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Objective. To examine the impact of pay for performance in Medicaid on the quality and utilization of care. Data Sources. Medicaid claims and encounter data in three intervention states (Pennsylvania, Minnesota, and Alabama) and three comparison states. Study Design. Difference-in-difference analysis with propensity score-matched comparison group. Primary outcomes of interest were Healthcare Effectiveness Data and Information Set (HEDIS)-like process measures of quality, utilization by service category, and ambulatory care-sensitive admissions and emergency department visits. Principal Findings. In Pennsylvania, there was a statistically significant reduction of 88 ambulatory visits per 1,000 enrollee months compared with Florida. In Minnesota, there was a significant decrease of 7.2 hospital admissions per thousand enrollee months compared with Wisconsin. In Alabama, where incentives were not paid out until the end of a 2-year waiver period, there was a decline of 1.6 hospital admissions per thousand member months, and an increase of 59 ambulatory visits per 1,000 enrollees compared with Georgia. No significant quality improvements in intervention relative to control states. Conclusions. Our findings are mixed, with no measurable quality improvements across the three states, but reductions in hospital admissions in two programs. As states move to value-based payment for patient-centered medical homes and Accountable Care Organizations, lessons learned from these pioneering states should inform program design. Key Words. Pay for performance, Medicaid, value-based purchasing in provider relationships, shared savings, Pay-for-performance (P4P) programs for health care providers are now widely implemented in the hope of improving the quality of care and, increasingly, to control costs. The Affordable Care Act of [...]

Background: The Chornobyl accident in 1986 exposed thousands of people to radioactive iodine isotopes, particularly [sup.131] I; this exposure was followed by a large increase in thyroid cancer among those exposed as children and adolescents, particularly in Belarus, the Russian Federation, and Ukraine. Here we report the results of the first cohort study of thyroid cancer among those exposed as children and adolescents following the Chornobyl accident. Methods: A cohort of 32 385 individuals younger than 18 years of age and resident in the most heavily contaminated areas in Ukraine at the time of the accident was invited to be screened for any thyroid pathology by ultrasound and palpation between 1998 and 2000; 13 127 individuals (44%) were actually screened. Individual estimates of radiation dose to the thyroid were available for all screenees based on radioactivity measurements made shortly after the accident and on interview data. The excess relative risk per gray (Gy) was estimated using individual doses and a linear excess relative risk model. Results: Forty-five pathologically confirmed cases of thyroid cancer were found during the 1998-2000 screening. Thyroid cancer showed a strong, monotonic, and approximately linear relationship with individual thyroid dose estimate (P

Background: Treatment of differentiated thyroid cancer has been studied for many years, but the benefits of extensive initial thyroid surgery and the addition of radioiodine therapy or external radiation therapy remain controversial. Objective: To determine the relations among extent of surgery, radioiodine therapy, and external radiation therapy in the treatment of high-risk papillary and non-Hurthle-cell follicular thyroid carcinoma. Design: Analysis of data from a multicenter study. Setting: 14 institutions in the United States and Canada participating in the National Thyroid Cancer Treatment Cooperative Study Registry. Patients: 385 patients with high-risk thyroid cancer (303 with papillary carcinoma and 82 with follicular carcinoma). Measurements: Death, disease progression, and disease-free survival. Results: Total or near-total thyroidectomy was done in 85.3% of patients with papillary carcinoma and 71.3% of patients with follicular cancer. Overall surgical complication rate was 14.3%. Total or near-total thyroidectomy improved overall survival (risk ratio [RR], 0.37 [95% CI, 0.18 to 0.75]) but not cancer-specific mortality, progression, or disease-free survival in patients with papillary cancer. No effect of extent of surgery was seen in patients with follicular thyroid cancer. Postoperative iodine-131 was given to 85.4% of patients with papillary cancer and 79.3% of patients with follicular cancer. In patients with papillary cancer, radioiodine therapy was associated with improvement in cancer-specific mortality (RR, 0.30 [CI, 0.09 to 0.93 by multivariate analysis only]) and progression (RR, 0.30 [CI, 0.13 to 0.72]). When tall-cell variants were excluded, the effect on outcome was not significant. After radioiodine therapy, patients with follicular thyroid cancer had improvement in overall mortality (RR, 0.17 [CI, 0.06 to 0.47]), cancer-specific mortality (RR, 0.12 [CI, 0.04 to 0.42]), progression (RR, 0.21 [CI, 0.08 to 0.56]), and disease-free survival (RR, 0.29 [CI, 0.08 to 1.01]). External radiation therapy to the neck was given to 18.5% of patients and was not associated with improved survival, lack of progression, or disease-free survival. Conclusions: This study supports improvement in overall and cancer-specific mortality among patients with papillary and follicular thyroid cancer after postoperative iodine-131 therapy. Radioiodine therapy was also associated with improvement in progression in patients with papillary cancer and improvement in progression and disease free survival in patients with follicular carcinoma., Thyroid gland removal and radioactive iodine therapy appear to be effective treatments for high-risk papillary and non-Hurthle-cell follicular thyroid carcinoma. Researchers compared the treatment outcomes of 385 thyroid cancer patients. Thyroidectomy was used in 71-83% of patients, which reduced the risk of death to 37% of the risk of death in those who did not have surgery. Radioiodine therapy was used in 79-85% of patients and was associated with greater survival and a substantial decrease in disease progression. External beam radiation did not improve survival or slow the progress of the disease.

