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Since the publication of Standards for Quality Improvement Reporting Excellence (SQUIRE 1.0) guidelines in 2008, the science of the field has advanced considerably. In this manuscript, we describe the development of SQUIRE 2.0 and its key components. We undertook the revision between 2012 and 2015 using (1) semi-structured interviews and focus groups to evaluate SQUIRE 1.0 plus feedback from an international steering group, (2) two face-to-face consensus meetings to develop interim drafts, and (3) pilot testing with authors and a public comment period. SQUIRE 2.0 emphasizes the reporting of three key components of systematic efforts to improve the quality, value, and safety of healthcare: the use of formal and informal theory in planning, implementing, and evaluating improvement work; the context in which the work is done; and the study of the intervention(s). SQUIRE 2.0 is intended for reporting the range of methods used to improve healthcare, recognizing that they can be complex and multi-dimensional. It provides common ground to share these discoveries in the scholarly literature (www.squire-statement.org).Desde la publicación de las guías llamadas Normas para la Excelencia en los Reportes sobre la Mejora de la Calidad (SQUIRE 1.0, Standards for Quality Improvement Reporting Excellence), en 2008, la ciencia en ese campo ha avanzado considerablemente. En este manuscrito se describe el desarrollo de SQUIRE 2.0 y sus componentes clave. La revisión se realizó entre 2012 y 2015 utilizando: (1) entrevistas semiestructuradas y grupos focales para evaluar SQUIRE 1.0 además de la retroalimentación de un grupo directivo internacional, (2) dos reuniones de consenso cara a cara para desarrollar borradores provisionales, y (3) pruebas piloto con los autores y un período de comentarios públicos. SQUIRE 2.0 hace hincapié en el reporte de tres componentes clave de los esfuerzos sistemáticos por mejorar la calidad, el valor y la seguridad de la asistencia sanitaria: el uso de la teoría formal e informal en la planificación, implementación y evaluación de los trabajos de mejora; el contexto en que se realiza el trabajo; y el estudio de la o las intervenciones. SQUIRE 2.0 está diseñado para reportar la gama de métodos utilizados para mejorar la atención sanitaria, reconociendo que esto puede ser complejo y multidimensional. Proporciona una base común para compartir estos hallazgos en la literatura académica (www.squire-statement.org).

Layered gadolinium hydroxides (LGdH) have significant potential in simultaneous drug delivery and magnetic resonance imaging (MRI). In this work, we synthesized LGdH nanocomposites surface functionalised with SiO2 nanodots (LGdH@SiO2). We find these to have good dispersibility in cell culture medium, and a reduced tendency to aggregate compared to their uncoated analogue. Under the optimal reaction conditions, SiO2 nanodots were evenly spread across the surface of the LGdH particles. We further intercalated ibuprofen (Ibu) and 5-fluorouracil (5FU) into LGdH@SiO2, and explored the use of the resultant composites for drug delivery in vitro. While the SiO2 coating could effectively reduce aggregation of the Ibu intercalate prepared by ion exchange from the parent LGdH, it was noted to increase aggregation in the case of the 5FU-loaded systems produced by coprecipitation. With a SiO2 coating, 5FU release from the composite was almost zero-order at pH 7.4. The LGdH-5FU@SiO2 composites can effectively inhibit the growth of A549 ​cells (a human adenocarcinoma cell line). In contrast, the Ibu-loaded materials are highly biocompatible. After SiO2 modification, LGdH-5FU@SiO2 retains the same proton relaxivity properties as LGdH-5FU, while LGdH-Ibu@SiO2 becomes suitable for use as a negative contrast agent in MRI.

International audience; [No abstract available]

The newly introduced pathologic diagnosis of noninvasive follicular thyroid neoplasm with papillary‐like nuclear features (NIFTP) will result in less bilateral thyroid surgery as well as deescalation in T4 suppressive and radioactive iodine treatment. Although, NIFTP is a nonmalignant lesion that has nuclear features of some papillary malignancies, the challenge for the surgeon is to identify a lesion as possibly NIFTP before the pathologic diagnosis. NIFTP, due to its reduction of overall rates of malignancy, will result in the initial surgical pendulum swinging toward lobectomy instead of initial total thyroidectomy. This American Head and Neck Society endocrine section consensus statement is intended to inform preoperative evaluation to attempt to identify those patients whose final pathology report may ultimately harbor NIFTP and can be offered a conservative surgical plan to assist in cost‐effective, optimal management of patients with NIFTP.

