Faculty Bibliography

INTRODUCTION/BACKGROUND:Papillary thyroid cancer (PTC) often follows an indolent course with a favorable prognosis. This has led to evolving guideline-based, low-intensity treatment options for low-risk patients. Recently, the purported benefit of total thyroidectomy (TT) over unilateral lobectomy for PTC with clinical lateral neck nodal metastasis (cN1b) has come into question. MATERIALS AND METHODS/METHODS:A retrospective analysis of the National Cancer Institute's Surveillance, Epidemiology, and End Results database was performed to study patients with PTC with ipsilateral cN1b disease from 1975 to 2020. Kaplan-Meier curves and log-rank tests were used to compare disease-specific survival (DSS) difference between lobectomy and TT at 10 y. Multivariable Cox proportional hazards analysis was performed to determine the independent association of lobectomy versus TT with DSS, correcting for age and lymph node ratio, defined as the ratio of pathologically positive lymph nodes to total number examined. RESULTS:Among 2943 patients (median [interquartile range] age, 45 [26] y), 42 underwent lobectomy and 2901 underwent TT. Unadjusted DSS at 10 y in the lobectomy and TT groups were 51.0% (95% confidence interval, 31.4%-82.8%) and 86.8% (95% confidence interval, 84.8%-88.9%), respectively. On multivariable analysis of all patients, older age (hazard ratio [HR], 1.08; P < 0.001) and male gender (HR, 1.74; P < 0.001) were associated with lower adjusted DSS, whereas treatment with TT (HR, 0.387; P = 0.005) and receipt of radioactive iodine (RAI) (HR, 0.604; P < 0.001) were associated with improved adjusted DSS. In addition, we observed that the magnitude of survival benefit conferred by RAI and TT were reduced with decreasing age (P < 0.001). CONCLUSIONS:This longitudinal cohort study suggests that, while TT is associated with a DSS benefit in most patients with PTC and ipsilateral cN1b disease, this association may not exist in a smaller cohort of younger patients. These findings raise the possibility that unilateral surgical clearance without RAI could offer adequate oncologic outcomes in selected younger individuals; however, further investigation is warranted to confirm these observations and inform clinical decision-making.

BACKGROUND:Fixed-dose combination (FDC) antihypertensives combine two or more agents. Compared with non-FDC antihypertensives of multiple classes (multi-pill therapy), combination-pill therapy using FDC antihypertensives may improve hypertension control. However, combination-pill therapy remains low. OBJECTIVES/OBJECTIVE:This study aims to assess: 1) the association between combination-pill therapy and medication adherence, health care utilization, and costs; and 2) the potential to mitigate racial and ethnic differences in medication adherence. METHODS:A retrospective cohort analysis was conducted using the 2017-2021 Merative MarketScan Medicaid database. The study sample included adults aged 18 to 64 years with hypertension, continuously enrolled 1 year before and after a random index date of prescription. The propensity score overlap weighting method was used to balance characteristics between individuals using combination- and multi-pill therapy. Logistic models were used for medication adherence (defined as medication possession ratio [MPR] ≥80%), linear models for continuous MPRs, negative binomial models for health care utilization, and generalized linear models for costs. RESULTS:Compared with multi-pill therapy, combination-pill therapy was associated with higher medication adherence (3.17 in MPR; 95% CI: 2.79-3.55), fewer hypertension-related emergency department visits (220 per 1,000 individuals; 95% CI: -235 to -204), fewer hospitalizations (153 per 1,000 individuals, 95% CI: -160 to -146), and lower costs ($2,862 per person, 95% CI: -$3,035 to -$2,689). However, differences in medication adherence persisted, with non-Hispanic Black adults demonstrating lower adherence than non-Hispanic White adults. CONCLUSIONS:Combination-pill therapy could improve hypertension management and save costs for the Medicaid program and beneficiaries. However, persistent racial and ethnic differences in adherence highlight the need for tailored interventions.

