Positive autobiographical memory recall does not influence temporal discounting: an internal meta-analysis of experimental studies.

People tend to discount the value of future rewards as the delay to receiving them increases. This phenomenon, known as temporal discounting, may underlie many impulsive behaviors, such as drug abuse and overeating. Given the potential role of temporal discounting in maladaptive behaviors, many efforts have been made to find experimental manipulations that reduce temporal discounting. One class of manipulations that has held some promise involves recalling positive autobiographical memories prior to making intertemporal choices. Just as imagining positive future events has been shown to reduce temporal discounting, a few studies have shown that recalling positive past events reduces temporal discounting, especially if memory retrieval evokes positive affective states, such as gratitude and nostalgia. However, we failed to replicate these findings. Here we present an internal meta-analysis combining data from 14 studies (n = 758) that involved within-subjects positive memory recall-based manipulations. In each study, temporal discounting was assessed using a monetary intertemporal choice task. The average effect size was not significantly different from zero. This finding helps elucidate the neurocognitive mechanisms of temporal discounting; whereas engaging the episodic memory system to imagine future events might promote more patience, engaging the episodic memory system to imagine past events does not.

Chronic Lymphocytic Thyroiditis May Limit the Utility of Molecular Testing in AUS/FLUS Thyroid Nodules.

INTRODUCTION: Chronic lymphocytic thyroiditis (CLT) may increase the likelihood of atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) results in thyroid nodules by fine needle aspiration (FNA). Gene expression classifier (GEC) and Thyroid Sequencing (ThyroSeq) may better stratify rate of malignancy (ROM) of AUS/FLUS thyroid nodules. This study compares the utility of molecular tests in determining malignancy in surgical patients with concomitant AUS/FLUS thyroid nodules and CLT. METHODS: A retrospective review of 1648 patients with index thyroid nodules who underwent FNA and thyroidectomy at a single institution was performed. Patients with concomitant AUS/FLUS thyroid nodules and CLT were subdivided into three diagnostic groups: FNA only, FNA with GEC, and FNA with ThyroSeq. Patients with AUS/FLUS thyroid nodules without CLT were subdivided into similar groups. Final histopathology of the cohorts was further stratified into benignity and malignancy and analyzed using Chi-squared statistics. RESULTS: Of 463 study patients, 86 had concomitant AUS/FLUS thyroid nodules and CLT with a 52% ROM, and the difference of ROM among FNA only (48%), suspicious GEC (50%), or positive ThyroSeq (69%) was not significant. In 377 patients with AUS/FLUS thyroid nodules without CL, ROM was 59%. ROM among these patients was significantly higher when molecular testing was used (FNA only 51%, suspicious GEC 65%, and positive ThyroSeq 68%; P < 0.05). CONCLUSIONS: Molecular tests may have limited value in predicting malignancy in surgical patients with concomitant AUS/FLUS thyroid nodules and CLT.

Transient Hypocalcemia After Total Thyroidectomy: The Obesity Paradox at Work?

INTRODUCTION: With increasing rates of obesity worldwide, a correlation between high body mass index (BMI) and postoperative morbidity after thyroid surgery remains unclear. Postoperative transient hypocalcemia is common after total thyroidectomy due to interruption of parathyroid function. This study examines the relationship between BMI and hypocalcemia after total thyroidectomy. MATERIALS AND METHODS: A retrospective review of prospectively collected data for 1135 patients who underwent total thyroidectomy for cancer, multinodular goiter (MNG), or Graves' disease between June 2009 and November 2020 at a single institution was performed. BMI groups followed the World Health Organization classification. Hypocalcemia was defined as serum calcium ≤8 mg/dL. Calcium levels measured on postoperative day 0 and the following morning were compared between the BMI groups. RESULTS: Of 1135 total thyroidectomy patients, 85% were women. The mean age and standard deviation of patients was 49 (± 13) y, with most of Hispanic origin (64%). Overall, 41.5% of patients had cancer, 45% nontoxic MNG, 5.8% toxic MNG, and 12% Graves' disease. Stratified by BMI, 27% of patients were normal, 34% overweight, and 39% obese. Overall, overweight and obese patients experienced less transient hypocalcemia at both time points compared to normal patients postoperatively (P = 0.01 and P = 0.009). Furthermore, overweight and obese patients with Graves' disease experienced less transient hypocalcemia at both time points (P = 0.04 and P = 0.05). There was no statistical difference in other groups. CONCLUSIONS: A protective role of higher BMI or "obesity paradox" for postoperative hypocalcemia may exist in those obese patients after total thyroidectomy.

