Predicting recurrence of papillary thyroid cancer using the eighth edition of the AJCC/UICC staging system.

BACKGROUND: The AJCC/UICC classification is widely used for predicting survival in papillary thyroid cancer (PTC), but has not been evaluated as a predictor of recurrence. The hypothesis of this study was that the eighth edition of the AJCC system can be used in this novel way. METHODS: All patients in the study underwent surgery for PTC at a high-volume endocrine surgery centre in France between 1985 and 2015. The seventh and eighth editions of the AJCC/UICC staging system for PTC were employed to predict recurrence and disease-specific survival using the Kaplan-Meier and log rank tests. RESULTS: Among 4124 patients (79·7 per cent female), median age was 50 (i.q.r. 38-60) years; 3906 patients (94·7 per cent) underwent total thyroidectomy, with lymph node dissection in 2495 (60·5 per cent). The eighth edition of the AJCC/UICC staging system placed 91·8, 7·1, 0·4 and 0·7 per cent of patients in stages I-IV respectively. After reclassifying patients from the seventh to the eighth AJCC/UICC edition, the disease was downstaged in 23·8 per cent. Over a median follow-up of 7 years, 260 patients (6·4 per cent) developed recurrent disease, including 5·2 per cent of patients with stage I, 19·6 per cent with stage II, 59 per cent with stage III and 50 per cent with stage IV disease, according to the eighth edition. The eighth edition was a better predictor of recurrence than the seventh edition. CONCLUSION: The eighth edition of the AJCC/UICC staging system appears to be a novel tool for predicting PTC recurrence, which is a meaningful outcome for this indolent disease. The eighth edition can be used to risk-stratify patients, keeping in mind that other molecular and pathological predictive factors must be integrated into the assessment of recurrence risk.

Patterns of Use and Short-Term Outcomes of Minimally Invasive Surgery for Malignant Pheochromocytoma: A Population-Level Study.

BACKGROUND: Malignant pheochromocytoma is rare, and there is a scarcity of data on the use of minimally invasive surgery (MIS) for treatment. The aims of this study were to analyze patterns of use of MIS for malignant pheochromocytoma in the U.S. and compare short-term outcomes to those of open adrenalectomy. METHODS: Patients with malignant pheochromocytoma undergoing MIS, including laparoscopy, robotic assisted, laparoscopy converted to open, or open adrenalectomy, were culled from the National Cancer Database, from 1998 to 2011. Data were examined using simple summary statistics, Χ2 and student's t tests, Mann-Whitney test, and logistic regression. RESULTS: A total of 36 MIS and 67 open adrenalectomies were identified in 2010-2011. No significant differences were observed between the two treatment groups in demographic characteristics or comorbidities. Preoperative diagnosis of malignancy was made in 52.8% of MIS and 48.5% of open patients (p=NS). MIS and open adrenalectomies did not differ with respect to lymph node metastases, vascular invasion, extra-adrenal-extension, and distant metastases (all p=NS). MIS tended to more often be used to perform partial adrenalectomy (38.9 vs. 20.4% open, p=0.061); surgical margins, 30-day readmission and mortality rates were similar to open adrenalectomy (all p=NS). Tumors removed via MIS were smaller (48.7 vs. 73.3 mm open, p=0.003) and associated with a shorter length of stay. CONCLUSIONS: A significant proportion of patients with malignant pheochromocytomas underwent MIS, with short-term outcomes which are comparable to those of open surgery. Further studies focused on long-term survival and recurrence are needed to assess the role of MIS in the management of these rare tumors.

Current management of medullary thyroid cancer.

Medullary thyroid carcinoma (MTC) is an uncommon malignancy of the parafollicular C cells of the thyroid, with a propensity for early lymph node spread and distant metastasis. It is hereditary in approximately 25% of cases, involving specific point mutations of the RET proto-oncogene inherited in an autosomal dominant fashion. While European professional organizations have put forth calcitonin screening guidelines for earlier detection of MTC, the American Thyroid Association, which has published recent guidelines for MTC treatment, have not had a position on routine screening in the USA. Surgical extirpation of the primary tumor and involved lymph node metastases is the mainstay of treatment and the only chance for cure. Conventional systemic chemotherapies for metastatic MTC have been disappointing; however, newer agents which affect specific RET proteins and tyrosine kinase growth factor receptors show promise in phase 1 and 2 clinical trials.

Management of follicular tumors of the thyroid.

The incidence of well-differentiated thyroid cancers is rising. Follicular cancer represents 10-20% of these lesions. While the vast majority of thyroid nodules of follicular origin are benign, fine needle aspiration cannot provide cytologic evidence of capsular and/or vascular invasion; therefore, patients should undergo surgical excision. Frozen section is not recommended for intraoperative evaluation of follicular neoplasia. Patients deemed to have follicular cancer require near-total or total thyroidectomy and postoperative (131)I ablation. The optimal management of minimally invasive follicular cancer remains an area of controversy, but long-term prognosis for these patients is excellent. Areas of research should focus on identification of molecular markers of malignancy and aggressiveness of follicular neoplasia.

The Sophie Davis School of Biomedical Education: the first 20 years of a unique BS-MD program.