Vitamin D (vit-D) deficiency is highly prevalent in patients with gastro-entero-pancreatic neuroendocrine tumors (GEP-NET) and has been linked to reduced overall survival. We here assessed the vit-D status in 183 patients with GEP-NET at the time of their first presentation in the ARDEN NET Centre. We further examined the effect of simple advice to increase vit-D intake using over-the-counter vit-D preparations [colecalciferol (Vit-D3), 1,000-2,000 units/day], over a prospective observation period of 24 mo. At baseline, only 33.3% of patients showed vit-D sufficiency (25-OH-vit-D;50 nmol/L), the remainder was insufficient (31.3%; 25-OH-vit-D; 25-50 nmol/L) or deficient (35.5%; 25-OH-vit-D;25 nmol/L). Repeated advice to increase vit-D intake at routine 6-monthly follow-up appointments was associated with increased 25-OH-vit-D from 37.8 ± 3.5 nmol/L at baseline to 60.4 ± 5.6 nmol/L (P0.0001) and 56.8 ± 7.0 nmol/L (P = 0.039) after 12 and 24 mo. Percentage of vit-D insufficiency decreased from 66.6% at baseline to 44.9% and 46.2% after 12 and 24 months, respectively. Previous abdominal surgery, but not treatment with somatostatin analogues predicted 25-OH-vit-D levels in bootstrapped linear regression analyses (P = 0.037). In summary, simple advice to increase vit-D intake using over-the-counter preparations was associated with significant improvement of vit-D deficiency/insufficiency, although, 15% of GEP-NET patients remained deficient and may benefit from additional measures of vit-D replacement.

Importance Clinicians and patients benefit when they have a clear understanding of how medical conditions influence patients’ life experiences. Patients’ perspectives on life with unilateral vocal fold paralysis have not been well described. Objective To promote patient-centered care by characterizing the patient experiences of living with unilateral vocal fold paralysis. Design, Setting, and Participants This study used mixed methods: surveys using the voice and dysphagia handicap indexes (VHI and DHI) and semistructured interviews with adults with unilateral vocal cord paralysis recruited from a tertiary voice center. Recorded interviews were transcribed, coded using a hierarchical coding system, and analyzed using an iterative inductive-deductive approach. Main Outcomes and Measures Symptom domains of the patient experience. Results In 36 patients (26 [72%] were female, and the median age and interquartile range [IQR] were 63 years [48-68 years]; median interview duration, 42 minutes), median VHI and DHI scores were 96 (IQR, 77-108) and 55.5 (IQR, 35-89) at the time of interviews, respectively.Frustration,isolation,fear, and altered self-identitywere primary themes permeating patients’ experiences. Frustrations related to limitations in communication, employment, and the medical system. Sources of fear included a loss of control, fear of further dysfunction or permanent disability, concern for health consequences (eg, aspiration pneumonia), and/or an inability to call for help in emergency situations. These experiences were modified by the following factors: resilience, self-efficacy, perceived sense of control, and social support systems. Conclusions and Relevance Effects of unilateral vocal fold paralysis extend beyond impaired voice and other somatic symptoms. Awareness of the extent to which these patients experience frustration, isolation, fear, and altered self-identity is important. A patient-centered approach to optimizing unilateral vocal fold paralysis treatment is enhanced by an understanding of both the physical dimension of this condition and how patients cope with the considerable emotional and social consequences. Recognizing the psychosocial dimensions of disease allows clinicians to communicate more effectively, be more empathetic, and to better personalize treatment plans, which may lead to improved patient care and patient satisfaction.

The purpose of this publication was to inform surgeons as to the modern state-of-the-art evidence-based guidelines for management of the recurrent laryngeal nerve invaded by malignancy through blending the domains of 1) surgical intraoperative information, 2) preoperative glottic function, and 3) intraoperative real-time electrophysiologic information. These guidelines generated by the International Neural Monitoring Study Group (INMSG) are envisioned to assist the clinical decision-making process involved in recurrent laryngeal nerve management during thyroid surgery by incorporating the important information domains of not only gross surgical findings but also intraoperative recurrent laryngeal nerve functional status and preoperative laryngoscopy findings. These guidelines are presented mainly through algorithmic workflow diagrams for convenience and the ease of application. These guidelines are published in conjunction with the INMSG Guidelines Part I: Staging Bilateral Thyroid Surgery With Monitoring Loss of Signal. Level of Evidence: 5 Laryngoscope, 128:S18-S27, 2018.