Morbidity Associated With Surgical Removal of Substernal Thyroid Goiters.

INTRODUCTION: Surgical excision of substernal thyroid goiters (STG) can be challenging while minimizing postoperative morbidity. Postoperative complication rates associated with transcervical and transthoracic approaches (i.e., partial or total sternotomy) for STG compared to multinodular goiters (MNG) limited to the neck (i.e., non-substernal) remains unclear. This study examines postoperative morbidity related to surgical approaches in the removal of STG and MNG. METHODS: A retrospective review of prospectively collected data of 988 patients with STG and non-substernal MNG from a single institution between 2010 and 2021 was performed. Patients were stratified by STG and conventional non-substernal MNG limited to the neck excised by transcervical and transthoracic approach. Postoperative complications including neck hematoma requiring return to the operating room, permanent recurrent laryngeal nerve injury and hypocalcemia, and transient or temporary recurrent laryngeal nerve injury and hypocalcemia were identified. Demographics including age, sex, and race, among others, were analyzed. RESULTS: Of the 988 cases, there were 887 (90%) MNG and 101 (10%) STG. Of the STG cohort, 11 (11%) required a partial sternotomy and 4 (4%) required a total sternotomy. Permanent complication rates for non-substernal MNG and STG patients were 1.5% and 0.9%, respectively. Only transient or temporary hypocalcemia rates were statistically different between the STG and MNG cohorts (9.9% versus 3.8%, P < 0.001). CONCLUSIONS: Regardless of transcervical or transthoracic approach, postoperative complications associated with the surgical removal of STG are low in the hands of experienced, high-volume thyroid surgeons.

Molecular Testing Has Limited Utility in the Surgical Evaluation of Bethesda III Thyroid Nodules.

BACKGROUND: The Bethesda System for Reporting Thyroid Cytopathology has 6 diagnostic categories, each with an implied cancer risk of malignancy (ROM). Bethesda III, defined as atypia or follicular lesions of undetermined significance (AUS/FLUS) on fine needle aspiration (FNA), has an indeterminate ROM. This study investigates the utility of Afirma Gene Expression Classifier (GEC) and Thyroid Sequencing (ThyroSeq) molecular testing to predict malignancy in AUS/FLUS thyroid nodules. METHODS: A retrospective review of prospectively collected data of 1457 patients with index thyroid nodules who underwent FNA and thyroidectomy at a single academic institution was performed. Use of GEC or ThyroSeq for AUS/FLUS thyroid nodules was examined. GEC testing was reported benign or suspicious for malignancy whereas ThyroSeq testing was reported on a spectrum of low, intermediate or high ROM. Descriptive statistics were utilized to compare the ROM among AUS/FLUS thyroid nodules. RESULTS: Of 1457 patients with FNA thyroid cytology, 359 (25%) corresponded to AUS/FLUS results. There were 132 (37%) patients with GEC testing and 88 (24%) had ThyroSeq testing. ROM without GEC or ThyroSeq testing was 49%, whereas ROM with suspicious GEC was 55%. ROM with positive ThyroSeq was 73%. Among ThyroSeq patients, 43 had intermediate-risk mutations with 60% malignancy, and 23 had high-risk mutations with 96% malignancy (P < 0.01). CONCLUSION: Surgical patients with AUS/FLUS thyroid nodules have a high ROM. High-risk ThyroSeq testing may have some utility in predicting malignancy, but GEC and intermediate-risk TGC results have limited value. Surgeons should carefully consider the utility of molecular tests to determine surgical resection.

Impact of Noninvasive Follicular Thyroid Neoplasm With Papillary-Like Nuclear Features on Revised Bethesda System Malignancy Rates at a Single Institution.

