Systematic reviews of diagnostic tests in endocrinology: an audit of methods, reporting, and performance

The Future of Thyroid Nodule Risk Stratification

Clinical evidence supports the association of ultrasound features with benign or malignant thyroid nodules and serves as the basis for sonographic stratification of thyroid nodules, according to an estimated thyroid cancer risk. Contemporary guidelines recommend management strategies according to thyroid cancer risk, thyroid nodule size, and the clinical scenario. Yet, reproducible and accurate thyroid nodule risk stratification requires expertise, time, and understanding of the weight different ultrasound features have on thyroid cancer risk. The application of artificial intelligence to overcome these limitations is promising and has the potential to improve the care of patients with thyroid nodules.

A deeper analysis in thyroid research: A meta-epidemiological study of the American Thyroid Association clinical guidelines

Background

The American Thyroid Association (ATA) uses the GRADE or the American College of Physicians (ACP) system to develop recommendations. Recommendations based on low-quality evidence should spur for the conduction of clinical studies, if feasible. The extent to which recommendations by the ATA based on low-quality of evidence are being actively researched remains unknown.

Methods

Clinical guidelines produced by the ATA using the GRADE or the ACP system to classify evidence were deemed eligible. Reviewers, in duplicate and independently, extracted therapeutic recommendations based on low-quality evidence, whereas recommendations with higher quality of evidence, aimed at diagnosis, or best practice statements were excluded. Eligible recommendations based on low-quality evidence were deconstructed to their components using the PICO format. We then searched on clinicaltrials.gov to identify ongoing research. Trials were deemed eligible if they addressed the PICO question with at least one of the intended outcomes.

Results

A total of 543 recommendations were retrieved, of which 305 (56%) were based on low-quality of evidence and only 90 were deemed eligible. Of these, we found that 33 (37%) recommendations were actively being researched in 53 clinical trials. Most of the trials were randomized and funded by non-profit organizations. Many clinical trials studied thyroid nodules and differentiated thyroid cancer (26/53; 49%), whereas few studied were aimed at anaplastic thyroid cancer (2/53; 4%).

Conclusion

One out of three of gaps in evidence, identified as low quality during the development of ATA guidelines, are currently actively researched. This finding calls for the need to develop a better research infrastructure and funding to support thyroid research.

Educational programs to teach shared decision making to medical trainees: A systematic review

OBJECTIVE

Shared decision-making (SDM) is a process of collaboration between patients and clinicians. An increasing number of educational programs to teach SDM have been developed. We aimed to summarize and evaluate the body of evidence assessing the outcomes of these programs.

METHODS

We conducted a systematic review of studies that aimed to teach SDM to medical trainees. Reviewers worked independently and in duplicate to select studies, extract data and evaluate the risk of bias.

RESULTS

Eighteen studies were included. Most studies focused on residents/fellows (61 %) and combined a didactic component with a practical experience (50 % used a standardized patient). Overall, participants reported satisfaction with the courses. The effects on knowledge, attitudes/confidence and comfort with SDM were small; no clear improvement on SDM skills was noted. Evaluation of clinical behavior and outcomes was limited (3/18 studies). Studies had moderate risk of bias.

CONCLUSION

Very low quality evidence suggests that educational programs for teaching SDM to medical trainees are viewed as satisfactory and have a small impact on knowledge and comfort with SDM. Their impact on clinical skills, behaviors and patient outcomes is less clear.

PRACTICAL IMPLICATIONS

Integration of formal and systematic outcomes evaluation (effects on behavior/clinical practice) should be part of future programs.

Thyroid nodules: diagnostic evaluation based on thyroid cancer risk assessment

Thyroid nodules are extremely common and can be detected by sensitive imaging in more than 60% of the general population. They are often identified in patients without symptoms who are undergoing evaluation for other medical complaints. Indiscriminate evaluation of thyroid nodules with thyroid biopsy could cause a harmful epidemic of diagnoses of thyroid cancer, but inadequate selection of thyroid nodules for biopsy can lead to missed diagnoses of clinically relevant thyroid cancer. Recent clinical guidelines advocate a more conservative approach in the evaluation of thyroid nodules based on risk assessment for thyroid cancer, as determined by clinical and ultrasound features to guide the need for biopsy. Moreover, newer evidence suggests that for patients with indeterminate thyroid biopsy results, a combined assessment including the initial ultrasound risk stratification or other ancillary testing (molecular markers, second opinion on thyroid cytology) can further clarify the risk of thyroid cancer and the management strategies. This review summarizes the clinical importance of adequate evaluation of thyroid nodules, focuses on the clinical evidence for diagnostic tests that can clarify the risk of thyroid cancer, and highlights the importance of considering the patient's values and preferences when deciding on management strategies in the setting of uncertainty about the risk of thyroid cancer.

Pitfalls in the interpretation of the cosyntropin stimulation test for the diagnosis of adrenal insufficiency

PURPOSE OF REVIEW

Adrenal insufficiency is a rare disease characterized by cortisol deficiency. The evaluation of patients suspected of having adrenal insufficiency can be challenging because of the rarity of the disease and limitations in the biochemical assessment of the cortisol status by either basal or dynamic testing [adrenocorticotropic hormone (ACTH) stimulation test]. Prompt and adequate diagnosis is of paramount importance to avoid adverse outcomes. We aimed to summarize the recent developments in the conduction and interpretation of the ACTH stimulation test for the diagnosis of adrenal insufficiency.

RECENT FINDINGS

The ACTH stimulation test is commonly performed in patients suspected of having adrenal insufficiency when the basal serum cortisol levels are inconclusive. Recent literature has evaluated the impact of technical aspects such as time of the day the test is performed, type of assay and sample source used for cortisol measurement on the clinical value of this test, as well as the feasibility of reliable low dose ACTH testing.

SUMMARY

Clinicians evaluating patients with suspected adrenal insufficiency should take into consideration the clinical presentation (likelihood of adrenal insufficiency before testing) when interpreting the results of the ACTH stimulation test and be aware of clinical and technical factors that can affect cortisol values and diagnostic accuracy of this test.