Of all the endocrine glands, only the ovaries are the source of more cancer fatalities than the thyroid gland. A clinical conference was conducted at the National Institutes of Health to discuss the features and prognosis of different forms of thyroid cancer, as well as to discuss the means by which the mortality rate might be reduced. Major forms of thyroid cancer include follicular cancer, medullary cancer, and papillary cancer. The medullary cancer and follicular cancers are more frequently fatal than the papillary cancer. However, among papillary cancers the 'tall-cell' variety is more commonly fatal. Older patients are at higher risk of mortality from thyroid cancer than are younger patients. As is the case with most cancers, the metastatic spread of cancer to distant parts of the body is associated with a poor prognosis; this is especially true since thyroid cancers are resistant to current chemotherapeutic treatments. The primary treatment for thyroid cancer is surgery, but it is important for the surgeon to be a specialist with considerable experience with thyroid cancer. There is some controversy over whether it is best to try to remove only the cancer or whether more extensive removal of thyroid tissue is more appropriate. The participants of the conference, however, felt that it is safer overall to remove more tissue in the first operation than to risk the additional surgery that would be necessary if the first operation did not remove all of the cancerous cells. Following surgery, radioactive iodine 131 may be used to obliterate any remaining deposits of cancer cells. Since thyroid cells actively take up iodine circulating in the blood, the cancerous thyroid cells will accumulate the radioactive isotope, which will destroy them. The most appropriate dose of iodine-131 is not fully established, and the dose may well be modulated depending on the risk factors of the individual patient. Young patients with low-risk cancer may be given about 30 milliCuries of radioactive iodine, while older patients with higher risk cancer should be given doses as high as 150 milliCuries. As is the case for many cancers, efforts expended by primary care physicians to detect thyroid cancer in its earlier stages may pay off in better chances for successful treatment. (Consumer Summary produced by Reliance Medical Information, Inc.)

AbstractThis paper formalizes and quantifies the secular stagnation hypothesis, defined as a persistently low or negative natural rate of interest leading to a chronically binding zero lower bound (ZLB). Output-inflation dynamics and policy prescriptions are fundamentally different from those in the standard New Keynesian framework. Using a 56-period quantitative life cycle model, a standard calibration to US data delivers a natural rate ranging from − 1.5 percent to − 2 percent, implying an elevated risk of ZLB episodes for the foreseeable future. We decompose the contribution of demographic and technological factors to the decline in interest rates since 1970 and quantify changes required to restore higher rates. (JEL E12, E23, E31, E32, E43, E52)

The rapid growth of Medicare managed care over the past decade has the potential to increase the efficiency of health-care delivery. Improvements in care management for some may improve efficiency system-wide, with implications for optimal payment policy in public insurance programs. These system-level effects may depend on local health-care market structure and vary based on patient characteristics. We use exogenous variation in the Medicare payment schedule to isolate the effects of market-level managed care enrollment on the quantity and quality of care delivered. We find that in areas with greater enrollment of Medicare beneficiaries in managed care, the non–managed care beneficiaries have fewer days in the hospital but more outpatient visits, consistent with a substitution of less expensive outpatient care for more expensive inpatient care, particularly at high levels of managed care. We find no evidence that care is of lower quality. Optimal payment policies for Medicare managed care enrollees that account for system-level spillovers may thus be higher than those that do not.