BACKGROUND: The Bethesda System for Reporting Thyroid Cytopathology (BSRTC) standardizes thyroid cytopathology reporting in six tier diagnostic categories. In recent years, noninvasive encapsulated follicular variant of papillary thyroid carcinoma was reclassified as noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP). This study examines the impact of NIFTP on the BSRTC risk of malignancy (ROM). METHODS: This was a retrospective review of prospectively collected data from 565 patients who underwent fine needle aspiration and thyroidectomy at a single institution. ROM for each Bethesda category was analyzed and calculated with NIFTP classified as a malignant and nonmalignant lesion. Absolute and relative differences between ROM were compared. RESULTS: Of 565 patients, 19 were Bethesda I, 159 were Bethesda II, 178 were Bethesda III, 46 were Bethesda IV, 42 were Bethesda V, and 121 were Bethesda VI. ROM differences with NIFTP classified as malignant versus nonmalignant for each class were as follows: Bethesda I, no change; Bethesda II, 18%-14%; Bethesda III, 55%-48%; Bethesda IV, 50%-35%; Bethesda V, 93%-91%; and Bethesda VI, 99%-98%. Absolute ROM differences for each category were as follows: Bethesda I, 0%; Bethesda II, 4%; Bethesda III, 7%; Bethesda IV, 15%; Bethesda V, 2%; and Bethesda VI, 1%. CONCLUSIONS: A decreasing trend in absolute and relative ROM was seen in Bethesda II, III, and IV categories; however, exclusion of NIFTP as a malignant lesion did not significantly alter the ROM of BSRTC categories. Surgeons should assess their respective institution's experiences with NIFTP and the BSRTC.

Inflammatory Breast Cancer in Pregnancy and Lactation.

Inflammatory breast cancer (IBC) represents only 1% to 5% of all breast malignancies and is an extremely aggressive subtype. At time of diagnosis, up to 85% of patients will present with regional nodal metastases and up to 30 % will have metastasis to distant organs. There is limited medical literature describing treatment guidelines for IBC during gestation. The best diagnostic tools are core needle and full-thickness skin punch biopsies to assess presence of dermal lymphatic invasion. Breast Ultrasound is preferred to mammogram, but mammography could still be done with proper fetal shielding. Ultrasound and Magnetic resonance imaging are used for staging. Pregnant patients should be managed with special attention to the health of the fetus by a multidisciplinary team. Treatment based on current guidelines consist of a sequence of systemic chemotherapy followed by mastectomy with axillary dissection (modified radical mastectomy), and even if good clinical nodal response to neoadjuvant therapy is obtained, sentinel node biopsy is not recommended. Radiation therapy is to be given once the baby has been delivered. Chemotherapy is not recommended in the first trimester, and anti-estrogen hormonal therapy, as well as targeted Her2-neu therapies are contraindicated during the length of the pregnancy. There is no evidence that early termination improves the outcome. However, given the poor prognosis of IBC, patients should be fully counseled on the risks and benefits of continuing or terminating an early pregnancy.

Is primary breast melanoma a true pathological entity? The argument against it.

Background: Previous studies have reported cases of primary melanoma of the breast parenchyma (PMBP), but the pathogenesis of this disease remains poorly understood. We review the presentation and outcomes of reported cases and provide detailed pathological analysis of four additional cases. Furthermore, we discuss potential theories regarding the pathogenesis of this clinical presentation. Results: We identified 29 published studies (n = 95 patients) and report four new cases (n = 99). Ninety-one (92 %) patients were female, with a median age of 50 years. Previous skin melanomas were reported by 56 % of patients, with the trunk being the most common location (32.7 %) followed by the upper extremities (20 %). The most common tumor location reported (n = 73) was the right (49 %) upper outer quadrant (56 %). The median time from skin melanoma diagnosis to the presence of a breast mass was 65 months (1-192). Nodal status at presentation was reported in n = 67 (68 %) patients. Of these, positive nodal metastases were seen in 40.3 %, while distant metastatic disease at presentation was reported in 30 % of patients. Surgery was performed in 66 %, being partial mastectomy (PM) the most common procedure in 82 %. Adjuvant therapy was described in 38 patients. The reported (n = 12) median survival was 11.5 (1-70) months. Conclusion: Melanomas identified in the breast parenchyma are likely the result of nodal or hematogenous spread from previously known or unknown melanomas, and should not be considered as PMBP. Management should be multidisciplinary, including surgical excision aimed at obtaining negative margins with lymphadenectomy of clinically positive nodes and neoadjuvant/adjuvant immunotherapy.

Low-Grade Fibromyxoid Sarcoma of the Distal Upper Extremity: A Systematic Review.