BACKGROUND:There are risks associated with excessive intravenous fluid (IVF) administration in critically ill children. Previous efforts have described opportunities to reduce positive cumulative fluid balance (CFB) in this population but have not been widely implemented. In the wake of Hurricane Helene, a national IVF shortage led to the implementation of IVF conservation guidelines. We sought to determine if this was associated with a reduction in IVF use and CFB. METHODS:The present study is a four-site cohort study of critically ill children utilizing a federated data collection framework to extract patient age, sex, weight, and daily fluid intake/output for days 1-4 of all admissions 28 days prior to and 28 days after the implementation of IVF conservation guidelines. Guidelines were individualized per institution. Total fluid intake, total IVF intake, % intake from IVF, and % CFB were compared between pre- and post-IVF conservation groups. RESULTS:All sites had similar conservation recommendations. There were 633 patients admitted pre- and 619 patients admitted post-IVF conservation guideline implementation, with similar age and weight distributions. There was no significant difference in IVF use pre- and post-IVF conservation; 29-35% of patients had > 5% CFB on day 1 pre-IVF conservation while 27-39% did post-conservation, with increasing numbers on day 2. CONCLUSIONS:Even in the setting of a national IVF shortage, simple recommendations without structured change were insufficient to change IVF administration practices. This indicates additional practices will be needed to reduce IVF intake and % CFB in this vulnerable population.

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry. Prim Care Companion CNS Disord 2025;27(4):25f03975. Author affiliations are listed at the end of this article.

Thoracic outlet syndrome (TOS) comprises a range of conditions characterized by compression of the brachial plexus, subclavian artery, or subclavian vein as these structures traverse the thoracic outlet. Although TOS was first documented in 1860 by Willshire, it remains a diagnostic and therapeutic challenge-particularly for cardiologists evaluating upper-extremity ischemia, suspected arm emboli, or unexplained swelling. This article provides a cardiology-focused overview of TOS, emphasizing the condition's subtypes (neurogenic, venous, and arterial), key diagnostic approaches, comparative surgical outcomes, and considerations relevant to cardiovascular specialists. Literature pertaining to TOS pathophysiology, clinical diagnosis, imaging, and surgical management was reviewed. Where available, quantitative outcome data and success rates are highlighted to guide evidence-based decision-making. TOS is commonly categorized into neurogenic, venous, and arterial forms. Each subtype necessitates a distinct approach. Developments in imaging (magnetic resonance imaging, computed tomography angiography, and dynamic ultrasound) and refined surgical techniques have improved diagnostic accuracy and therapeutic success: yet questions remain regarding long-term efficacy and optimal procedural approaches. Prompt differentiation between TOS and intrinsic cardiac or major vascular etiologies is essential for preventing severe complications such as limb ischemia and permanent nerve damage. A multidisciplinary model integrating cardiologists, vascular surgeons, neurologists, and physical therapists offers the best outcomes. Further studies, particularly large-scale comparative trials, are needed to standardize diagnostic protocols and evaluate emerging surgical approaches.

OBJECTIVE:To increase the rate of low dose aspirin (LDA) counseling and treatment in patients with 2 or more moderate risk factors of preeclampsia(PMRF) from 9% to 50% within a four-month period after implementation of interventions. STUDY DESIGN/METHODS:A single-institution quality improvement initiative aimed at LDA screening and counseling of those with PMRF. Two groups were evaluated: pre-intervention (January - April 2022) and post-intervention (January - April 2023). This initiative focused on identifying PMRF and monitoring rates of LDA counseling and treatment. Rates were assessed at two-week intervals and presented on a run chart to visualize trends and measure progress over time. Providers underwent education utilizing preeclampsia (PEC) screening flowsheets and integrated a clinical decision-making (CDM) tool in initial prenatal visit documentation using a smart-tool. Patients were provided with educational flyers. RESULTS:In the pre-intervention group (n=126), 8.7% of patients received counseling on PMRF risk factors and LDA use, 7.9% were treated with LDA. In the post-intervention group (n=112) 52.7% of patients received counseling on PMRF risk factors and LDA use, and 35.7% were treated with LDA. There was an 83.5% increase in the percentage of patients counseled following intervention implementation. A progressive increase was noted in counseling rates within the 18 weeks post-intervention. CONCLUSION/CONCLUSIONS:Integrating PEC screening flowsheets, clinical decision-making tools, and patient education flyers effectively enhances LDA counseling for patients with ≥2 PMRF with additional benefits seen in high-risk patients. These interventions offer a replicable model to enhance guideline adherence and reduce preeclampsia risk in vulnerable populations.