Telemedicine applications are expanding to improve access to specialty care in rural areas. Telemedicine is not routinely used to evaluate new patients in otolaryngology, and it remains unclear which patients could benefit from this technology. This study estimates the rate of telemedicine eligibility among specific otolaryngology diagnoses. We conducted a retrospective cohort study of all ear, nose, and throat consults between August 1, 2013, and July 31, 2015. We paired diagnoses ( International Classification of Disease, Ninth Revision) with office-based procedures ( Current Procedural Terminology) and applied prespecified telemedicine eligibility criteria to encounters retroactively. If a specialized procedure was necessary to reach a diagnosis, the diagnosis was considered ineligible for telemedicine. We found that 62% of otolaryngology encounters would likely be eligible for telemedicine. Patients with inner and middle ear problems were more likely eligible for telemedicine, while patients with problems affecting the larynx and external ear were least likely eligible. Nearly 90% of veterans drove >1 hour round-trip for services. Understanding which otolaryngology problem types are more frequently eligible for telemedicine may assist those who are planning to implement a telemedicine program.

Since the publication of S tandards for QU ality I mprovement R eporting E xcellence (SQUIRE 1.0) guidelines in 2008, the science of the field has advanced considerably. In this manuscript, we describe the development of SQUIRE 2.0 and its key components. We undertook the revision between 2012 and 2015 using (1) semi-structured interviews and focus groups to evaluate SQUIRE 1.0 plus feedback from an international steering group, (2) two face-to-face consensus meetings to develop interim drafts, and (3) pilot testing with authors and a public comment period. SQUIRE 2.0 emphasizes the reporting of three key components of systematic efforts to improve the quality, value, and safety of healthcare: the use of formal and informal theory in planning, implementing, and evaluating improvement work; the context in which the work is done; and the study of the intervention(s). SQUIRE 2.0 is intended for reporting the range of methods used to improve healthcare, recognizing that they can be complex and multidimensional. It provides common ground to share these discoveries in the scholarly literature ( http://www.squire-statement.org ). J Contin Educ Nurs . 2015;46(11):501–507.

In the past several years, the science of health care improvement has advanced considerably. In this article, we describe the development of SQUIRE 2.0 and its key components. We undertook the revision between 2012 and 2015 using (1) interviews and focus groups to evaluate SQUIRE 1.0 plus feedback from an international steering group, (2) face-to-face consensus meetings to develop interim drafts, and (3) pilot testing with authors and a public comment period. SQUIRE 2.0 emphasizes 3 key components of systematic efforts to improve the quality, value, and safety of health care: formal and informal theory in planning, implementing, and evaluating improvement work; the context in which the work is done; and the study of the intervention(s). SQUIRE 2.0 is intended for reporting the range of methods used to improve health care, recognizing that they can be complex and multidimensional. It provides common ground to share these discoveries in the scholarly literature (www.squire-statement.org).

Professor Michael Levitt (Stanford University, USA) won the 2013 Nobel Prize in Chemistry for the development of multiscale models for complex chemical systems—computational tools which can calculate the course of chemical reactions. Professor Levitt was born in Pretoria, South Africa; he came to the UK on a summer vacation aged 16, where he decided to stay and study for his A‑levels. His interest in the physics of living systems drove him to study biophysics at King’s College London, before securing a PhD position at the Laboratory of Molecular Biology in Cambridge. In the interim year between his degree and beginning his PhD, Professor Levitt worked at the Weizmann Institute of Science in Israel, where he met his future wife. They married later that year and moved to Cambridge, where their three children were born. After completing his PhD, he spent time working in Israel, Cambridge, the Salk Institute and Stanford (both California). Since 1986, he has split his time between Israel and California. Outside of science, he is a keen hiker and he is well-known to have attended the eclectic ‘Burning Man’ Festival in California. [1] Professor Levitt visited the University of Warwick to speak at the Computational Molecular Science Annual Conference in March 2015. In this interview, Dr Gemma-Louise Davies, an Institute of Advanced Study Global Research Fellow, spoke to Professor Levitt about the importance of Interdisciplinarity in his field, role models in Academia, and his plans for the future. Image: Professor Michael Levitt (left) with Dr Scott Habershon (right, organiser of the 2015 Computational Molecular Science Annual Conference) during his visit to the University of Warwick in March 2015. [1] ‘Burning Man’ is a unique annual festival dedicated to community, art, music, self-expression and self-reliance. Tens of thousands of people flock to this temporary metropolis built in the Californian desert.

