Disparities in Thyroid Care

Rates of diagnostic and therapeutic procedures in a cohort of patients undergoing first endocrine consultation for thyroid nodular disease

PURPOSE

This study aimed to evaluate the rates of necessary diagnostic and therapeutic procedures in a cohort of patients undergoing their first endocrine consultation for thyroid nodular disease.

METHODS

This was an observational study conducted between January 1 and June 30, 2023, on patients undergoing their first endocrine consultation for thyroid nodular disease. Data were collected, including age, thyroid-stimulating hormone (TSH) concentration, reasons for performing thyroid ultrasound (US), and thyroid US reports. The US was performed at the time of the endocrine consultation according to the American College of Radiology Thyroid Imaging, Reporting and Data System (ACR-TIRADS) risk stratification system. Patients underwent further investigations/treatment or simple US follow-up as necessary.

RESULTS

A total of 373 patients with thyroid nodules were evaluated. Reasons for undergoing thyroid US were unrelated to suspected thyroid disease in 126 (33.8%), incidentalomas in 91 (24.4%), dysfunction or positivity for thyroid antibodies in 67 (18%), symptoms or visible nodules in 61 (16.3%), and family history of thyroid disease in 28 (7.5%). A total of 193 diagnostic or therapeutic procedures were performed in 133 (35.7%) patients [fine-needle aspiration (FNA): 121 (62.7%), surgery: 28 (14.5%), percutaneous ethanol injection: 20 (10.4%), scintigraphy: 10 (5.2%); thermal ablation: 7 (3.6%), and radioactive treatment: 7 (3.6%)].

CONCLUSIONS

In the present study only one-third of the patients undergoing endocrine consultation with first detected thyroid nodules required any diagnostic or therapeutic procedures.

The impact of social determinants of health on thyroid cancer mortality and time to treatment

BACKGROUND

Whereas racial disparities in thyroid cancer care are well established, the role of social determinants of health is less clear. We aimed to assess the individual and cumulative impact of social determinants of health on mortality and time to treatment among patients with thyroid cancer.

METHODS

We collected social determinants of health data from thyroid cancer patients registered in the National Cancer Database from 2004 to 2017. We created a count variable for patients in the lowest quartile of each social determinant of health (ie, low income, low education, and no insurance). We assessed the association of social determinants of health with mortality and time to treatment and the association between cumulative social determinants of health count and time to treatment using Cox regression.

RESULTS

Of the 142,024 patients we identified, patients with longer time to treatment had greater mortality compared to patients treated within 90 days (90-180 days, adjusted hazard ratio 1.21 (95% confidence interval 1.13-1.29, P < .001); >180 days, adjusted hazard ratio 1.57 (95% confidence interval 1.41-1.76, (P < .001). Compared to patients with no adverse social determinants of health, patients with 1, 2, or 3 adverse social determinants of health had a 10%, 12%, and 34%, respectively, higher likelihood of longer time to treatment (1 social determinant of health, hazard ratio 0.90, 95% confidence interval 0.89-0.92, P < .001; 2 social determinants of health, hazard ratio 0.88, 95% confidence interval 0.87-0.90, P < .001; 3 social determinants of health, hazard ratio 0.66, 95% confidence interval 0.62-0.71, P < .001 for all). On subgroup analysis by race, each adverse social determinant of health was associated with an increased likelihood of a longer time to treatment for Black and Hispanic patients (P < .05).

CONCLUSION

A greater number of adverse social determinants of health leads to a higher likelihood of a longer time to treatment for patients with thyroid cancer, which, in turn, is associated with an increased risk for mortality.

Assessing saliency models of observers' visual attention on acquired facial differences

Purpose

Saliency models that predict observers' visual attention to facial differences could enable psychosocial interventions to help patients and their families anticipate staring behaviors. The purpose of this study was to assess the ability of existing saliency models to predict observers' visual attention to acquired facial differences arising from head and neck cancer and its treatment.

Approach

Saliency maps predicted by graph-based visual saliency (GBVS), an artificial neural network (ANN), and a face-specific model were compared to observer fixation maps generated from eye-tracking of lay observers presented with clinical facial photographs of patients with a visible or functional impairment manifesting in the head and neck region. We used a linear mixed-effects model to investigate observer and stimulus factors associated with the saliency models' accuracy.

