticipated, with members of only nine families accessing the site. The majority of these hits were on peer discussion groups. CONCLUSION: Further research is warranted to examine whether the Internet is a viable method of delivering support to families affected by childhood cancer. The current pattern of results suggests that the timing of its introduction and the method used to train families may affect utilization.