Since the publication of Standards for QUality Improvement Reporting Excellence (SQUIRE 1.0) guidelines in 2008, the science of the field has advanced considerably. In this manuscript, we describe the development of SQUIRE 2.0 and its key components. We undertook the revision between 2012 and 2015 using (1) semistructured interviews and focus groups to evaluate SQUIRE 1.0 plus feedback from an international steering group, (2) two face-to-face consensus meetings to develop interim drafts and (3) pilot testing with authors and a public comment period. SQUIRE 2.0 emphasises the reporting of three key components of systematic efforts to improve the quality, value and safety of healthcare: the use of formal and informal theory in planning, implementing and evaluating improvement work; the context in which the work is done and the study of the intervention(s). SQUIRE 2.0 is intended for reporting the range of methods used to improve healthcare, recognising that they can be complex and multidimensional. It provides common ground to share these discoveries in the scholarly literature (http://www.squire-statement.org).

Background The Standards for Quality Improvement Reporting Excellence (SQUIRE) Guideline was published in 2008 (SQUIRE 1.0) and was the first publication guideline specifically designed to advance the science of healthcare improvement. Advances in the discipline of improvement prompted us to revise it. We adopted a novel approach to the revision by asking end-users to ‘road test’ a draft version of SQUIRE 2.0. The aim was to determine whether they understood and implemented the guidelines as intended by the developers. Methods Forty-four participants were assigned a manuscript section (ie, introduction, methods, results, discussion) and asked to use the draft Guidelines to guide their writing process. They indicated the text that corresponded to each SQUIRE item used and submitted it along with a confidential survey. The survey examined usability of the Guidelines using Likert-scaled questions and participants’ interpretation of key concepts in SQUIRE using open-ended questions. On the submitted text, we evaluated concordance between participants’ item usage/interpretation and the developers’ intended application. For the survey, the Likert-scaled responses were summarised using descriptive statistics and the open-ended questions were analysed by content analysis. Results Consistent with the SQUIRE Guidelines’ recommendation that not every item be included, less than one-third (n=14) of participants applied every item in their section in full. Of the 85 instances when an item was partially used or was omitted, only 7 (8.2%) of these instances were due to participants not understanding the item. Usage of Guideline items was highest for items most similar to standard scientific reporting (ie, ‘Specific aim of the improvement’ (introduction), ‘Description of the improvement’ (methods) and ‘Implications for further studies’ (discussion)) and lowest (

Thyroid cancer fulfills the criteria for overdiagnosis by having a reservoir of indolent cancers and practice patterns leading to the diagnosis of incidental cancers from the reservoir. The occurrence of overdiagnosis is also supported by population-based data showing an alarming rise in thyroid cancer incidence without change in mortality. Because one of the activities leading to overdiagnosis is the workup of incidental thyroid nodules detected on imaging, it is critical that radiologists understand the issue of overdiagnosis and their role in the problem and solution. This article addresses 1) essential thyroid cancer facts, 2) the evidence supporting overdiagnosis, 3) the role of radiology in overdiagnosis, 4) harms of overdiagnosis, and 5) steps radiologists can take to minimize the problem.

Background The Standards for Quality Improvement Reporting Excellence (SQUIRE) Guidelines were published in 2008 to increase the completeness, precision and accuracy of published reports of systematic efforts to improve the quality, value and safety of healthcare. Since that time, the field has expanded. We asked people from the field to evaluate the Guidelines, a novel approach to a first step in revision. Methods Evaluative design using focus groups and semi-structured interviews with 29 end users and an advisory group of 18 thinkers in the field. Sampling of end users was purposive to achieve variation in work setting, geographic location, area of expertise, manuscript writing experience, healthcare improvement and research experience. Results Study participants reported that SQUIRE was useful in planning a healthcare improvement project, but not as helpful during writing because of redundancies, uncertainty about what was important to include and lack of clarity in items. The concept "planning the study of the intervention" (item 10) was hard for many participants to understand. Participants varied in their interpretation of the meaning of item 10b "the concept of the mechanism by which changes were expected to occur". Participants disagreed about whether iterations of an intervention should be reported. Level of experience in writing, knowledge of the science of improvement and the evolving meaning of some terms in the field are hypothesised as the reasons for these findings. Conclusions The original SQUIRE Guidelines help with planning healthcare improvement work, but are perceived as complicated and unclear during writing. Key goals of the revision will be to clarify items where conflict was identified and outline the key components necessary for complete reporting of improvement work.