Miles Hall's said what dealers have been saying for years, but nothing is done ('Dealers' Troubles Are The Industry's Troubles,' March 2009). It is unfortunate, but I fear the heads [...]

This analysis was performed to determine the effect of initial therapy on the outcomes of thyroid cancer patients. The study setting was a prospectively followed multi-institutional registry. Patients were stratified as low risk (stages I and II) or high risk (stages III and IV). Treatments employed included near-total thyroidectomy, administration of radioactive iodine, and thyroid hormone suppression therapy. Outcome measures were overall survival, disease-specific survival, and disease-free survival. Near-total thyroidectomy, radioactive iodine, and aggressive thyroid hormone suppression therapy were each independently associated with longer overall survival in high-risk patients. Near-total thyroidectomy followed by radioactive iodine therapy, and moderate thyroid hormone suppression therapy, both predicted improved overall survival in stage II patients. No treatment modality, including lack of radioactive iodine, was associated with altered survival in stage I patients. Based on our overall survival data, we confirm that near-total thyroidectomy is indicated in high-risk patients. We also conclude that radioactive iodine therapy is beneficial for stage II, III, and IV patients. Importantly, we show for the first time that superior outcomes are associated with aggressive thyroid hormone suppression therapy in high-risk patients, but are achieved with modest suppression in stage II patients. We were unable to show any impact, positive or negative, of specific therapies in stage I patients.

AbstractAs introduction to the First International Congress on Transthyretin in Health and Disease, this lecture traces the origin of the subject from the discovery in the 1950s that a serum protein migrating ahead of albumin in an electrical field binds the thyroid hormone, thyroxine. Early work defined the molecular and biological properties of thyroxine-binding prealbumin (TBPA). Its tetrameric structure, first recognized from a polymorphism in monkeys, was later elaborated by crystallographic studies, and the very different affinity of its two identical thyroxine-binding sites was explained by an allosteric effect upon occupation of the first site. The far higher concentration of TBPA in cerebrospinal fluid compared to blood was explained by the discovery, 30 years later, that TBPA is synthesized by cells of the choroid plexus, and its rapid turnover in the body made TBPA a convenient marker of malnutrition and chronic disease. Late in the 1960s it was learned that TBPA also carries vitamin A in the circulation by interacting with retinol-binding protein (RBP). TBPA then was renamed transthyretin (TTR), in recognition of its dual transport function, and it was shown that retinol-RBP-TTR interactions are mutually enhancing. Investigation of the molecular genetics of TTR began in 1980 and a large number of inherited variants were discovered in the ensuing years. Some affect thyroxine and/or RBP binding but the majority are associated with familial amyloidotic polyneuropathy. Seizing on this discovery, structural biologists are now investigating why mutated TTR changes from a compact, soluble molecule into a fibrillar, insoluble polymer, and how this pathological transformation might be prevented.

The major fallout of radionuclides from the nuclear power station accident at Chernobyl on 26 April, 1986, occurred in regions of Ukraine and Belarus that are believed to be moderately deficient in dietary iodine. On 17 November, 2000, in conjunction with the Ukraine-Belarus-USA study of developing thyroid disease in a cohort of individuals exposed as children, a workshop was held to review what is known about iodine nutrition in the region, how this might influence the risk of thyroid tumor formation from radioiodine, and whether and how iodine nutrition should be monitored in this long-term project. This report is a summary of the workshop proceedings. Although no precise information about iodine intake in 1986 was found, the prevalence of mild goiter in the region's children suggested iodine deficiency and urinary iodine measurements begun in 1990 indicated that mild to moderate deficiency existed. Increased thyroid iodine uptake and increased thyroid size in 1986 resulting from iodine deficiency would have had counteracting influence on the thyroid radiation dose and knowledge of these parameters is required for dose reconstruction. More problematic is the possible role of iodine deficiency in the years following the accident. Theoretically, the resulting increase in thyroid cellular activity might increase the risk of tumorigenesis but experimental or clinical evidence supporting this hypothesis is meager or absent. Despite this limitation it was considered important to monitor iodine nutrition in the cohort subjects in relation to their place of residence and over time. Methods to accomplish this were discussed.

