Background The impact of recent medical advances on disease presentation, extent of surgery, and disease specific survival (DSS) for patients with medullary thyroid cancer (MTC) is unclear. Methods We used the Surveillance, Epidemiology, and End Results registry to compare trends over three time periods, 1983–1992, 1993–2002, and 2003–2012. Results There were 2,940 patients diagnosed with MTC between 1983 and 2012. The incidence of MTC increased during this time period from 0.14 to 0.21 per 100,000 population, and mean age at diagnosis increased from 49.8 to 53.8 (p<0.001). The proportion of tumors ≤1cm also increased from 11.4% in 1983–1992, 19.6% in 1993–2002, to 25.1% in 2003–2012 (p<0.001), but stage at diagnosis remained constant (p=0.57). In addition, the proportion of patients undergoing a total thyroidectomy and lymph node dissection increased from 58.2% to 76.5% during the study period (p<0.001). In the most recent time interval, 5-year DSS improved from 86% to 89% in all patients (p<0.001), but especially for patients with regional (82% to 91%, p=0.003) and distant (40% to 51%, p=0.02) disease. Conclusions These data demonstrate that the extent of surgery is increasing for patients with MTC. DSS is also improving, primarily in patients with regional and distant disease.

Background Thyroidectomy and parathyroidectomy are the most commonly performed endocrine operations, and increasingly are completed on a same-day basis. Little data exists regarding the outpatient post-operative pain requirement of these patients. We aimed to describe the outpatient narcotic medication needs for patients undergoing thyroid and parathyroid surgery, and to identify predictors of higher requirement. Method We examined patients undergoing thyroid and parathyroid surgery at two large academic institutions from January1-May 30, 2014. Prospective data was collected on pain scores and the oral morphine equivalents (OMEQ) taken by these patients by their post-operative visit. Results 313 adult patients underwent thyroidectomy or parathyroidectomy during the study period. 83% of patients took 10 or fewer OMEQ, and 93% took 20 or fewer OMEQ. Patients who took more than 10 OMEQ were younger (p<0.001) and reported significantly higher overall mean pain scores at their post-operative visit (p<0.001) than patients who took fewer than 10 OMEQ. A multivariate model was constructed on pre and intraoperative factors that may predict usage of greater than 10 OMEQ post-operatively. Age < 45 years (p=0.002), previous narcotic use (p=0.037) and whether parathyroid or thyroid surgery was performed (p=0.003) independently predicted the use of more than 10 OMEQ after surgery. A subgroup analysis was then performed on thyroidectomy only patients. Conclusion 93% of patients undergoing thyroidectomy and parathyroidectomy require 20 or fewer OMEQ by their post-operative visit. We therefore recommend these patients be discharged with 20 oral morphine equivalents, both to minimize waste and increase patient safety.

IMPORTANCE Untreated primary hyperparathyroidism impairs quality of life and incurs substantial costs. Parathyroidectomy is a low-risk, high-success, definitive intervention.OBJECTIVES To determine the appropriateness of diagnostic evaluation for primary hyperparathyroidism in patients with hypercalcemia and the use of parathyroidectomy for the treatment of primary hyperparathyroidism across the Veterans Affairs (VA) health care system. DESIGN, SETTING, AND PARTICIPANTSA retrospective cohort study of veterans with hypercalcemia and primary hyperparathyroidism was conducted from January 1, 2000, through September 30, 2015, using the VA Corporate Data Warehouse, a national electronic health record-based repository. The study included 371 370 veterans with chronic hypercalcemia and 47 158 veterans with biochemical evidence of primary hyperparathyroidism diagnosed by hypercalcemia, elevated serum parathyroid hormone levels, and near-normal serum creatinine levels. Statistical analysis was performed from April 21, 2017, to April 10, 2019. MAIN OUTCOMES AND MEASURESThe proportion of veterans with hypercalcemia who have parathyroid hormone levels evaluated, the proportion of veterans with hyperparathyroidism who are treated surgically, and the factors associated with parathyroidectomy using generalized linear latent and mixed model regression. RESULTSOf 371 370 patients with chronic hypercalcemia, 86 887 (23.4%) received further testing with parathyroid hormone level. Of 47 158 patients meeting diagnostic criteria for primary hyperparathyroidism (42 737 men [90.6%] and 4421 women [9.4%]; mean [SD] age, 67.3 [11.8] years), 6048 (12.8%) underwent parathyroidectomy. Of 5793 patients with primary hyperparathyroidism presenting with a serum calcium level more than 1 mg/dL above the upper limit of normal, 1501 (25.9%) underwent parathyroidectomy. There was a decreasing trend in the use of parathyroidectomy over time. Factors positively associated with parathyroidectomy were nephrolithiasis (odds ratio [OR], 2.23; 95% CI, 1.90-2.61) and non-Hispanic white race/ethnicity (OR, 1.31; 95% CI, 1.17-1.46), while age (OR, 0.95; 95% CI, 0.95-0.96), Elixhauser Comorbidity Index score (OR, 0.76; 95% CI, 0.72-0.80), decreased estimated glomerular filtration rate (OR, 0.52; 95% CI, 0.45-0.60), and diagnosis of osteoporosis (OR, 0.65; 95% CI, 0.52-0.80) were inversely related to surgery.CONCLUSIONS AND RELEVANCE From this study's findings, parathyroid hormone level is infrequently tested in patients with hypercalcemia, suggesting underdiagnosis of primary hyperparathyroidism. Patients meeting diagnostic criteria for primary hyperparathyroidism are undertreated with recommended parathyroidectomy. Similar gaps have previously been observed in non-VA care of primary hyperparathyroidism, suggesting the need for a systematic evaluation of barriers to diagnosis and treatment that informs intervention design.