(1) Describe current epidemiology of thyroid cancer in the United States; (2) evaluate hypothesized causes of the increased incidence of thyroid cancer; and (3) suggest next steps in research and clinical action.Analysis of data from Surveillance, Epidemiology and End Results System and the National Center for Vital Statistics. Literature review of published English-language articles through December 31, 2013.The incidence of thyroid cancer has tripled over the past 30 years, whereas mortality is stable. The increase is mainly comprised of smaller tumors. These facts together suggest the major reason for the increased incidence is detection of subclinical, nonlethal disease. This has likely occurred through: health care system access, incidental detection on imaging, more frequent biopsy, greater volumes of and extent of surgery, and changes in pathology practices. Because larger-size tumors have increased in incidence also, it is possible that there is a concomitant true rise in thyroid cancer incidence. The only clearly identifiable contributor is radiation exposure, which has likely resulted in a few additional cases annually. The contribution of the following causes to the increasing incidence is unclear: iodine excess or insufficiency, diabetes and obesity, and molecular disruptions. The following mechanisms do not currently have strong evidence to support a link with the development of thyroid cancer: estrogen, dietary nitrate, and autoimmune thyroid disease.Research should focus on illuminating which thyroid cancers need treatment. Patients should be advised of the benefits as well as harms that can occur with treatment of incidentally identified, small, asymptomatic thyroid cancers.

“Emerging Nanomaterials for Healthcare”, a one-day conference held at the University of Warwick on 28 November 2014, brought together over 80 academics, postgraduates and industrialists from 17 institutions and organisations from across the UK. The aim of the meeting was to provide an interdisciplinary forum to discuss research towards solving current problems in healthcare using “smart” treatments based on nanomaterials. In addition to stories of success, an emphasis was also placed on lessons learned, as well as visions for future directions in this rapidly expanding field. Seven speakers and over twenty poster presentations directed discussion throughout the day, while the meeting closed with an interactive panel discussion.

BACKGROUND Survival rates are commonly used to measure success in treating cancer, but can be misleading. Modern diagnostic practices can lead to the appearance of improving cancer survival, as tumors are diagnosed earlier (lead-time bias) or as an increasing proportion are slow-growing (length bias), whereas the actual burden of cancer deaths is unchanged. Increasingly, more subclinical thyroid cancers are being diagnosed. The objective of the current study was to determine whether thyroid cancer survival rates have been affected by this phenomenon. METHODS The authors analyzed survival data from patients with thyroid cancer who were treated at Memorial Sloan Kettering Cancer Center (MSKCC) from 1950 to 2005, and United States population-based incidence, prevalence, and survival data from 1973 to 2009 in the Surveillance, Epidemiology, and End Results data set. RESULTS US thyroid cancer incidence has increased 3-fold from 1975 to 2009. Over time, the proportion of thyroid cancers that are subcentimeter in size has increased from 23% (1983) to 36% (2009). At MSKCC, this percentage rose from 20% (1950) to 35% (2005). The incidence rates of large tumors (>6 cm) and distant metastasis have not changed. In the United States, 10-year relative survival improved from 95.4% to 98.6% (1983-1999). At MSKCC, 10-year disease-specific survival improved from 91.1% to 96.1% (1950-2005). However, when stratified by tumor size and stage, no changes in survival outcomes were observed. US thyroid cancer mortality rates have remained stable (1975-2009). CONCLUSIONS Modern medical practices increasingly uncover small, asymptomatic thyroid cancers. Survival rates appear improved, but this finding is spurious, attributable instead to shifts in the characteristics of disease being diagnosed. Relying on survival rates to measure success in treating thyroid cancer may reinforce inappropriately aggressive management. Treatment decisions in thyroid cancer should be made based on mortality, not survival data. Cancer 2015;121:1793–1799. © 2015 American Cancer Society.

Inspired by nature's exploitation of the 1,2-dihydroxybenzene unit (or catechol) in mammalian and bacterial siderophores, we report the first example of a nanoparticle sensing system that utilises the strong catechol–Fe3+ binding motif to trigger nanoparticle aggregation, promoting a powerful optical response. Gold nanoparticles are functionalised with RAFT polymerisation-prepared water-soluble poly(N-hydroxyethyl acrylamide) containing a catechol moiety at the α-chain-end. A strong red-to-purple colorimetric response occurs in the presence of Fe3+ at serum concentrations (8–25 μM) in saline solution. Sodium chloride is critical in generating a strong optical output, as is the length of polymer used to coat the AuNPs. This behaviour is also demonstrated to be selective for Fe3+ over a host of other biologically relevant ions.

