Down the Rabbit Hole: Evaluation of Internet Information Quality in Parathyroid and Thyroid Surgery.

INTRODUCTION: Patients often discuss information obtained from Internet sources during clinic visits, which can be of variable quality and depth. We sought to review and assess information on the Internet regarding common operations within endocrine surgery. METHODS: Using Google's search engine, the top 100 websites from the search phrase "parathyroid surgery," and the top 100 websites from the phrase "thyroid surgery" were identified. Each website was evaluated for accessibility, accuracy, and completeness of information about gland hormone function, associated disease processes, and surgery itself. Results were stratified based on the website type, and bivariate analysis was performed to determine accuracy by category. Presence of author credentials, last webpage update, and presence of advertisements were also assessed. Inter-rater reliability was calculated for each variable. RESULTS: For parathyroid surgery, at least two-thirds of all websites included information about surgery, hormone function, and disease processes. For thyroid surgery, 71% of websites included procedure information, but only 52% included information about hormone function and 56% about disease processes. Less than 30% of all websites included advertisements and less than 25% listed author credentials or provided references. Academic or research-affiliated sources were most likely to have zero inaccuracies, but 44% of all websites had at least one potential inaccuracy. Inter-rater reliability achieved at least moderate agreement (>0.41) for 56% of variables. CONCLUSIONS: There is a wide array of information available to patients online, and accuracy varies based on multiple factors including the type of website. Endocrine surgeons and related practitioners must be cognizant of this fact when discussing treatment plans with patients.

The Association of Socioeconomic Factors and Well-Differentiated Thyroid Cancer.

INTRODUCTION: Well-differentiated thyroid cancer (WDTC) is the most common thyroid malignancy, and the worldwide incidence is increasing. Early stage disease is curable with surgery. We hypothesized that patients who live at greater distances from health care institutions or have complicating socioeconomic barriers may present with more advanced diseases and have worse outcomes. METHODS: The National Cancer Database (NCDB) was used to identify patients who were diagnosed with WDTC between 2004 and 2018. Race, ethnicity, insurance status, income status, and distance from residence to health care clinic of diagnosis (great circle distance [GCD]) were analyzed with respect to the severity of disease at presentation (stage) and outcomes. Binary logistic regression and Cox regression were used to determine associations between socioeconomic variables and tumor stage or survival. RESULTS: The Hispanic (OR: 1.49, CI: 1.45-1.54, P < 0.001) and Asian (OR: 1.49, CI: 1.43-1.55, P < 0.001) populations had higher odds of developing an advanced disease when compared to the White population separately. Patients without insurance displayed higher odds of developing an advanced disease at diagnosis compared to those with insurance (OR: 1.39, CI: 1.31-1.47, P < 0.001). Adjusted-Cox regression analysis of survival revealed that Black patients had detrimental survival outcomes when compared to White patients (HR: 1.24, P < 0.001), and patients with private insurance had improved survival outcomes when compared to those without insurance (HR: 0.58, P < 0.001). CONCLUSIONS: Hispanic and Asian patients were found to be more likely to present with an advanced disease but also displayed greater overall survival when compared to the White population. The Black population, patients without insurance, and patients with lower income status exhibited worse survival outcomes.

Enhancement of Cetuximab-Induced Radiosensitization by JAK-1 Inhibition.

BACKGROUND: It is known that cetuximab (an epidermal growth factor receptor [EGFr] inhibitor) is a radiosensitizer. Also, cetuximab is known to only partially inhibit the signal transducer and activator of transcription - 3 (STAT-3); a mediator of protection from apoptosis. Studies were performed to determine if the radiosensitizing effects of cetuximab could be enhanced with the addition of an inhibitor of STAT-3. METHODS/RESULTS: The interaction of JAK-STAT-3 inhibition ([JAK1i]; Calbiochem, LaJolla, CA) and EGFr inhibition (cetuximab) was assessed with and without radiation. Four human head and neck cell lines were studied: UM-SCC-1 and UM-SCC-5, and two modified UM-SCC-5 lines; a STAT-3 knockdown line (STAT-3-2.4) and control (NEG-4.17). Exposure to either 0.5 µg/ml of cetuximab or 1 µM JAK1i for 8 or 24 h resulted in reduced activated STAT-3 (immunoblot), and the combination treatment showed greater reduction in activated STAT-3 compared to the individual treatments. The use of either post-radiation JAK1i (1 µM for 72 h) or post-radiation cetuximab (0.5 µg/ml) enhanced radiation-induced anti-proliferative and apoptotic effects but the greatest enhancement was seen when cells were exposed to both JAK1i and cetuximab post-radiation. Similar results were seen for radiosensitization as assessed by colony formation. Finally, the combination treatment of JAK1i (1 µM) and cetuximab (0.5 µg/ml), following radiation, resulted in an increase of unrepaired radiation-induced DNA double strand breaks at 6 and 24 h after radiation compared to the use of post-radiation JAK1i or cetuximab alone as delineated by neutral comet assay. CONCLUSIONS: These findings suggest that dual inhibition of EGFr (cetuximab) and JAK-STAT-3 (JAK1i) leads to greater radiosensitization than with either cetuximab or JAK1i alone and suggests that this combination treatment may be clinically relevant even for tumors with a marked range of STAT-3 activity.

