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News Article | May 9, 2017
Site: www.eurekalert.org

The U.S. Preventive Services Task Force (USPSTF) recommends against screening for thyroid cancer in adults without any signs or symptoms. The report appears in the May 9 issue of JAMA. This is a D recommendation, indicating that there is moderate or high certainty that screening has no net benefit or that the harms outweigh the benefits. The incidence of thyroid cancer detection has increased by 4.5 percent per year over the last 10 years, faster than for any other cancer; however, the mortality rate from thyroid cancer has not changed substantially, despite the increase in diagnoses. In 2013, the incidence rate of thyroid cancer in the United States was 15.3 cases per 100,000 persons. Most cases of thyroid cancer have a good prognosis; the 5-year survival rate for thyroid cancer overall is 98.1 percent. To update its 1996 recommendation, the USPSTF reviewed the evidence on the benefits and harms of screening for thyroid cancer in asymptomatic adults, the diagnostic accuracy of screening (including by neck palpation and ultrasound), and the benefits and harms of treatment of screen-detected thyroid cancer. The USPSTF is an independent, volunteer panel of experts that makes recommendations about the effectiveness of specific preventive care services such as screenings, counseling services, and preventive medications. The USPSTF found inadequate evidence to estimate the accuracy of neck palpation or ultrasound as a screening test for thyroid cancer in asymptomatic persons. The USPSTF found inadequate direct evidence to determine whether screening for thyroid cancer in asymptomatic persons using neck palpation or ultrasound improves health outcomes. However, the USPSTF determined that the magnitude of benefit can be bounded as no greater than small, based on the relative rarity of thyroid cancer, the apparent lack of difference in outcomes between patients who are treated vs only monitored (i.e., for the most common tumor types), and the observational evidence demonstrating no change in mortality over time after introduction of a population-based screening program. The USPSTF found inadequate direct evidence to assess the harms of screening for thyroid cancer in asymptomatic persons. The USPSTF found adequate evidence to bound the magnitude of the overall harms of screening and treatment as at least moderate, based on adequate evidence of serious harms of treatment of thyroid cancer and evidence that overdiagnosis and overtreatment are likely consequences of screening. The USPSTF concludes with moderate certainty that screening for thyroid cancer in asymptomatic persons results in harms that outweigh the benefits. Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. Note: More information about the U.S. Preventive Services Task Force, its process, and its recommendations can be found on the newsroom page of its website. To place an electronic embedded link to this report in your story This link will be live at the embargo time: http://jamanetwork. Screening for Thyroid Cancer Updated Evidence Report and Systematic Review for the US Preventive Services Task Force Jennifer S. Lin, M.D., M.C.R., Kaiser Permanente Center for Health Research, Portland, Ore., and colleagues Editorial: How to Look for Thyroid Cancer Anne R. Cappola, M.D., Sc.M., University of Pennsylvania, Philadelphia; Associate Editor, JAMA Editorial: Cancer Screening, Overdiagnosis, and Regulatory Capture H. Gilbert Welch, M.D., M.P.H., Dartmouth Institute of Health Policy and Clinical Practice, Geisel School of Medicine, Hanover, N.H. Editorial: The USPSTF Recommendation on Thyroid Cancer Screening Louise Davies, M.D., M.S., Department of Veterans Affairs Medical Center, White River Junction, Vt., and Luc G. T. Morris, M.D., M.Sc., Memorial Sloan Kettering Cancer Center, New York Editorial: Striving for Clarity About the Best Approach to Thyroid Cancer Screening and Treatment Julie Ann Sosa, M.D., M.A., Duke University Medical Center, Durham, N.C., and colleagues

Longacre M.R.,Community Health Research Program | Drake K.M.,Community Health Research Program | Drake K.M.,Dartmouth Institute of Health Policy and Clinical Practice | MacKenzie T.A.,Dartmouth Institute of Health Policy and Clinical Practice | And 6 more authors.
American Journal of Preventive Medicine | Year: 2012