Importance Research on variation in rates of procedures across otherwise similar geographic regions provides vital insight into practice patterns. It reveals the degree of consensus on how a particular condition is managed, shows areas where access to care may be inadequate, and other areas where the population may be receiving inappropriately high levels of care. Objective To test the hypothesis that rates of thyroid surgery vary across US geographic regions Design, Setting, and Participants A cross-sectional analysis of Medicare data for 15 888 beneficiaries aged 65 years or older from 2014 was carried out. Main Outcome and Measures Overall and hospital referral region-specific thyroidectomy rate per 100 000 Medicare beneficiaries. Results In 2014, 15 888 thyroidectomies were performed on Medicare beneficiaries in the United States (partial n = 7506, total n = 8382), representing a national average rate of 60 per 100 000 beneficiaries (median, 59 per 100 000 beneficiaries; IQR, 43-70 per 100 000). A 6.2-fold difference in thyroidectomy rates was observed across US regions (range, 22-139 per 100 000 Medicare beneficiaries). Conclusions and Relevance Thyroidectomy rates in the United States vary 6.2 fold, more than prostatectomy rates, which are usually held as the example of the procedure with the widest variation in the United States. This wide variation in thyroidectomy rates observed among Medicare beneficiaries suggests widely divergent local beliefs and practice patterns surrounding the management of thyroid nodules and cancer because rates appeared to be unrelated to health care availability, regional socioeconomic status, or surgeons per capita. A better understanding for the reasons underlying this variation is needed.

Rare earth metal doped silica nanoparticles have significant advantages over traditional organic dyes and quantum dots. Silsesquioxanes are promising precursors in the production of silica nanoparticles by thermolysis, due to their structural similarities with silica materials. This manuscript describes the production of a new Eu3+-based metallasilsesquioxane species and its use as a single source precursor in the thermolytic production of luminescent rare earth metal doped silica nanoparticles with characteristic emission in the visible region of the spectrum.

Importance Overdiagnosis of cancer—the identification of cancers that are unlikely to progress—is a source of discomfort and challenge for patients, physicians, and health care systems. A major cause of this discomfort is the inability to know prospectively with certainty which cancers are overdiagnosed. In thyroid cancer, as patients have begun to understand this concept, some individuals are independently deciding not to intervene, despite this practice not yet being widely accepted. Objective To describe the current experience of people who independently self-identify as having an overdiagnosed cancer and elect not to intervene. Design, Setting, and Participants In this qualitative study, semistructured interviews were conducted between July 1 and December 31, 2015, with 22 community-dwelling adults aged 21 to 75 years who had an incidentally identified thyroid finding that was known or suspected to be malignant and who questioned the intervention recommended by their physicians. Verbatim transcripts were analyzed using constant comparative analysis. Main Outcomes and Measures The experience of individuals who self-identify as having an overdiagnosed cancer and elect not to intervene. Results Of the 22 people interviewed (16 females and 6 males; mean age, 48.5 years), 18 had elected not to intervene on their thyroid finding and had been living with the decision for a mean of 39 months (median, 40 months; range, 1-88 months). Twelve of the 18 participants reported that they experienced significant anxiety about cancer progression, but had considered reasons for choosing nonintervention: understanding issues of precision in diagnostic testing and the varied behavior of cancer, surgical risks, medication use, and low risk of death from the cancer. Twelve participants described their decisions as met with nonreassuring, unsupportive responses. Medical professionals, friends, and internet discussion groups told them they were “being stupid,” “were wrong,” or were “crazy” to not intervene. Although 14 individuals said they wished to connect with others about their experiences, only 3 reported success in doing so. Fifteen participants reported that they managed their overall experience through secret keeping. By the time of this study, 5 of the 18 individuals had discontinued surveillance, the recommended alternative to intervention. Despite this, only 7 participants “wished they did not know” about their thyroid finding. Conclusions and Relevance Isolation and anxiety characterize the current experience of patients with thyroid cancer who are living with the decision to not intervene. These patients are at risk of disengaging from health care. Successful de-escalation of intervention for patients who self-identify as having overdiagnosed cancers requires explicit social and health system support and education. We hypothesize that improved support would also promote quality of care by increasing the likelihood that patients could be kept engaged for recommended surveillance.

The incidence of thyroid cancer has dramatically increased over the past several decades, while mortality from thyroid cancer remains exceedingly low. Mortality has increased slightly in more recent years, by less than 1% per year. The simplest explanation for this pattern is an increase in the radiologic detection and pathologic reporting of identified thyroid nodules with very little change in underlying biology. A number of biologic mechanisms have been proposed but are unlikely to account for the dramatic upward trend in incidence over such a short time. Radiation exposure at a young age is an established cause of thyroid cancer, but this typically requires doses equivalent to nuclear catastrophe or radiation cancer treatment and thus is unlikely to have a significant global impact on thyroid cancer incidence. Similarly a number of behavioral and environmental factors influence TSH levels and other proposed hormonal drivers of thyroid cancer cell proliferation. Of these, an increase in obesity and a decrease in smoking may contribute to a small increase in thyroid cancer, but this will require significantly larger and more rigorous studies to formally establish.