Adoption of MIS for the treatment of colorectal cancer has been slow. Additional studies to evaluate barriers in the adoption of MIS for colon cancer resection are warranted.

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Purpose We sought to determine the long-term risk of cardiovascular disease (CVD)-stroke and myocardial infarction-and congestive heart failure (CHF) in older patients with colorectal cancer, as well as to understand the roles that preexisting comorbidities and cancer therapy play in increasing this risk. Patients and Methods We evaluated individuals from the SEER-Medicare database with incident stage I to III colorectal cancer at age older than 65 years between January 1, 2000, and December 31, 2011 (n = 72,408) and compared these patients with a matched cohort of Medicare patients without cancer (n = 72,408). Results Median age at diagnosis of colorectal cancer was 78 years (range, 66 years to 106 years), and median follow-up was 8 years since diagnosis. The 10-year cumulative incidence of new-onset CVD and CHF were 57.4% and 54.5% compared with 22% and 18% for control, respectively ( P < .001). The interaction between hypertension and chemotherapy was significant ( P < .001) for CVD, and that between diabetes and chemotherapy was significant ( P < .001) for CHF. Within the first 2 years since diagnosis, exposure to capecitabine alone increased CHF hazard (hazard ratio [HR], 3.6; 95% CI, 12.76 to 4.38) compared with exposure to fluorouracil alone. Conversely, patients who were treated with fluorouracil alone had a higher CVD hazard at < 2 years and > 2 years since diagnosis compared with patients who received capecitabine alone (< 2 years HR, 0.63; 95% CI, 0.53 to 0.75; > 2 years HR, 0.72; 95% CI, 0.62 to 0.84). Conclusion Older patients with colorectal cancer are at increased risk of developing CVD and CHF. Diabetes and hypertension interact with chemotherapy to increase the risk of cardiovascular morbidity. Future studies should assess the potential for personalized therapeutic options for those with preexisting morbidities and for structured monitoring for patients with a history of exposure to chemotherapy regimens, as well as explore the management of preexisting comorbidities to address long-term cardiovascular morbidity.

The capacity of glatiramer acetate (GA), a random copolymer of alanine, lysine, glutamic acid, and tyrosine to stimulate primary in vitro human and murine T cell proliferation was examined. PBMCs isolated from healthy humans and relapsing remitting multiple sclerosis patients and spleen cells from inbred strains of mice, expressing different H-2 haplotypes, were used as sources of non-GA-primed lymphocytes. GA functioned as a universal Ag, inducing dose-dependent proliferation of all non-GA-primed human and murine T cell populations tested. Moreover, GA stimulated PBMCs derived ex vivo from human cord blood, strongly suggesting that GA can activate both naive and memory T cells. The human T cell proliferative responses to GA were HLA class II DR-restricted by virtue of the ability of anti-class II Ab to inhibit T cell proliferation, and the demonstration that individual GA specific human T cell clones were HLA class II DR-restricted by either restriction element but not both. Furthermore, GA-reactive T cells secreted Th0 cytokines and expressed a diverse repertoire of TCR. Limiting dilution analysis indicated that the T cell precursor frequency among the healthy human adults tested ranged from 1:5,000 to 1:125,000. Given that all of the T cell populations tested were isolated from non-GA-primed donors, it appears that virtually all humans and murine strains contain significant numbers of T cell populations cross-reactive with GA. These findings may explain the recent clinical finding that daily s.c. administration of GA ameliorates the progression of multiple sclerosis.

Patients with papillary thyroid cancer commonly confront the perception that their malignancy is "good," but the favorable prognosis and treatability of the disease do not comprehensively represent their cancer fight. The "good cancer" perception is at the root of many mixed and confusing emotions. Clinicians emphasize optimistic outcomes, hoping to comfort, but they might inadvertently invalidate the impact thyroid cancer has on patients' lives.