Background: Little is known about the influence of in-town fast-food availability on family-level fast-food intake in nonmetropolitan areas. Purpose: The purpose of the current study was to determine whether the presence of chain fast-food outlets was associated with fast-food intake among adolescents and parents, and to assess whether this relationship was moderated by family access to motor vehicles. Methods: Telephone surveys were conducted with 1547 adolescent-parent dyads in 32 New Hampshire and Vermont communities between 2007 and 2008. Fast-food intake in the past week was measured through self-report. In-town fast-food outlets were located and enumerated using an onsite audit. Family motor vehicle access was categorized based on the number of vehicles per licensed drivers in the household. Poisson regression was used to determine unadjusted and adjusted risk ratios (RRs). Analyses were conducted in 2011. Results: About half (52.1%) of adolescents and 34.7% of parents consumed fast food at least once in the past week. Adolescents and parents who lived in towns with five or more fast-food outlets were about 30% more likely to eat fast food compared to those in towns with no fast-food outlets, even after adjusting for individual, family, and town characteristics (RR=1.29, 95% CI= 1.10, 1.51; RR=1.32, 95% CI=1.07, 1.62, respectively). Interaction models demonstrated that the influence of in-town fast-food outlets on fast-food intake was strongest among families with low motor vehicle access. Conclusions: In nonmetropolitan areas, household transportation should be considered as an important moderator of the relationship between in-town fast-food outlets and family intake. © 2012 American Journal of Preventive Medicine.

Valde S P.A.,Dartmouth College | Kim A.,Ontario Cancer Institute | Brantsch M.,Ontario Cancer Institute | Niu C.,Ontario Cancer Institute | And 11 more authors.
Neuro-Oncology | Year: 2011

Extent of resection is a major goal and prognostic factor in the treatment of gliomas. In this study we evaluate whether quantitative ex vivo tissue measurements of d-aminolevulinic acid-induced protoporphyrin IX (PpIX) identify regions of increasing malignancy in low- and high-grade gliomas beyond the capabilities of current fluorescence imaging in patients undergoing fluorescence- guided resection (FGR). Surgical specimens were collected from 133 biopsies in 23 patients and processed for ex vivo neuropathological analysis: P pIX fluorimetry to measure P pIX concentrations (CP pIX) and Ki-67 immunohistochemistry to assess tissue proliferation. Samples displaying visible levels of fluorescence showed significantly higher levels of CP pIX and tissue proliferation. CP pIX was strongly correlated with histopathological score (nonparametric) and tissue proliferation (parametric), such that increasing levels of CP pIX were identified with regions of increasing malignancy. Furthermore, a large percentage of tumor-positive biopsy sites (∼40%) that were not visibly fluorescent under the operating microscope had levels of CP pIX greater than 0.1 μg/mL, which indicates that significant P pIX accumulation exists below the detection threshold of current fluorescence imaging. Although P pIX fluorescence is recognized as a visual biomarker for neurosurgical resection guidance, these data show that it is quantitatively related at the microscopic level to increasing malignancy in both low- and high-grade gliomas. This work suggests a need for improved P pIX fluorescence detection technologies to achieve better sensitivity and quantification of P pIX in tissue during surgery. © 2011 The Author(s).

Chatterjee A.,Dartmouth Hitchcock Medical Center | Chen L.,Dartmouth College | Goldenberg E.A.,Concord Hospital | Bae H.T.,Dartmouth Institute of Health Policy and Clinical Practice | Finlayson S.R.G.,Dartmouth Hitchcock Medical Center
Surgical Endoscopy and Other Interventional Techniques | Year: 2010