Thermoresponsive polymers have attracted huge interest as a way of developing smart/adaptable materials for biomedicine, particularly due to changes in their solubility above the LCST. However, temperature is not always an appropriate or desirable stimulus given the variety of other cellular microenvironments that exist, including pH, redox potentials, ionic strength, and metal ion concentration. Here, we achieve a highly specific, isothermal solubility switch for poly(N-isopropylacrylamide) by application of ferric iron (Fe3+), a species implicated in a range of neurodegenerative conditions. This is achieved by the site-specific incorporation of (Fe3+-binding) catechol units onto the polymer chain-end, inspired by the mechanism by which bacterial siderophores sequester iron from mammalian hosts. The ability to manipulate the hydrophilicity of responsive systems without the need for a temperature gradient offers an exciting approach toward preparing increasingly selective, targeted polymeric materials.

For young children with autism spectrum disorder (ASD) in regular schools, ASD specific service delivery options include regular class placement with itinerant consultative support and support class placement. This study provided an examination of levels of parent, teacher and principal satisfaction with both regular class placement (n = 39) and a satellite support class option (n=35), which provides a more gradual transition into regular class. Given that regular class placement was the ultimate goal for children enrolled in the study, factors that either facilitated or acted as barriers to successful inclusion were examined for those children currently in regular classes. There were relatively high levels of parent, teacher and principal satisfaction with both satellite support class and regular class placement for children with ASD, with higher levels of parental satisfaction with satellite support placement. Across all respondents, the most frequently identified facilitating factors were related to teaching practices and skills. In contrast, barriers identified were generally related to child characteristics. A number of suggestions for future research are offered.

Purpose of review Between 1975 and 2009, the incidence of thyroid cancer has increased from 4.9 to 14.3 cases per 100 000 individuals, with a more pronounced increase in women (from 6.5 to 21.4 cases per 100 000 women). In the USA, in 2013, there are now more cases of thyroid cancer than all leukemias, pancreas and liver cancers combined. This review assesses the current evidence around the hypothesis that thyroid cancer is overdiagnosed: cancers are being detected that were never destined to cause a patient harm. Recent findings There is a large reservoir of slow or nonprogressing thyroid cancers; up to one-third of the population may unknowingly harbor a thyroid cancer. At least two activities have contributed to the detection of this reservoir of thyroid cancer: the increasing use of advanced imaging modalities in the recent years (i.e., computed tomography and MRI) and increased rates of thyroid surgery coupled with more aggressive evaluation of excised thyroid glands. Despite the increased incidence of thyroid cancer, mortality has not changed over the last 4 decades. This mismatch between incidence and mortality is most consistent with increased identification of nonlethal disease (overdiagnosis). Summary Thyroid cancer incidence is increasing, although mortality is stable. The major cause of the increased incidence is detection of subclinical disease - overdiagnosis. Patients are still treated aggressively and are exposed to side-effects of treatment without any certainty of benefit. Strategies to avoid unnecessary intervention and to explicitly involve patients in decision-making should be pursued. Research is needed to help predict which cancers are likely to become problematic.

Background— Contrast-induced acute kidney injury (CI-AKI) is associated with increased morbidity and mortality after percutaneous coronary interventions and is a patient safety objective of the National Quality Forum. However, no formal quality improvement program to prevent CI-AKI has been conducted. Therefore, we sought to determine whether a 6-year regional multicenter quality improvement intervention could reduce CI-AKI after percutaneous coronary interventions. Methods and Results— We conducted a prospective multicenter quality improvement study to prevent CI-AKI (serum creatinine increase ≥0.3 mg/dL within 48 hours or ≥50% during hospitalization) among 21 067 nonemergent patients undergoing percutaneous coronary interventions at 10 hospitals between 2007 and 2012. Six intervention hospitals participated in the quality improvement intervention. Two hospitals with significantly lower baseline rates of CI-AKI, which served as benchmark sites and were used to develop the intervention, and 2 hospitals not receiving the intervention were used as controls. Using time series analysis and multilevel poisson regression clustering to the hospital level, we calculated adjusted risk ratios for CI-AKI comparing the intervention period to baseline. Adjusted rates of CI-AKI were significantly reduced in hospitals receiving the intervention by 21% (risk ratio, 0.79; 95% confidence interval: 0.67–0.93; P =0.005) for all patients and by 28% in patients with baseline estimated glomerular filtration rate 2 (risk ratio, 0.72; 95% confidence interval: 0.56–0.91; P =0.007). Benchmark hospitals had no significant changes in CI-AKI. Key qualitative system factors associated with improvement included multidisciplinary teams, limiting contrast volume, standardized fluid orders, intravenous fluid bolus, and patient education about oral hydration. Conclusions— Simple cost-effective quality improvement interventions can prevent ≤1 in 5 CI-AKI events in patients with undergoing nonemergent percutaneous coronary interventions.