Results

The GBVS model predicted many irrelevant regions (e.g., shirt collars) as being salient. The ANN model underestimated observers' attention to facial differences relative to the central region of the face. Compared with GBVS and ANN, the face-specific saliency model was more accurate on this task; however, the face-specific model underestimated the saliency of deviations from the typical structure of human faces. The linear mixed-effects model revealed that the location of the facial difference (midface versus periphery) was significantly associated with saliency model performance. Model performance was also significantly impacted by interobserver variability.

Conclusions

Existing saliency models are not adequate for predicting observers' visual attention to facial differences. Extensions of face-specific saliency models are needed to accurately predict the saliency of acquired facial differences arising from head and neck cancer and its treatment.

Effects of fast track surgery on perioperative recovery, stress indicators and swallowing function in patients with thyroid cancer

OBJECTIVE

To explore the effects of fast track surgery (FTS) on perioperative recovery, stress indicators and swallowing function in patients with thyroid cancer.

METHODS

One hundred and thirty patients with thyroid cancer admitted to Huzhou Central Hospital, Zhejiang University Huzhou Hospital, Affiliated Hospital of Huzhou Normal University from January 2019 to December 2020 were retrospectively included as study subjects, and were divided into a control group (n = 63, conventional nursing) and a study group (n = 67, FTS). The perioperative recovery indicators, complications, stress response, and swallowing function were compared between the two groups. Logistic regression analysis was used to analyze the risk factors for accelerating postoperative recovery.

RESULTS

No statistically significant differences were observed in the scores of Kubota drinking test and Ichiro Fujishima rating scale (IFRS) between the two groups before intervention (P > 0.05). After nursing, the study group had lower scores of Kubota drinking test and higher scores of IFRS than the control group (P < 0.05). The time to drainage tube removal, time to first anal exhaust, time to first getting out of bed activity, length of hospitalization, and medical costs in the study group were lower than those in the control group (P < 0.05). The study group showed lower incidence of postoperative complications than the control group (8.96% vs. 28.57%, P < 0.05). The postoperative C-reactive protein, glucose, epinephrine, cortisol levels and numerical rating scale scores in the study group were lower than those in the control group (P < 0.05). Logistic regression analysis showed that age was an important negative factor for accelerating postoperative recovery of patients with thyroid cancer, and the length of postoperative hospital stay increased significantly with age (P < 0.05).

CONCLUSION

The intervention of FTS in the perioperative period for thyroid cancer patients can improve the swallowing function, shorten the recovery time and reduce the incidence of complications, which may be related to the improvement of the perioperative stress response of patients with FTS.

Evaluating health outcomes in the treatment of hypothyroidism

Clinical hypothyroidism is defined by the inadequate production of thyroid hormone from the thyroid gland to maintain normal organ system functions. For nearly all patients with clinical hypothyroidism, lifelong treatment with thyroid hormone replacement is required. The primary goal of treatment is to provide the appropriate daily dose of thyroid hormone to restore normal thyroid function for each individual patient. In current clinical practice, normalization of thyrotropin (TSH) level is the primary measure of effectiveness of treatment, however the use of a single biomarker to define adequate thyroid hormone replacement is being reevaluated. The assessment of clinical health outcomes and patient-reported outcomes (PROs), often within the context of intensity of treatment as defined by thyroid function tests (i.e., undertreatment, appropriate treatment, or overtreatment), may play a role in evaluating the effectiveness of treatment. The purpose of this narrative review is to summarize the prominent health outcomes literature in patients with treated hypothyroidism. To date, overall mortality, cardiovascular morbidity and mortality, bone health and cognitive function have been evaluated as endpoints in clinical outcomes studies in patients with treated hypothyroidism. More recent investigations have sought to establish the relationships between these end results and thyroid function during the treatment course. In addition to clinical event outcomes, patient-reported quality of life (QoL) has also been considered in the assessment of adequacy of hypothyroidism treatment. From a health care quality perspective, treatment of hypothyroidism should be evaluated not just on its effectiveness for the individual patients but also to the extent to which patients of different sociodemographic groups are treated equally. Ultimately, more research is needed to explore differences in health outcomes between different sociodemographic groups with hypothyroidism. Future prospective studies of treated hypothyroidism that integrate biochemical testing, PROs, and end result clinical outcomes could provide a more complete picture into the effectiveness of treatment of hypothyroidism.