Background Opportunity cost is the value of an activity forgone for participation in some other activity. With respect to surgery, an innovation incurs an opportunity cost when it uses additional operating time that could otherwise be used in a productive way. This report describes an example of assessing opportunity cost in the transition from open to laparoscopic colectomy using pooled analysis data from the surgical literature and hospital financial data. Methods A MEDLINE literature search was performed between the years 1998 and 2008. Data were pooled from the identified studies used for the statistical analysis of cost and operating room time differences between laparoscopic versus open colectomy. The analysis identified five commonly performed, elective general surgery procedures. The profit margins of these procedures then were determined and divided by their average surgical time to calculate a range of opportunity cost multipliers. Finally, these opportunity cost multipliers were applied to the additional time required for performance of laparoscopic colectomy to demonstrate that procedure's true overall cost. Results Seven comparative studies were identified. The pooled analysis showed that the operating time was longer for a laparoscopic colectomy by 27.08 min (p<0.0001). Additionally, laparoscopic colectomies had slightly higher total costs ($104.67 difference), but this difference was not statistically significant (p = 0.28). The five commonly performed, elective procedures chosen were laparoscopic cholecystectomy, laparoscopic inguinal hernia repair, breast biopsy, partial mastectomy, and total thyroidectomy, and their opportunity cost multipliers ranged from $9 to $26 per minute. Depending on the opportunity cost multiplier used, the opportunity cost of an additional 27.08 min required to perform laparoscopic colectomy ranges from $243.72 to $704.08, which is approximately two to six times greater than the point estimate of the difference in total costs based on published studies. Conclusions Although frequently overlooked, opportunity cost is a potentially very important element in assessing the true costs of surgical innovation. © Springer Science+Business Media, LLC 2009.

Stroud A.M.,Dartmouth Hitchcock Medical Center | Parker D.,Dartmouth Institute of Health Policy and Clinical Practice | Croitoru D.P.,Dartmouth Hitchcock Medical Center
Journal of Pediatric Surgery | Year: 2016

Purpose Although controversial, bariatric surgery is increasingly being performed in adolescents. We developed a model to simulate the effect of timing of gastric bypass in obese adolescents on quantity and quality of life. Methods A Markov state-transition model was constructed comparing two treatment strategies: gastric bypass surgery at age 16 versus delayed surgery in adulthood. The model simulated a hypothetical cohort of adolescents with body mass index of 45 kg/m2. Model inputs were derived from current literature. The main outcome measure was quality and quantity of life, measured using quality-adjusted life-years (QALYs). Results For females, early gastric bypass surgery was favored by 2.02 QALYs compared to delaying surgery until age 35 (48.91 vs. 46.89 QALYs). The benefit was even greater for males, where early surgery was favored by 2.9 QALYs (48.30 vs. 45.40 QALYs). The absolute benefit of surgery at age 16 increased; the later surgery was delayed into adulthood. Sensitivity analyses demonstrated that adult surgery was favored only when the values for adverse events were unrealistically high. Conclusions In our model, early gastric bypass in obese adolescents improved both quality and quantity of life. These findings are useful for surgeons and pediatricians when counseling adolescents considering weight loss surgery. © 2016 Elsevier Inc.

Faerber A.E.,Dartmouth Institute of Health Policy and Clinical Practice | Horvath R.,Dartmouth Hitchcock Medical Center | Stillman C.,Dartmouth Hitchcock Medical Center | O'Connell M.L.,Dartmouth Hitchcock Medical Center | And 5 more authors.
BMC Medical Informatics and Decision Making | Year: 2015