The Dismal State of Federal Funding for Experimental Evaluations of Interventions to Reduce Greenhouse Gas Emissions.

The threats of climate change to human well-being are well-documented and are growing in number and intensity. Despite the international community investing heavily in technological innovation and policy initiatives to solve the problem, emissions continue to rise. Experts are recognizing that eliminating emissions cannot be achieved without modifying the human behavior of which emissions are a function. However, little attention has been allocated to expanding the use of strategies developed by the behavioral-science community to reduce emissions on large scales. One possible reason is that federal funding has not been arranged to select such research. Therefore, we conducted an analysis of six sources of information about federal funding to fight climate change (the Government Accountability Office, the National Science Foundation, the Environmental Protection Agency, the Department of Energy, the National Institutes of Health, and the Center for Disease Control) and examined the extent to which they are funding behavioral science research to reduce emissions. Our results show an appalling lack of funding for behavioral science research to reduce emissions, especially experimental evaluations of strategies for reducing them. Implications and recommendations for funding of future research are discussed.

A Survey of Otolaryngology Residency Programs on Adapting to the United States Medical Licensing Examination (USMLE) Step 1 Transitioning to Pass/Fail.

Objectives In February 2020, the National Board of Medical Examiners (NBME) announced that the United States Medical Licensing Examination (USMLE) Step 1 licensing examination would change from a numerical score to Pass/Fail (P/F). After implementation, many believe that USMLE-Step 2-Clinical Knowledge (CK) will become an important metric for students applying to otolaryngology (ENT). The purpose of this study is to determine factors important to resident selection after these changes. Methods A survey containing 15 questions related to resident selection practices and how changing USMLE Step 1 to P/F would impact future resident selection was designed. It was distributed to all ENT residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME). Results Forty percent of programs responded; 66% (95% confidence interval (CI): 51.1%-78.4%) felt that changing Step 1 scoring would not lead to students being more prepared for clinical rotations; 55% believe class rank will increase in significance (95% CI: 35.7%-64.3%). There was also an increase in the importance of Step 2 CK, which had a mean ranking of 10.67 prior to changes in Step 1 scoring and increased to 7.80 after P/F. Conclusions The changes in Step 1 scoring will likely lead to increasing importance of other objective measures like class rank or Step 2 CK. This may defeat the intended purpose put forth by the NBME. Therefore, further guidance on measures correlated with student performance as a resident will be integral to the selection process.

Under-Representation of Racial Groups in Genomics Studies of Gastroenteropancreatic Neuroendocrine Neoplasms.

Not all populations are poised to benefit from advancing genomics in gastroenteropancreatic neuroendocrine neoplasms (GEP-NEN), as genomics have focused on White patients. This study aimed to evaluate racial populations represented in genomic studies of GEP-NENs and to provide evidence of differential genomic findings between racial groups in GEP-NENs. Manuscripts analyzing DNA, RNA, or DNA methylation in GEP-NENs were queried using PUBMED and EMBASE. NIH race/ethnicity term frequency was then determined by Natural Language Processing, followed by manual evaluation of tumor types and subjects by racial group. IHC of institutional tissue micro-arrays and analysis of AACR GENIE data analyzed was performed to determine mutational differences between Black and White pancreatic NEN (pNEN) patients. 313 manuscripts conducted the requisite genomic analyses, 16 of which included subject race data. Race data were included in 13/184 DNA, 4/107 RNA, and 1/54 DNA Methylation analyses. These studies included 89% White subjects (n = 2032), 5.8% Asian subjects (n = 132), 4.0% "Other" subjects (n = 93), and 1.2% Black subjects (n = 27). No Native American/Alaska Native, Native Hawaiian/Pacific Islander, or ethnically Hispanic/Latinx subjects were represented. There were significant differences in MEN1 mutations among Black and White patients in immunohistochemical (13:40) and GENIE data (24:268 patients per group, respectively), with 9 additional genes differentially mutated in the GENIE dataset. Genomic sequencing data for GEP-NENs is almost racially homogenous. Differences in pNEN genomics may exist between racial groups, highlighting a need for diversity in future genomic analyses of GEP-NENs to understand the putative influence of interracial genomic variation on GEP-NEN prevention, diagnosis, and therapy. Significance: There is little diversity in genomic studies of GEP-NENs, which may exhibit clinically impactful variation in their tumor biology among racial groups. Improved diversity in such studies is imperative for understanding this variation and its potential impacts on disease prevention, diagnosis, therapeutic targeting, and clinical outcomes.

Analysis of unexpected disruptive effects of contingent food reinforcement on automatically maintained self-injury.