From 1974 to 1980, we studied six patients, five treated for Hodgkin's disease and one for a hemangioma, in whom thyroid nodules developed after high-dose (2,500 to 4,000 rad) thyroid radiation. Fine-needle aspiration cytology of the thyroid in five cases showed moderate to severe cellular atypia in four (three of whom had elevated serum thyrotropin levels) and mild atypia in one (who was overtly hypothyroid). In the four with marked atypia, surgical pathology disclosed Hashimoto's thyroiditis in one, diffuse hyperplasia and epithelial atypia in two, and a sclerosing papillary carcinoma in one. Among five patients who had total thyroidectomy, three had carcinoma (microscopic papillary, papillary-follicular, or sclerosing papillary) in addition to one or more follicular adenomas or colloid nodules. Thyroid nodules and neoplasia may be more common than previously appreciated in patients exposed to high-dose radiation.(JAMA 1982;247:3217-3220)

Thyroid function was evaluated in the Marshallese who were accidentally exposed to fallout-containing radioiodine isotopes in 1954. Measurements of thyrotrophin (TSH, thyroid-stimulating hormone) levels and free thyroxine (T4) index (FT4I) have revealed that, among 86 persons exposed on Rongelap and Ailingnae atolls, 14 have shown evidence of thyroid hypofunction. This was first noted in some individuals about ten years after exposure. Only two of these showed clinical evidence of hypothyroidism. The most marked TSH elevations were noted in nine persons exposed when younger than 6 years, with estimated doses to the thyroid from 390 to 2,100 rad. Most of this group subsequently had surgery for removal of thyroid nodules. The remaining five cases have been noted more recently among 36 surviving adults exposed at an older age who showed no other detectable thyroid abnormalities. This group had received estimated thyroid doses ranging from 135 to 335 rad and showed modest elevation of serum TSH levels (6 to 9 μU/mL) and a slightly subnormal FT4I. No abnormalities were found in persons on Utirik who received substantially less radiation, and hypothyroidism was present in less than 1% of the control, unexposed Marshallese. The high prevalence of a thyroid hypofunction in these persons indicates that this condition, as well as thyroid nodularity, can be a delayed complication of exposure to early fallout from a nuclear explosion. The fact that a significant fraction of the radiation to the thyroid was from short-lived radioiodine isotopes (132I,133I,135I), as opposed to131I, may account for the severity of the thyroid damage.(JAMA 1982;247:1571-1575)

Two genetic variants of Rhesus monkey prealbumin, Pt 1-1 and Pt 2-2, have been purified by ion exchange chromatography followed by preparative polyacrylamide gel electrophoresis. Both monkey proteins have molecular weights of approximately 54,000 as determined by ultracentrifugation. Amino acid compositions of both variants are very similar. Peptide maps of the two monkey prealbumins differ definitely from each other in only one peptide. The NH2-terminal sequences (1 to 21) suggest that each variant of Rhesus prealbumin is composed of identical subunits; an interchange of valine and isoleucine is found at residue 5 in Rhesus prealbumin. The structural features of both Rhesus prealbumins are very similar to those of human prealbumin.

• The diagnostic accuracy of fine-needle aspiration biopsy of thyroid nodules was assessed in 111 patients who underwent thyroidectomy and in three persons whose thyroid glands were examined at autopsy. The basis for not performing surgery in 107 patients studied during the same period is also discussed. Carcinoma (excluding incidental occult carcinoma) was found in 76% of the nodules with malignant cytologic findings (class 5,10/10; and class 4,3/7), 20% (3/15) of the nodules with suspicious cytologic findings (class 3), and 9% (8/87) of the nodules with benign cytologic findings (classes 1 and 2). The major reasons for avoiding surgery included resolution of the nodule after aspirating a cyst (eight cases) or after hemorrhage (two cases), multinodular goiter (13 cases), functioning nodule (ten cases), lymphocytic thyroiditis (nine cases), high operative risk without suspicious cytologic findings (15 cases), and response to suppression therapy (27 cases). Among 186 patients given thyroxine suppression therapy, 10% of the nodules disappeared and 12% decreased to less than 1 cm in diameter or more than 50% in volume. Aspiration biopsy is useful to select patients for early surgery or for long-term medical management. Its lack of precision, however, requires that it be employed as an adjunct to other clinical considerations.(Arch Intern Med 1984;144:1169-1173)

Thyroxine-binding globulin, transthyretin, and albumin are the major thyroid hormone-binding proteins in human serum. Inherited and acquired variations in serum concentration or affinity of these proteins are described. These changes produce substantial variations in the total serum concentration of thyroid hormones, but do not affect the metabolically active thyroid status. Recognition of thyroid hormone binding protein abnormalities is crucial to avoid inappropriate and detrimental treatments for hyperthyroidism or hypothyroidism.