Background: Patients with no history of stroke but with stenosis of the carotid arteries can reduce the risk of future stroke with surgery or stenting. At present, a physicians' ability to recommend optimal treatments based on an individual's risk profile requires estimating the likelihood that a patient will have a poor peri-operative outcomes and the likelihood that the patient will survive long enough to gain benefit from the procedure. We describe the development of the CArotid Risk Assessment Tool (CARAT) into a 2-year mortality risk calculator within the electronic medical record, integrating the tool into the clinical workflow, training the clinical team to use the tool, and assessing the feasibility and acceptability of the tool in one clinic setting. Methods: We modified an existing clinical flowsheet with the local electronic medical record for the CARAT risk model. To understand how CARAT would fit into the existing clinical workflow, we observed the clinic and talked with the clinical staff to develop a process map for the existing clinical workflow. CARAT was completed by the clinic nurse for patients identified on the clinic schedule as having carotid narrowing. We analyzed post-implementation assessment in two ways: quantifying the proportion of eligible patients with whom CARAT was utilized, and surveying surgeons to understand the impact of CARAT on decision-making and clinical workflow. Results: With minimum investment of institutional resources, we were able to produce a workable tool and pilot the tool in our clinic within a 6 month time period. Over 4 months, 287 patients were seen in the clinic with carotid narrowing, and clinic staff completed CARAT for 195 (68%). Per-surgeon completion rates ranged from 29 to 81%. Most patients (191 of 195, 98%) patients had a low 2-year calculated mortality risk. Most surgeons believed the risk assessment aligned with their expectations of patient predicted risk. Conclusions: We successfully integrated CARAT into the existing electronic medical record and have preliminary evidence that CARAT can be a valuable tool for evaluating mortality risk for patients with diseased carotid arteries. Accuracy of the risk calculations must be evaluated in larger, multi-center studies. © 2015 Faerber et al.; licensee BioMed Central.

Stroud A.M.,Dartmouth Hitchcock Medical Center | Tulanont D.D.,Dartmouth Institute of Health Policy and Clinical Practice | Coates T.E.,Dartmouth Institute of Health Policy and Clinical Practice | Goodney P.P.,Dartmouth Hitchcock Medical Center | Croitoru D.P.,Childrens Hospital at Dartmouth
Journal of Pediatric Surgery | Year: 2014

Background/Purpose The minimally invasive pectus excavatum repair (MIPER) is a painful procedure. The ideal approach to postoperative analgesia is debated. We performed a systematic review and meta-analysis to assess the efficacy and safety of epidural analgesia compared to intravenous Patient Controlled Analgesia (PCA) following MIPER. Methods We searched MEDLINE (1946-2012) and the Cochrane Library (inception-2012) for randomized controlled trials (RCT) and cohort studies comparing epidural analgesia to PCA for postoperative pain management in children following MIPER. We calculated weighted mean differences (WMD) for numeric pain scores and summarized secondary outcomes qualitatively. Results Of 699 studies, 3 RCTs and 3 retrospective cohorts met inclusion criteria. Compared to PCA, mean pain scores were modestly lower with epidural immediately (WMD - 1.04, 95% CI - 2.11 to 0.03, p = 0.06), 12 hours (WMD - 1.12; 95% CI - 1.61 to - 0.62, p < 0.001), 24 hours (WMD - 0.51, 95%CI - 1.05 to 0.02, p = 0.06), and 48 hours (WMD - 0.85, 95% CI - 1.62 to - 0.07, p = 0.03) after surgery. We found no statistically significant differences between secondary outcomes. Conclusions Epidural analgesia may provide superior pain control but was comparable with PCA for secondary outcomes. Better designed studies are needed. Currently the analgesic technique should be based on patient preference and institutional resources. © 2014 Elsevier Inc.

Hebert C.,Ohio State University | Shivade C.,Ohio State University | Foraker R.,Ohio State University | Wasserman J.,Ohio State University | And 5 more authors.
BMC Medical Informatics and Decision Making | Year: 2014

Background: Readmissions after hospital discharge are a common occurrence and are costly for both hospitals and patients. Previous attempts to create universal risk prediction models for readmission have not met with success. In this study we leveraged a comprehensive electronic health record to create readmission-risk models that were institution- and patient- specific in an attempt to improve our ability to predict readmission.Methods. This is a retrospective cohort study performed at a large midwestern tertiary care medical center. All patients with a primary discharge diagnosis of congestive heart failure, acute myocardial infarction or pneumonia over a two-year time period were included in the analysis.The main outcome was 30-day readmission. Demographic, comorbidity, laboratory, and medication data were collected on all patients from a comprehensive information warehouse. Using multivariable analysis with stepwise removal we created three risk disease-specific risk prediction models and a combined model. These models were then validated on separate cohorts.Results: 3572 patients were included in the derivation cohort. Overall there was a 16.2% readmission rate. The acute myocardial infarction and pneumonia readmission-risk models performed well on a random sample validation cohort (AUC range 0.73 to 0.76) but less well on a historical validation cohort (AUC 0.66 for both). The congestive heart failure model performed poorly on both validation cohorts (AUC 0.63 and 0.64).Conclusions: The readmission-risk models for acute myocardial infarction and pneumonia validated well on a contemporary cohort, but not as well on a historical cohort, suggesting that models such as these need to be continuously trained and adjusted to respond to local trends. The poor performance of the congestive heart failure model may suggest that for chronic disease conditions social and behavioral variables are of greater importance and improved documentation of these variables within the electronic health record should be encouraged. © 2014 Hebert et al.; licensee BioMed Central Ltd.