Research has identified treatment-responsive and treatment-resistant subtypes of automatically maintained self-injurious behavior (ASIB) based on patterns of responding in the functional analysis (FA) reflecting its sensitivity to disruption by alternative reinforcement, and the presence of self-restraint. Rooker et al. (2019) unexpectedly observed reductions in treatment-resistant self-injury while participants performed an operant task. The current study further examined this in nine participants with treatment-resistant ASIB in an example of discovery-based research. An operant task engendering high rates of responding (switch-pressing) to produce food, reduced self-injury across all participants, and eliminated self-injury for some participants under certain schedules. Although this finding must be replicated and evaluated over longer time periods, it provides some evidence that alternative reinforcement can disrupt self-injury in these treatment-resistant subtypes under some conditions. Reinforcer and response competition are discussed as possible mechanisms underlying these disruptive effects, as are the potential implications of these findings regarding treatment.

Differential Reinforcement of Low Rate Schedules Reduce Severe Problem Behavior.

Differential-reinforcement-of-low-rate (DRL) schedules are reinforcement contingencies designed to reduce response rates. A common variation of the DRL arrangement is known as full-session DRL ( f-DRL), in which a reinforcer is presented at the end of an interval if the response rate during that interval is below a predetermined criterion. Prior human operant research involving arbitrary mouse clicks has shown that the f-DRL is likely to reduce target responding to near zero rates. Similarly, applied research has shown that the f-DRL is likely to reduce minimally disruptive classroom behavior. There are, however, relatively few successful applications of the f-DRL to severe forms of problem behavior (e.g., self-injurious behavior). Thus, the purpose of this study was to examine the effects of f-DRL on the severe problem behavior of individuals with intellectual and developmental disabilities. For four participants, the f-DRL reduced severe problem behavior by clinically significant levels. Furthermore, results of a contingency strength analysis showed a strong negative contingency strength between target responding and reinforcer delivery for all participants.

Behavioral treatment of automatically reinforced SIB: 1982 - 2015.

Some individuals diagnosed with intellectual and developmental disabilities engage in automatically reinforced self-injurious behavior (SIB). For these individuals, identifying effective treatments may be difficult due to the nature of the reinforcement contingency. The purpose of this study was to review the literature on the treatment of automatically reinforced SIB to determine commonalities in procedures that produced effective and ineffective treatment outcomes, as well as historical trends in the treatment of this class of SIB. Results of this review indicated that there were many high-quality studies on this topic, but also a wide range in the quality of studies. As for effective treatments, noncontingent reinforcement (the most common treatment component) was found to be more effective when informed by a competing stimulus assessment rather than a preference assessment. Suggestions to improve the quality of the published record and areas in which additional research is needed are discussed.

Further analysis of subtypes of automatically reinforced SIB: A replication and quantitative analysis of published datasets.

Hagopian, Rooker, and Zarcone (2015) evaluated a model for subtyping automatically reinforced self-injurious behavior (SIB) based on its sensitivity to changes in functional analysis conditions and the presence of self-restraint. The current study tested the generality of the model by applying it to all datasets of automatically reinforced SIB published from 1982 to 2015. We identified 49 datasets that included sufficient data to permit subtyping. Similar to the original study, Subtype-1 SIB was generally amenable to treatment using reinforcement alone, whereas Subtype-2 SIB was not. Conclusions could not be drawn about Subtype-3 SIB due to the small number of datasets. Nevertheless, the findings support the generality of the model and suggest that sensitivity of SIB to disruption by alternative reinforcement is an important dimension of automatically reinforced SIB. Findings also suggest that automatically reinforced SIB should no longer be considered a single category and that additional research is needed to better understand and treat Subtype-2 SIB.

Measuring the Complexity of Treatment for Challenging Behavior using the Treatment Intensity Rating Form.

OBJECTIVES: The goal of this study was to develop and evaluate a tool to measure the complexity and intensity of psychotropic medication interventions, behavioral interventions, and issues related to crisis management for challenging behavior using a standardized rating form. METHOD: The Treatment Intensity Rating Form (TIRF) is a 10-item scale with three categories: pharmacological interventions, behavior supports, and protective equipment. In a retrospective review we examined the final treatment recommendations for 74 individuals with self-injurious behavior (SIB) based on psychiatric and behavioral notes and reports. We also compared whether TIRF scores differed across individuals for whom SIB was maintained by social reinforcement (e.g., to access attention or toys/activities, or escape from tasks) versus those for whom SIB was maintained by automatic reinforcement (e.g., occurs independent of social variables, and is presumed to be maintained by sensory reinforcement). RESULTS: The TIRF was demonstrated to have strong inter-rater reliability (98%) and appears to have good face validity. As hypothesized, individuals with SIB maintained by automatic reinforcement had significantly more medication trials (p=0.0005) and required more protective equipment than individuals with SIB maintained by social reinforcement (p=0.0002). Antidepressant medication was used more often with individuals with automatically reinforced SIB, although antipsychotics and anticonvulsants were also commonly used across both groups. CONCLUSION: Findings provide initial support for the TIRF's reliability, and face validity as a measure the level of complexity of medical and behavioral treatment plans - although additional research is needed to fully evaluate its psychometric properties.