Background
Patients often struggle to attain euthyroidism after thyroidectomy, and multiple dosing schemes have been proposed to supplant the standard weight-based approach for initial levothyroxine (LT4) dosing. The objectives of this study were to review the literature for existing LT4 dosing schemes and compare estimation accuracies with novel schemes developed with machine learning.
Methods
This study retrospectively analyzed 598 patients who attained euthyroidism after total or completion thyroidectomy for benign disease. A scoping review identified existing LT4 dosing schemes. 13 machine learning algorithms estimated euthyroid dose. Using 10-fold cross-validation, we compared schemes by the proportion of patients having a predicted dose within 12.5 μg/day of their euthyroid dose.
Results
Of 264 reviewed articles, 7 articles proposed retrospectively implementable dosing schemes. A novel Poisson regression model proved most accurate, correctly predicting 64.8% of doses. Incorporating 7 variables, Poisson regression was significantly more accurate than the best scheme in the literature (BMI/weight based) that correctly predicted 60.9% of doses (p=0.031). Standard weight-based dosing (1.6 μg/kg/day) correctly predicted 51.3% of doses, and the least effective scheme (age/sex/weight based) correctly predicted 27.4% of doses.
Conclusion
Using readily available variables, a novel Poisson regression dosing scheme outperforms other machine learning algorithms and all existing schemes in estimating LT4 dose.
Severe obesity affects nearly 20 million adults in the United States and is associated with significant morbidity and mortality. Bariatric surgery is the most effective treatment for weight loss and resolution of obesity-related co-morbidities. Of adults with severe obesity,<1% undergo bariatric surgery annually. Both contextual (health system, clinicians, and community) and individual factors contribute to the underutilization of bariatric surgery. In this review, we summarize potential barriers to undergoing bariatric surgery within the framework of Andersen's Behavioral Model of Health Services Use.
Margin positivity after resection for noninvasive IPMNs is primarily due to low grade dysplasia and is not associated with developing recurrence in the remnant pancreas or at the resection margin. Long-term surveillance is required for all patients, as a significant number of recurrences developed over 5 years after the index operation.
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