Bruce M.L.,Dartmouth Institute of Health Policy and Clinical Practice
American Journal of Geriatric Psychiatry | Year: 2016

Looking back to 1993, the articles published in the American Journal of Geriatric Psychiatry's inaugural issue focused on central questions in geriatric psychiatry - from how age-related changes in brain structure and function affect illness etiology, expression, course, and outcomes1 to how best to identify and address the unmet mental health needs in different populations of older adult.2 Today's journal reflects both an enduring commitment to these questions and the growth of the field itself, both in terms of scientific advancement and the breadth of research that is relevant. Thus, questions with pressing clinical and public health significance continue to be addressed but with increasing sophistication in specificity to the questions and the availability of tools to investigate them. © 2016 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.

Kim D.A.,Harvard University | Hwong A.R.,Harvard University | Stafford D.,Yale University | Hughes D.A.,University of California at San Diego | And 3 more authors.
The Lancet | Year: 2015

Background Information and behaviour can spread through interpersonal ties. By targeting influential individuals, health interventions that harness the distributive properties of social networks could be made more effective and efficient than those that do not. Our aim was to assess which targeting methods produce the greatest cascades or spillover effects and hence maximise population-level behaviour change. Methods In this cluster randomised trial, participants were recruited from villages of the Department of Lempira, Honduras. We blocked villages on the basis of network size, socioeconomic status, and baseline rates of water purification, for delivery of two public health interventions: chlorine for water purification and multiVitamins for micronutrient deficiencies. We then randomised villages, separately for each intervention, to one of three targeting methods, introducing the interventions to 5% samples composed of either: randomly selected villagers (n=9 villages for each intervention); villagers with the most social ties (n=9); or nominated friends of random villagers (n=9; the last strategy exploiting the so-called friendship paradox of social networks). Participants and data collectors were not aware of the targeting methods. Primary endpoints were the proportions of available products redeemed by the entire population under each targeting method. This trial is registered with ClinicalTrials.gov, number NCT01672580. Findings Between Aug 4, and Aug 14, 2012, 32 villages in rural Honduras (25-541 participants each; total study population of 5773) received public health interventions. For each intervention, nine villages (each with 1-20 initial target individuals) were randomised, using a blocked design, to each of the three targeting methods. In nomination-targeted villages, 951 (74·3%) of 1280 available multiVitamin tickets were redeemed compared with 940 (66·2%) of 1420 in randomly targeted villages and 744 (61·0%) of 1220 in indegree-targeted villages. All pairwise differences in redemption rates were significant (p<0·01) after correction for multiple comparisons. Targeting nominated friends increased adoption of the nutritional intervention by 12·2% compared with random targeting (95% CI 6·9-17·9). Targeting the most highly connected individuals, by contrast, produced no greater adoption of either intervention, compared with random targeting. Interpretation Introduction of a health intervention to the nominated friends of random individuals can enhance that intervention's diffusion by exploiting intrinsic properties of human social networks. This method has the additional advantage of scalability because it can be implemented without mapping the network. Deployment of certain types of health interventions via network targeting, without increasing the number of individuals targeted or the resources used, could enhance the adoption and efficiency of those interventions, thereby improving population health. Funding National Institutes of Health, The Bill & Melinda Gates Foundation, Star Family Foundation, and the Canadian Institutes of Health Research. © 2015 Elsevier Ltd.

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