A Prospective Mixed-Methods Study of Decision-Making on Surgery or Active Surveillance for Low-Risk Papillary Thyroid Cancer.

Background: Active surveillance (AS) of small, low-risk papillary thyroid cancers (PTCs) is increasingly being considered. There is limited understanding of why individuals with low-risk PTC may choose AS over traditional surgical management. Methods: We present a mixed-methods analysis of a prospective observational real-life decision-making study regarding the choice of thyroidectomy or AS for management of localized, low-risk PTCs <2 cm in maximum diameter (NCT03271892). Patients were provided standardized medical information and were interviewed after making their decision (which dictated disease management). We evaluated patients' levels of decision-self efficacy (confidence in medical decision-making ability) at the time information was presented and their level of decision satisfaction after finalizing their decision (using standardized questionnaires). We asked patients to explain the reason for their choice and qualitatively analyzed the results. Results: We enrolled 74 women and 26 men of mean age 52.4 years, with a mean PTC size of 11.0 mm (interquartile range 9.0, 14.0 mm). Seventy-one patients (71.0% [95% confidence interval 60.9-79.4%]) chose AS over surgery. Ninety-four percent (94/100) of participants independently made their own disease management choice; the rest shared the decision with their physician. Participants had a high baseline level of decision self-efficacy (mean 94.3, standard deviation 9.6 on a 100-point scale). Almost all (98%, 98/100) participants reported high decision satisfaction. Factors reported by patients as influencing their decision included the following: perceived risk of thyroidectomy or the cancer, family considerations, treatment timing in the context of life circumstances, and trust in health care providers. Conclusions: In this Canadian study, ∼7 out of 10 patients with small, low-risk PTC, who were offered the choice of AS or surgery, chose AS. Personal perceptions about cancer or thyroidectomy, contextual factors, family considerations, and trust in health care providers strongly influenced patients' disease management choices.

Bone-conduction hearing and the occlusion effect in otosclerosis and normal controls.

OBJECTIVE: The goal of this study was to better understand bone-conduction hearing in subjects with normal hearing and in those with otosclerosis through the occlusion effect. With this study, the authors hope to lend credence to commonly accepted theories of bone-conduction hearing and the effect of lateralization during the Weber tuning fork test. BACKGROUND: There are three accepted theories defining bone-conduction hearing: compressional bone conduction describes an auditory percept produced by the compression and expansion of the cochlea leading to basilar membrane vibration; inertial bone conduction describes the inertia of the ossicular chain as a result of skull vibration during bone conduction testing; whereas skull vibration may also be transmitted to the external auditory canal, surrounding soft tissues, and para-auditory structures to illicit tympanic membrane vibration known as osseotympanic bone conduction. METHODS: Twenty normal volunteers and 17 unilateral otosclerosis patients underwent external canal sound pressure level measurement during bone-conduction testing using a standardized bone oscillator placement and stimulation paradigm. Sound was detected with a probe microphone placed in the external auditory canal in nonoccluded and occluded conditions after a 50-dB hearing level bone-conduction stimulus. RESULTS: There was no significant difference in sound pressure level between otosclerosis and normal subjects when the external auditory canals were nonoccluded. With occlusion, sound pressure level increased in both groups, but at a statistically significantly higher level for the otosclerosis group. CONCLUSION: Sound measured in the external canal likely represents energy lost to the environment transmitted through the middle and external ear systems, aided by the effect of both inertial and osseotympanic bone conduction. Occluding the ear leads to sound trapping and amplification. Also, the pressure exerted against the tympanic membrane reduces middle ear compliance and increases the impedance mismatch between air and the middle ear system, reflecting sound back into the external canal. This effect is further enhanced by stapes fixation to explain our data in both groups of subjects. The final common pathway in "lateralization" is probably a product of higher than normal impedance mismatch at the oval window.