Thyroid iodine release measured by the double isotope method of Nicoloff was studied in patients with manic-depressive illness before, during and after treatment with lithium carbonate. The urinary 125I/131I isotope ratio was measured following administration of Na125I and 131I-thyroxine. In three of four subjects, lithium caused a transient decrease in diurnal variation and a temporary reduction in the normal increase of the 125I/131I ratio during the first week of therapy or after a lithium dose increase. In addition, in two of three subjects, a rebound increase in the isotope ratio occurred following cessation of lithium administration. These changes most likely represent a direct inhibitory effect of lithium on the thyroid iodine release process.

A novel prognostic staging classification encompassing all forms of thyroid carcinoma was created for the National Thyroid Cancer Treatment Cooperative Study (NTCTCS) Registry, with the goal of prospective validation and comparison with other available staging classifications. Patient information was recorded prospectively from 14 institutions. Clinicopathologic staging was based on patient age at diagnosis, tumor histology, tumor size, intrathyroidal multifocality, extraglandular invasion, metastases, and tumor differentiation. Between 1987 and 1995, 1607 patients were registered. Approximately 43% of patients were classified as NTCTCS Stage I, 24% Stage II, 24% Stage III, and 9% Stage IV. Patients with follicular carcinoma were more likely to have "high risk" Stage III or IV disease than those with papillary carcinoma. Of 1562 patients for whom censored follow-up was available (median follow-up, 40 months), 78 died of thyroid carcinoma or complications of its treatment. Five-year product-limit patient disease specific survival was 99.8% for Stage I, 100% for Stage II, 91.9% for Stage III, and 48.9% for Stage IV (P < 0.0001). The frequency of remaining disease free also declined significantly with increasing stage (94.3% for Stage I, 93.1% for Stage II, 77.8% for Stage III, and 24.6% for Stage IV). The same patients also were staged applying six previously published classifications as appropriate for their tumor type. The predictive value of the NTCTCS Registry staging classification consistently was among the highest for disease specific mortality and for remaining disease free, regardless of the tumor type. The NTCTCS Registry staging classification provides a prospectively validated scheme for predicting short term prognosis for patients with thyroid carcinoma. [See editorial counterpoint on pages 844-7 and reply to counterpoint on pages 848-50, this issue.] Cancer 1998;83:1012-1021. © 1998 American Cancer Society.

The interaction of human plasma retinol-binding protein with plasma prealbumin was studied by the techniques of velocity ultracentrifugation and polarization of retinol fluorescence. In the first method the unbound fraction of retinol-binding protein, which sediments more slowly than its complexes with prealbumin, was measured by its absorption. A stoichiometry of retinol-binding protein to prealbumin, 4:1 was found. The polarization of fluorescence of retinol increases when retinol-binding protein combines with prealbumin; the relaxation time of retinol-binding protein was 6.6 x10-8s at 25° and increased to 28 x10-8s for the complex. The polarization data indicate that there are four independent binding sites with an apparent association constant of approximately 1.2 x106m-1at 25° and pH 7.4. The affinity was maximal near pH 7.4 and decreased gradually at lower and higher pH values. Between pH 6.0 and 9.4, the extent of interaction between retinol-binding protein and prealbumin was dependent on ionic strength. In this pH range almost no binding occurred without added salt and the affinity increased rapidly with increasing KCl concentration to 0.1 m. At pH values below 6 the interaction was less dependent on ionic strength and became independent at pH 4.2.

THE EARLY studies with radioactive iodine by Hertz, Roberts, and Evans1 and by Hamilton and Soley,2 in which it was demonstrated that the natural avidity of the thyroid for iodine could be used to selectively deposit radioactive isotopes of iodine in thyroid tissues, led to the hopeful hypothesis that diseased thyroid tissue might be effectively irradiated by administering radioactive iodine to patients suffering with such maladies. Already it has been amply demonstrated in many clinics that exophthalmic goiter (Graves's disease) can be successfully treated with radioactive iodine. Indeed, the complete replacement of surgical and other forms of treatment by radioiodine is delayed only by an uncertainty as to its possible subsequent undesirable effects on the remaining thyroid tissue.In following the above hopeful hypothesis, a group of investigators at Presbyterian Hospital and Columbia University reported the first attempts to localize radioactive iodine in cancers of the thyroid in