BACKGROUND: Low-grade fibromyxoid sarcoma (LGFMS) is a rare soft-tissue tumor that usually occurs in the proximal extremities and trunk. The purpose of this systematic review was to assess patient demographics, treatment approach, and outcomes for patients with LGFMS of the distal upper extremity. METHODS: We performed a literature review of case reports and patient reports of LGFMS using Medical Literature Analysis and Retrieval System Online (MEDLINE) and PubMed. Inclusion criteria included case reports and case series of patients with LGFMS of the distal upper extremity. Animal studies, comments, and non-English publications were excluded. Data on available patient demographics, treatment regimen, recurrence, and metastasis were collected. RESULTS: A total of 365 publications were reviewed. After applying the inclusion and exclusion criteria, 19 articles were included. There were 24 unique patients with LGFMS of the distal upper extremity. The median age was 32 years, and most patients were treated with a surgical excision. Of the 15 reported outcomes, 4 patients had local recurrences, and no patient had metastases or died due to the tumor. CONCLUSIONS: Although LGFMS of the distal upper extremity is less common, it is critical for surgeons to consider it as a differential. The current approach is a wide excision with negative margins, and chemotherapy or radiotherapy may not be necessary. We found decreased proportions of local recurrence and metastases in the distal upper extremity compared with other anatomical regions. We recommend that surgeons follow up with their patients indefinitely given the slow mitotic rate of LGFMS.

Depth of mediastinal extension can predict sternotomy need for substernal thyroid goiters.

BACKGROUND: Surgical excision of substernal thyroid goiters is usually achieved through a conventional transcervical approach, and transthoracic excision is rarely necessary. Currently, there are no clear guidelines for substernal thyroid goiters that may require a transthoracic approach. This study examined what preoperative factors were significantly associated with transthoracic surgical excision for substernal thyroid goiters. METHODS: A retrospective review of prospectively collected data of 109 patients with substernal thyroid goiters from a single institution was performed. The patients were stratified by transcervical and transthoracic approaches for substernal thyroid goiters. The factors possibly predictive of a transthoracic approach, including substernal extension beyond the thoracic inlet, patient-reported symptoms, tracheal deviation, and malignancy, were analyzed. Demographics including age, sex, and race, among others, were also studied. RESULTS: Of 1,080 patients who underwent surgical resection for multinodular goiter, there were 109 (10%) patients with substernal thyroid goiters. Of the substernal thyroid goiter group, 11 (10%) patients underwent partial sternotomy, whereas 6 (5.5%) underwent total sternotomy. On logistic regression, only substernal component of the thyroid goiter extending beyond the sternal notch into the mediastinum was statistically significant in predicting sternotomy (odds ratio 3.43, confidence interval 1.65-6.41, P < .001). Substernal thyroid goiters with mediastinal extension of ≥5 cm beyond the sternal notch showed a sensitivity of 94% and specificity of 86.5% to predict need of sternotomy. CONCLUSION: Patients with substernal thyroid goiters who exhibit progressive enlargement and/or compressive symptoms should undergo surgical excision. Although most are removed through the conventional transcervical approach, substernal thyroid goiters with a depth of mediastinal extension ≥5 cm have a high likelihood of requiring sternotomy.

Fine needle aspiration and the Bethesda system: Correlation with histopathology in 1,228 surgical patients.

BACKGROUND: Fine-needle aspiration combined with the Bethesda System for Reporting Thyroid Cytopathology is indispensable in the diagnostic evaluation of thyroid nodules. Their increased detection over the last few decades mandates the determination of which thyroid nodules require surgical management for malignancy. This study examines the correlation of fine-needle aspiration to final histopathology of dominant thyroid nodules in a large series of surgical patients undergoing thyroidectomy at a single academic institution. METHODS: A retrospective review of prospectively collected data of 1,228 patients who underwent fine-needle aspiration for a dominant thyroid nodule and thyroidectomy from a single institution between 2010 and 2019 was performed. The cases were stratified into all 6 Bethesda categories. Fine-needle aspiration results were compared to index thyroid nodule malignancy on final histopathology. RESULTS: Of 1,228 patients who underwent thyroidectomy, the overall malignancy rate was 53%. When fine-needle aspiration was stratified by the Bethesda System for Reporting Thyroid Cytopathology, malignancy rate was 29% for nondiagnostic; 11% for benign; 51% for atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS); 47% for follicular neoplasm/suspicious for follicular neoplasm (FN/SFN); 84% for suspicious for malignancy (SFM); and 98% for malignant results on final histopathology. There was a false positive rate of 1% and false negative rate ranging from 7 to 11%. CONCLUSION: Fine-needle aspiration of a dominant thyroid nodule in patients who underwent thyroidectomy had an overall malignancy rate of 53%. False negative and false positive rates are within the reported range in surgical patient populations. The majority of patients with AUS/FLUS, FN/SFN and SFM results with underlying malignancy received the appropriate surgical resection.