We present our ongoing experience in the use of postsurgical stimulated serum thyroglobulin (Stim-Tg) to assist in radioiodine remnant ablation (RRA) decision-making.Patients with low-risk well-differentiated thyroid carcinoma (WDTC) with undetectable anti-Tg antibodies were prospectively followed after total thyroidectomy and therapeutic central compartment neck dissection, when indicated.Stim-Tg was performed 3 months postoperatively and used to base RRA selection.Of 104 patients, 59 patients (56.7%) had an undetectable Stim-Tg after thyroidectomy, 35 (33.7%) had Stim-Tg values of 1-5 microg/L, and 10 (9.6%) had Stim-Tg values >5 microg/L. RRA was administered to 1 patient (1.7%) with undetectable Stim-Tg, 6 patients (17.1%) with Stim-Tg1-5 microg/L, and 9 patients (90%) with Stim-Tg >5 microg/L, for a total of 16 patients (15.4%) receiving RRA. When compared to current RRA selection guidelines, the proposed protocol achieved a significantly lower RRA administration rate.Stim-Tg measurement performed several months after total thyroidectomy is a useful objective parameter in assisting RRA decision-making for patients with low-risk WDTC. (
Background Chronic rhinosinusitis (CRS) has been identified as a high‐priority disease category for quality improvement. To this end, this study aimed to develop CRS‐specific quality indicators (QIs) to evaluate diagnosis and management that relieves patient discomfort, improves quality of life, and prevents complications. Methods A guideline‐based approach, proposed in 2012 by Kötter et al. was used to develop QIs for CRS. Candidate indicators (CIs) were extracted from 3 practice guidelines and 1 international consensus statement on the diagnosis and management of CRS. Guidelines were evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. Each CI and its supporting evidence was summarized and reviewed by an expert panel based on validity, reliability, and feasibility of measurement. Final QIs were selected from CIs utilizing the modified RAND Corporation–University of California, Los Angeles (RAND/UCLA) appropriateness methodology. Results Thirty‐nine CIs were identified after literature review and evaluated by our panel. Of these, 9 CIs reached consensus as being appropriate QIs, with 4 requiring additional discussion. After a second round of evaluations, the panel selected 9 QIs as appropriate measures of high‐quality care. Conclusion This study proposes 9 QIs for the diagnosis and management of patients with CRS. These QIs can serve multiple purposes, including documenting the quality of care; comparing institutions and providers; prioritizing quality improvement initiatives; supporting accountability, regulation, and accreditation; and determining pay‐for‐performance initiatives.
Background The high incidence of pediatric acute otitis media (AOM) makes the implications of overdiagnosis and overtreatment far-reaching. Quality indicators (QIs) for AOM are limited, drawing from generalized upper respiratory infection QIs, or locally developed benchmarks. Recognizing this, we sought to develop pediatric AOM QIs to build a foundation for future quality improvement efforts. Methods Candidate indicators (CIs) were extracted from existing guidelines and position statements. The modified RAND Corporation/University of California, Los Angeles (RAND/UCLA) appropriateness methodology was used to select the final QIs by an 11-member expert panel consisting of otolaryngology—head and neck surgeons, a pediatrician and family physician. Results Twenty-seven CIs were identified after literature review, with an additional CI developed by the expert panel. After the first round of evaluations, the panel agreed on 4 CIs as appropriate QIs. After an expert panel meeting and subsequent second round of evaluations, the panel agreed on 8 final QIs as appropriate measures of high-quality care. The 8 final QIs focus on topics of antimicrobial management, specialty referral, and tympanostomy tube counseling. Conclusions Evidence of variable and substandard care persists in the diagnosis and management of pediatric AOM despite the existence of high-quality guidelines. This study proposes 8 QIs which compliment guideline recommendations and are meant to facilitate future quality improvement initiatives that can improve patient outcomes.
Thyroid cancer is the most common endocrinological malignancy worldwide and its incidence is increasing faster than for any other cancer. The majority of this increase has been in well differentiated thyroid carcinoma (WDTC) which comprises 90% of all thyroid malignancies. Recent advances in the diagnosis, surgical treatment, and long-term monitoring have enhanced the detection of primary and recurrent disease, as well as treatment modalities. These developments have prompted institutions to revise their guidelines on the management of thyroid disorders. In the diagnosis of thyroid nodules, recommendations have been made regarding initial evaluation, use of TSH and radionuclide studies, clinical and ultrasound criteria for fine-needle aspiration biopsy (FNAB), and the interpretation of FNAB results. Thyroidectomy (removal of gross thyroid tissue) and lymph node dissection have been established as efficacious initial therapies to reduce disease recurrence although the extent of surgical resection is hotly debated. Following surgical therapy, appropriate use of radioactive iodine (RAI) therapy to destroy microscopic disease is discussed, including its controversial use in low-risk patients. Guidelines for long-term management include recommendations on the use of TSH suppression therapy, surveillance of recurrent disease using ultrasound and serum thyroglobulin, and the treatment of recurrent/metastatic disease. Here, we review the recent developments and recommendations in the management of WDTC.