The incorporation of carbohydrates has been studied in vitroin the experimental rat thyroid tumor 1-1C2. The uptake of N-[3H]acetylmannosamine, a precursor of sialic acid, is less than 5% of that in normal thyroid gland; no label is found in 19 S thyroglobulin or its precursors either in the soluble or in the solubilized proteins. N-[3H]Acetylglucosamine is incorporated at a slower rate than in normal thyroid gland and is present in the membrane-bound thyroglobulin; there is no conversion into sialic acid in the soluble thyroglobulin of tumor as occurs in normal thyroid. [14C]Mannose and [14C]galactose are incorporated at an almost normal rate and [14C]fucose, at a subnormal rate; they are present mainly in the particle-bound proteins as ∼18 S thyroglobulin and its precursors.

The fetus is totally dependent in early pregnancy on maternal thyroxine for normal brain development. Adequate maternal dietary intake of iodine during pregnancy is essential for maternal thyroxine production and later for thyroid function in the fetus. If iodine insufficiency leads to inadequate production of thyroid hormones and hypothyroidism during pregnancy, then irreversible fetal brain damage can result. In the United States, the median urinary iodine (UI) was 168 µg/L in 2001–2002, well within the range of normal established by the World Health Organization (WHO), but whereas the UI of pregnant women (173 µg/L; 95% CI 75–229 µg/L) was within the range recommended by WHO (150–249 µg/L), the lower 95% CI was less than 150 µg/L. Therefore, until additional physiologic data are available to make a better judgment, the American Thyroid Association recommends that women receive 150 µg iodine supplements daily during pregnancy and lactation and that all prenatal vitamin/mineral preparations contain 150 µg of iodine.

An 88-year-old woman patient had received 250 mg. of chlorpropamide daily for two weeks as a substitute for insulin therapy. When the blood sugar level was found to be 220 mg.%, the dosage was increased to 250 mg. twice daily. After one day, the patient was hospitalized in coma but was released from the emergency room after apparent complete recovery. On the next morning, she was again hospitalized in deep coma and the blood sugar level was 31 mg.%. The next morning it was 8 mg.%. Dramatic recovery was brought about by intravenous administration of dextrose and supplementary feedings. It would appear mandatory that patients receiving chlorpropamide be kept under close clinical observation, with frequent blood sugar level determinations.

Jaundice, thought to be induced by methimazole, developed in a 54-year-old woman while she was receiving large doses of corticosteroids for malignant exophthalmos. Liver biopsy, taken seven days after the jaundice appeared, showed eosinophilic infiltration in the portal areas which disappeared when use of the drug was discontinued. Four previous cases of hepatitis from methimazole are reviewed and special attention is directed to the occurrence of a "hypersensitivity" drug hepatitis in a patient receiving large doses of corticosteroids.

IT HAS recently been reported1 that, among patients undergoing mammography at a hospital in Detroit, the prevalence of breast cancer was higher in women receiving thyroid hormone therapy than in those who were not. Prevalence of breast cancer was said to increase with increasing duration of thyroid hormone treatment, particularly in nulliparous women. Since the time that this report appeared and was widely publicized by the news media, many patients have expressed concern that the thyroid hormone they are taking may be dangerous, and they have inquired as to whether such treatment should be stopped.The American Thyroid Association, whose membership comprises physicians and basic scientists interested in the thyroid and its diseases, views the aforementioned article with concern, both because of its implication of a possible basic relationship between thyroid therapy and breast cancer and because of its potential impact on the treatment of patients who require thyroid

Focuses on urinary tract infection (UTI) in diabetics. Reason for UTI occurrence in diabetic women; Disagreement regarding UTI prevalence in women diabetics.

We appreciate the interest of Miller et al in our article on fineneedle biopsy of thyroid nodules. We agree that experience gained by the cytologist and the individuals performing the aspirations is important in achieving a high degree of accuracy in the procedure. Our report included all of our results, dating back to 1972 when we first began to use the technique, and we attempted to provide a cytologic diagnosis even when the amount of cellular material in the aspirate was rather meager. We can make the following additional comments about the eight false-negative aspiration diagnoses that we obtained: four were on nodules smaller than 1.5 cm in diameter, one being "barely palpable"; three of the five false-negative papillary carcinomas had purely follicular architecture and the other two were surrounded by follicular adenomas or colloid nodules; one of the two falsenegative follicular carcinomas had major areas of hemorrhagic degeneration; the