BACKGROUND: Since 1973 the Sophie Davis School of Biomedical Education, City University of New York Medical School, has integrated baccalaureate education with preclinical medical education; its graduates earn BS degrees in five years and are then eligible for entry into the traditional third year of medical school at one of seven participating medical schools in New York State. The school has a twofold mission: (1) to expand access to medical careers among inner-city youths, particularly among underrepresented minorities, and (2) to encourage the pursuit of primary care specialties among its graduates. METHOD: To assess the extent to which the two goals of the school have been met, the authors collected and analyzed information on the 1,402 students who entered Sophie Davis between 1973 and 1992, especially the 1,068 students from the 15 classes that entered the school from 1973-74 through 1987-88. In particular, the analysis focused on data on academic achievement and on choice of practice specialty. Where possible, state and national data were used for comparison. RESULTS: The results suggest that the school has achieved varying degrees of success: (1) The program has expanded access to medical careers among underrepresented-minority students at success rates well above national averages for college freshmen entering traditional premedical curricula. (2) Graduates have chosen primary care specialties at a somewhat higher rate than the national average, despite the school's lack of official involvement with students once they began clinical training in medical school. CONCLUSION: The aggregate data show that the school has achieved success in expanding access to medical careers for inner-city youth (especially among underrepresented minorities) and has been at least partially successful in nurturing primary care physicians. The latter goal may be realized more fully if the school becomes more involved in the clinical education of its graduates.

Refining a method of identifying CUNY Medical School graduates practicing in underserved areas.

PURPOSE: To determine what percentage of graduates from the City University of New York (CUNY) Medical School/Sophie Davis School of Biomedical Education practiced in underserved areas of New York State and, in the process, to develop a reliable way of collecting and verifying the information needed to carry out such an outcomes study. METHOD: The study group consisted of the 414 CUNY graduates who had completed their MD degrees by 1986. Addresses of graduates' practices were confirmed for 79% of the graduates, 49% of whom practiced in New York State. New York State zip codes were used as a way to identify underserved areas throughout the state. RESULTS: Of the 160 graduates with practices in New York State, 33% had practices in underserved areas (and 81% of these were located in New York City). In all, 26% of the whites, 73% of the African Americans, 43% of the Asian Americans, 50% of the Latinos, 34% of the women, and 32% of the men had practices in underserved areas. CONCLUSION: The graduates' race-ethnicity was an important factor in the likelihood of their practicing in an underserved area, whereas gender was not, a finding consistent with previous studies. Medical schools and residency programs need to institute long-term programs to track the career paths of all their graduates so that questions about the proportions of graduates in underserved areas will be relatively easy to answer.

Analysis of errors in laparoscopic surgical procedures.

BACKGROUND: The determination of laparoscopic surgeon ability is essential to training error avoidance. The present study describes a practical method of surgical error analysis. METHODS: After review of practice videotapes of the excisional phase of laparoscopic cholecystectomy, consensus on the identification of eight errors was achieved. Interrater agreement at the end of this phase was 84-96%. Fourteen study videotapes of gallbladder excision were then observed independently by expert reviewers blinded to surgical team identity. Procedures were assessed using a scoring matrix of 1-min segments with each error reported each minute. RESULTS: Interrater agreement was 84-100% for all error categories. CONCLUSIONS: The present study demonstrates that excellent interrater agreement of procedural errors can be achieved by carefully defining and training recognition of targeted events. Extension of this simple and reliable analysis tool to other procedures should be feasible to define behaviors leading to adverse clinical outcomes.

Health policy and the underserved.

Historically, the provision of health benefits and health services has been wedded to the needs of an industrial society to maintain a productive labor force. The casual observer will note that since the late 19th century the role of government as a participant either in the provision for health services or the delivery of health services has been strongly tied to the labor movement in Western Europe. Overtime benefits, initially procured for the worker, were expanded to include the dependents of the worker and, finally, to include the former worker who was no longer able to work due to age or infirmity. The provision of health care to the poor was considered an act of charity and was never liberal enough to reward poverty nor was it essentially humane, for poverty was a condition to be punished. The rise of "alms houses" and public hospitals for the poor provided constant physical reassurance to the worker that he was, indeed, successful. Such institutions were also warnings to the worker lest he slip into the numbers of the poor.

Health manpower-planning without objectives.

Health manpower developments of the past decade have resulted in an absolute increase in the number of health personnel, the expansion of the roles of some traditional categories of personnel, and the introduction of new professional categories. Inherent in these developments has been the acceptance of the principal that the relative and absolute increase in manpower would result in an increased availability of health services. Unfortunately, in the last decade, the correlation between increased numbers and increased services is not a strong one. The failure to link manpower needs to specific service objectives and to identify appropriate rates of substitution among professional types has resulted in a wastage of funds and energies.A framework for future planning must now be developed which (1) defines service priorities, (2) delineates the functions required to deliver those services, and (3) defines appropriate manpower categories with their rates of substitution to perform those functions. Training programs must be coordinated to allow appropriate linkages among categorical types of personnel. The maldistribution of health care service must be viewed as a result of the demographic maldistribution among the health professions as well as the maldistribution of organizational and financial incentives for provision of priority services as well as utilization of priority services.

Predicting minority student performance in the first medical school year.

Impressions and anecdotal evidence have raised concerns that traditional cognitive measures of past performance may not be predictive of the performance among minority students in medical school. This study assessed the relationship between nine objective measures and actual first year academic performance for cohorts of minority students enrolled in a single medical school between 1973 and 1976.The findings support previous impressions that objective measures together explain less than half of the variance in academic performance. Furthermore, the cumulative undergraduate college average and the competitiveness of the undergraduate college are consistently the strongest predictors of academic performance among this group.

Health maintenance organizations: are they for the inner cities?

Health Maintenance Organizations present some major limitations as a means to address the health care needs in our nation's inner cities. The HMO as it has been affected by HMO legislation is discussed and an identification made of those areas that may adversely affect the delivery of health services to inner-city residents where costs may be greatest for those who can least afford it.