Recent Publications by CFE Educators

CONTEXT

Use of recombinant human TSH (rhTSH) prior to radioactive iodine remnant ablation for patients with differentiated thyroid cancer avoids the hypothyroid state and improves quality of life. European studies have shown that use of rhTSH vs. thyroid hormone withdrawal is a cost-effective method for preparing patients for ablation.

OBJECTIVE

The objective of the study was to determine the cost-utility of rhTSH prior to ablation in the United States.

DESIGN/SETTING/SUBJECTS

A Markov decision model was developed for a hypothetical group of adult patients with low-risk differentiated thyroid cancer who were prepared for ablation by either rhTSH or thyroid hormone withdrawal. Patients entered the model after initial thyroidectomy; follow-up was in accordance with current American Thyroid Association guidelines. Input data were obtained from the literature, Medicare reimbursement schedule, and U.S. Bureau of Labor Statistics. Sensitivity analyses were performed for all clinically relevant inputs.

MAIN OUTCOME MEASURES

Cost-utility, measured in U.S. dollars per quality-adjusted life-year ($/QALY), was measured.

RESULTS

Use of rhTSH yielded an incremental cost-utility of $52,554/QALY (95% confidence interval $52,058-53,050/QALY) (incremental societal cost of $1,365/patient; incremental benefit of 0.026 QALY/patient). The majority of cost and benefit occurs during the preablation, ablation, and postablation period; differences in cost are due to cost of rhTSH and differences in productivity loss (days off work). The model was most sensitive to changes in time off work, cost of rhTSH, and differences in utilities of health states.

CONCLUSIONS

In the United States, the cost-effectiveness of rhTSH for ablation in patients with low-risk differentiated thyroid cancer is highly dependent on potential variations in cost of rhTSH, rates of remnant ablation, time off work, and quality of life.

OBJECTIVES/HYPOTHESIS

Compare parathyroidectomy patients based on age, including demographics, outcomes, and complications.

STUDY DESIGN

Retrospective review.

METHODS

Prospective parathyroidectomy database covering 1998 to 2007 was reviewed retrospectively.

RESULTS

A total of 687 patients underwent parathyroidectomy, including 247 (36%) >65 years old. Discharge was more often on day of surgery in younger patients (42.5% vs. 29.2%, P = .007) and >23 hours for older patients (24.7% vs. 12.3%, P .0001). Older patients stayed longer in the recovery room (134 vs. 107 minutes, P = .005). Despite postoperative normocalcemia, older patients tended to have persistently elevated parathyroid hormone (PTH) (10.5% vs. 6.4%, P = .07), whereas younger patients had normal PTH (81.6% vs. 70%, P = .0007). PTH levels were low-abnormal (56-110) in younger patients (47% vs. 29%, P = .046), but high-abnormal (>220) in older patients (16.6% vs. 9.55%, P = .009). Overall complication rates were low (6%-8%), with >93% in either group having no major complications. There was no difference in timing or types of complications, except elderly patients were more likely to have cardiac complications (2.83% vs. 0.45%, P = .022).

CONCLUSIONS

Nearly 700 parathyroidectomies were performed at our institution over 10 years. Elderly patients comprised one third of this population. They were likely to have longer hospital and recovery room stays, and postoperative normocalcemia with elevated PTH, which may actually be a normal finding for these patients, but it warrants further study. The rate, timing, and types of complications were similar between age groups, although elderly patients had more cardiac complications. When properly indicated, parathyroidectomy remains a safe and effective option for management of hyperparathyroidism in elderly patients.

The association between the clinical use of nitroglycerin (NTG) and headache has led to the examination of NTG as a model trigger for migraine and related headache disorders, both in humans and laboratory animals. In this study in mice, we hypothesized that NTG could trigger behavioural and physiological responses that resemble a common manifestation of migraine in humans. We report that animals exhibit a dose-dependent and prolonged NTG-induced thermal and mechanical allodynia, starting 30-60 min after intraperitoneal injection of NTG at 5-10 mg/kg. NTG administration also induced Fos expression, an anatomical marker of neuronal activity in neurons of the trigeminal nucleus caudalis and cervical spinal cord dorsal horn, suggesting that enhanced nociceptive processing within the spinal cord contributes to the increased nociceptive behaviour. Moreover, sumatriptan, a drug with relative specificity for migraine, alleviated the NTG-induced allodynia. We also tested whether NTG reduces the threshold for cortical spreading depression (CSD), an event considered to be the physiological substrate of the migraine aura. We found that the threshold of CSD was unaffected by NTG, suggesting that NTG stimulates migraine mechanisms that are independent of the regulation of cortical excitability.

