Recent Publications by CFE Educators

PURPOSE OF REVIEW

Patient age at diagnosis is a well established prognostic factor for thyroid cancer survival; it is included in the American Joint Committee on Cancer (AJCC) thyroid cancer-staging system. This review provides an update on the epidemiology, risk stratification, and staging of differentiated thyroid cancer (DTC), in the context of patient age.

RECENT FINDINGS

In the eighth edition AJCC staging system for DTC, the age cut-point was increased from 45 to 55 years. The appropriate age-cut point remains a subject of debate, as some studies have found a linear association of age and survival, and therefore, questioned the use of an age cut-point in the DTC staging system altogether. Emerging data on the additive role of molecular markers in the compromised survival of older patients with DTC raise the prospect of eventual inclusion of genetic markers in the management of patients and risk-stratification systems.

SUMMARY

DTC staging is evolving. The pathogenesis of the compromised survival of older patients with DTC is complex, multifactorial, and not well understood. Recent advances in molecular testing are promising. More studies are needed prior to the formal inclusion of molecular markers in the staging system of DTC.

PURPOSE

To describe attitudes of first- and second-year U.S. medical students toward value-added medical education, assess their self-reported desire to participate in value-added activities, and identify potentially modifiable factors influencing their engagement.

METHOD

The authors conducted a cross-sectional survey of first- and second-year students at nine U.S. medical schools in 2017. Survey items measured students' attitudes toward value-added medical education (n = 7), desire to participate in value-added activities (n = 20), and factors influencing potential engagement (n = 18).

RESULTS

Of 2,670 students invited to participate, 1,372 (51%) responded. Seventy-six percent (1,043/1,368) moderately or strongly agreed they should make meaningful contributions to patient care. Students' desire to participate was highest for patient care activities approximating those traditionally performed by physicians, followed by systems improvement activities and lowest for activities not typically performed by physicians. Factors increasing desire to participate included opportunities to interact with practicing physicians (1,182/1,244; 95%), patients (1,177/1,246; 95%), and residents or fellows (1,166/1,246; 94%). Factors decreasing desire to participate included making changes to the health care system (365/1,227; 30%), interacting with patients via phone or electronic communication (410/1,243; 33%), and lack of curricular time (634/1,233; 51%).

CONCLUSIONS

First- and second-year medical students agree they should add value to patient care, but their desire to participate in value-added activities varies depending on the nature of the tasks. Medical schools may be able to increase students' desire to participate by enabling face-to-face interactions with patients, embedding students in health care teams, and providing dedicated curricular time.

BACKGROUND

Primary hyperparathyroidism (PHPT) is a common endocrine disorder that predominantly affects patients >60 and is increasing in prevalence. Identifying risk factors for poor outcomes after parathyroidectomy in older adults will help tailor operative decision making. The impact of frailty on surgical outcomes in parathyroidectomy has not been established.

METHODS

We performed a retrospective review of patients ≥40 years who underwent parathyroidectomy in the 2005-2010 ACS NSQIP. Frailty was assessed using the modified frailty index (mFI). Multivariable regression was used to determine the association of frailty with 30-day complications, length of stay (LOS), and reoperation.

RESULTS

We identified 13,123 patients ≥40 who underwent parathyroidectomy for PHPT. The majority of patients were not frail, with 80% with a low NSQIP mFI score (0-1 frailty traits), 19% with an intermediate mFI score (2-3), and 0.9% with a high mFI score (≥4). Overall 30-day complications were rare, occurring in 141 (1.1%) patients. Increasing frailty was associated with an increased risk of complications with adjusted odds ratios (ORs) of 1.76 (95% CI 1.20-2.59; p = 0.004) for intermediate and 8.43 (95% CI 4.33-16.41; p  0.001) for high mFI score. Patient age was independently associated with an increased risk of complications only when ≥75, as was African-American race. Anesthesia with local, monitored anesthesia care, or regional block was the only factor associated with decreased odds of complications. A high NSQIP mFI was also associated with a significant 4.77-day adjusted increase in LOS (95% CI 4.28-5.25; p  0.001) and increased odds of reoperation (OR 4.20, 95% CI 1.64-10.74; p = 0.003).

CONCLUSION

Patient frailty is associated with increased complications, reoperation and prolonged LOS in patients undergoing parathyroidectomy for PHPT. The risks of surgical management should be weighed against potential benefits in frail patients with PHPT to individualize treatment decisions in this vulnerable population.