Previous studies describe the financial burden of chronic rhinosinusitis (CRS) from the perspective of third-party payers, but, to our knowledge, none analyze the costs borne by patients (i.e., out-of-pocket expenses [OOPE]). Furthermore, this burden has not been previously investigated in the context of a publicly funded health care system.The purpose of this study was to characterize the financial impact of CRS on patients, specifically by evaluating its associated OOPEs and the perceived financial burden. The secondary aim was to determine the factors predictive of OOPEs and perceived burden.Patients with CRS at a tertiary care sinus center completed a self-administered questionnaire that assessed their socioeconomic characteristics, disease-specific quality of life (22-item Sino-Nasal Outcome Test [SNOT-22]), workdays missed due to CRS, perceived financial burden, and direct medical and nonmedical OOPEs over a 12-month period. Total OOPEs were calculated from the sum of direct medical and nonmedical OOPEs. Regression analyses determined factors predictive of OOPEs and the perceived burden.A total of 84 patients completed the questionnaires. After accounting for health insurance coverage and the median direct medical, direct nonmedical, and total OOPEs per patient over a 12-month period were Canadian dollars (CAD) $336.00 (2011) [U.S. $339.85], CAD $129.87 [U.S. $131.86], and CAD $607.10 [U.S. $614.06], respectively. CRS resulted in an average of 20.6 workdays missed over a 12-month period. Factors predictive of a higher financial burden included younger age, a greater number of previous sinus surgeries, <80% health insurance coverage, residing out of town, and higher SNOT-22 scores.Total OOPEs incurred from the treatment of CRS may amount to CAD $607.10 [U.S. $614.06] per patient per year, within the context of a single-payer health care system. Managing clinicians should be aware of patient groups with a greater perceived financial burden and consider counseling them on strategies to offset expenses, including obtaining travel grants, using telemedicine for follow-up assessments, providing drug samples, and streamlining diagnostic testing with medical visits.
Background Immunodeficiency is a risk factor for recalcitrant chronic rhinosinusitis (CRS). Currently, there is no consensus on effective treatment modalities for immunodeficient CRS patients. This review aims to evaluate the existing evidence on the treatment outcomes and its limitations in patients with CRS and immunodeficiency. Methods MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched from inception to April 2019 for studies reporting measurable medical or surgical treatment outcomes for adult patients with CRS and underlying primary or secondary immunodeficiency. Results Of the 2459 articles screened, 13 studies met the inclusion criteria: 2 prospective double‐blind placebo‐controlled trials, 2 prospective case‐control studies, 2 prospective cohort studies, and 7 case series. The high degree of study heterogeneity precluded a meta‐analysis. Antibiotic monotherapy was not linked with significant improvement in clinical, radiographic, or endoscopic outcomes. Immunoglobulin replacement therapy may potentially reduce the frequency of acute or chronic sinusitis in patients with primary immunodeficiency (PID) but may not improve their sinonasal symptoms. Outcomes from endoscopic sinus surgery (ESS) were reported in 8 studies, which found that surgery was linked with improvement in symptoms, disease‐specific quality of life, endoscopy scores, and radiographic scores. The average reported ESS revision rate was 14%. Conclusion Patients with CRS and immunodeficiency likely benefit from ESS based on the available evidence. Data supporting medical therapy in this targeted population is limited overall, but there may be a potential role for immunoglobulin therapy in patients with PID and CRS.
This study examined the association between screen media use, media content, and language development among 119 Hispanic infants and toddlers. Children and their caregivers were recruited through an urban, Early Head Start program. Duration and content of screen media exposure was measured through a 24-hour recall questionnaire, and language development was measured at baseline and at 1-year follow up. Children in the sample spent an average of 3.29 hours engaged with screen media (median 2.5 hours per day). In both cross-sectional and longitudinal analyses, children who watched over 2 hours of television per day had increased odds of low communication scores. Whereas child-directed media was associated with low language scores, adult-directed media was not. Our findings support the mounting literature on the deleterious impacts of screen media in toddler's language development. Guidance and alternatives to screen media use should be available to families in pediatric practices and early childhood centers.