Overactive bladder (OAB) is a common condition in the elderly. Treatments for OAB include nonpharmacological or behavioral therapy, pharmacological therapy, and surgical therapy. Antimuscarinic agents are the current pharmacological treatment for OAB and are known to cause memory impairment. A 66-year-old female presented with memory loss secondary to the administration of oxybutynin, which resulted in medication nonadherence. Upon review of her medications, the pharmacist recommended discontinuing the oxybutynin because of the anticholinergic effects on cognition. At a three-week follow-up visit, the patient reported an improvement in memory and medication adherence. Pharmacists can play a vital role in recognizing drug-induced side effects and educating patients in an effort to improve medication adherence.

BACKGROUND

The aim of this study was to benchmark national practice patterns against American Thyroid Association guidelines for thyroidectomy, lymphadenectomy, and radioactive iodine (RAI) for differentiated thyroid cancer (DTC).

METHODS

A cross-sectional analysis of patients with DTC in Surveillance, Epidemiology, and End Results was performed. Outcomes were practice accordance with guidelines for extent of surgery and RAI treatment. Predictors of accordance were identified.

RESULTS

A total of 52,964 patients with DTC were included. Seventy-six percent were women, and 83% white. There was 71% accordance with surgery recommendations; among these, 15% underwent central lymphadenectomy, 31% had RAI but no lymphadenectomy, and 25% had RAI and lymphadenectomy. The highest accordance with guidelines was for patients aged 45 years with stage II disease (80%); the lowest accordance was for patients aged > or = 45 years with stage II disease (52%). Patients aged >65 years and of black race had the lowest accordance (P .001).

CONCLUSIONS

Variation in practice suggests variation in the quality of care for DTC. Greater dissemination of evidence-based recommendations is needed for elderly and minority patients.

CONTEXT

We report the extraction of acetaminophen by continuous venovenous hemodiafiltration (CVVHD) during treatment of an acute ingestion of 200 g with a peak recorded serum acetaminophen level of 1,614 mg/L (10,652 micromol/L).

CASE DETAILS

The patient presented with early onset of coma, metabolic acidosis, and hypotension in the absence of significant hepatic injury. In addition to N-acetylcysteine (NAC) therapy, CVVHD was performed to manage the acid-base disturbance. Flow rate, effluent volume, and serum and effluent drug concentrations were obtained at hourly intervals. During 16 h of CVVHD the acetaminophen level dropped from 1,212 to 247 mg/L.

DISCUSSION

The average clearance of acetaminophen by CVVHD was 2.53 L/h, with removal of 24 g of acetaminophen over 16 h. As NAC is effective in preventing hepatic injury after acute acetaminophen overdose, the role of dialysis or CVVHD is limited.

Violent and agitated patients are high risk because they may pose a physical threat to the staff, may harm themselves, and may have dangerous comorbidities and illness that are causing the violence. The emergency physician must quickly control these behaviors, and thoroughly identify and treat their etiology, while simultaneously protecting the patients' rights and reducing the risks of injury to themselves, other patients, and medical staff. This article highlights potentially high-risk situations and describes corresponding mitigation tactics.

Older adults often receive suboptimal care during hospitalizations and transitions to postacute settings. Inpatient geriatric services have been shown to increase care quality but have not improved patient outcomes consistently. Acute Care for the Elderly units improve patient outcomes but are resource intensive. Transitional care has been shown to reduce hospital readmissions and healthcare costs. This article describes the Geriatric Floating Interdisciplinary Transition Team (Geri-FITT), a model that combines the strengths of inpatient geriatric evaluation and comanagement and transitional care models by creating an inpatient comanagement service that also delivers transitional care. The Geri-FITT model is designed to improve the hospital care of older adults and their transitions to postacute settings. In Geri-FITT, a geriatrician-geriatric nurse practitioner team assesses patients, comanages geriatric syndromes, provides staff education, encourages patient self-management, communicates with primary care providers, and follows up with patients soon after discharge. This pilot cohort study of Geri-FITT included hospitalized patients aged 70 and older on four general medicine services (two Geri-FITT, two usual care) at an academic medical center (N=717). The study assessed the effect of Geri-FITT on patients' care transition quality (Care Transitions Measure) and their satisfaction with hospital care (four questions). The results indicate that Geri-FITT is associated with slightly higher, though not statistically significantly so, quality care transitions and greater patient satisfaction with inpatient care. Geri-FITT may be a feasible approach to enhancing inpatient management and transitional care for older adults. Further study of its effect on these and other outcomes in other healthcare settings seems warranted.