29 Background: Efforts to improve cancer care delivery have been driven by two approaches: quality improvement (QI) and implementation science (IS). QI and IS have developed independently but have potential for synergy. To inform efforts to better align these fields, we examined 20 cancer-related QI and IS articles to identify differences and areas of commonality. Methods: We searched PubMed for cancer care studies that used IS or QI methods and were published in the past 5 years in one of 17 leading journals. Through consensus-based discussions, we categorized studies as QI if they evaluated efforts to improve the quality, value, or safety of care, or IS if they evaluated efforts to promote the adoption of evidence-based interventions into practice. We identified the 10 most frequently cited studies from each category (20 total studies), characterizing and comparing their objectives, methods – including use of theoretical frameworks involvement of stakeholders – and terminology. Results: All IS studies (10/10) and half (5/10) of QI studies addressed barriers to uptake of evidence-based practices. The remaining five QI studies sought to improve clinical outcomes, reduce costs, and/or address logistical issues. QI and IS studies employed common approaches to change provider and/or organizational practice (e.g., training, performance monitoring/feedback, decision support). However, the terminology used to describe these approaches was inconsistent within and between IS and QI studies. Fewer than half (8/20) of studies (4 from each category) used a theoretical or conceptual framework and only 4/20 (2 from each category) consulted key stakeholders in developing their approach. Most studies (10/10 IS and 6/10 QI) were multi-site, and most were observational, with only 4/20 studies (2 from each category) using a randomized design to evaluate their approach. Conclusions: Cancer-related QI and IS studies had overlapping objectives and used similar approaches but used inconsistent terminology. The impact of IS and QI on cancer care delivery could be enhanced by greater harmonization of language and by promoting rigor through the use of conceptual frameworks and stakeholder input.

The toll of inadequate health care is well-substantiated, but recognition is mounting that "too much" is also possible. Overdiagnosis represents one harm of too much medicine, but the concept can be confusing: It is often conflated with related harms (such as overtreatment, misclassification, false-positive results, and overdetection) and is difficult to measure because it cannot be directly observed. Because the U.S. Preventive Services Task Force (USPSTF) issues screening recommendations aimed largely at healthy persons, it has a particular interest in understanding harms related to screening, especially but not limited to overdiagnosis. In support of the USPSTF, the authors summarize the knowledge and provide guidance on defining, estimating, and communicating overdiagnosis in cancer screening. To improve consistency, thinking, and reporting about overdiagnosis, they suggest a specific definition. The authors articulate how variation in estimates of overdiagnosis can arise, identify approaches to estimating overdiagnosis, and describe best practices for communicating the potential for harm due to overdiagnosis.

Objectives/Hypothesis Historically, histologic grade has not been considered a useful prognostic factor in head and neck squamous cell carcinoma (SCC). However, in other solid tumors, grade is known to affect prognosis. We test the hypothesis that histologic grade is an independent predictor of prognosis in oral cavity SCC. Study Design Population-based cohort study using the Surveillance, Epidemiology, and End Results (SEER) database of the National Cancer Institute. Methods Fifteen year cause-specific survival. Multivariate analysis was performed on a subset of patients diagnosed between 2004 and 2008. Results Among patients 20 to 65 years of age with American Joint Committee on Cancer (AJCC) stage I or II cancer, the adjusted risk of death is 2.7 times greater (95% CI 1.72–4.11) if the tumor is poorly differentiated or undifferentiated than it is if the tumor is well differentiated. Among patients 66 to 94 years of age, the risk of death is 3.0 (95% CI 2.02–4.54) times greater. For those over age 65, moderately differentiated tumors also confer an estimated 42% increased risk of death, but this estimate is only borderline significant (P = 0.05). Conclusions There is a strong association between histologic grade and survival in patients with AJCC stage I or II oral cavity SCC. High histologic grade in early stage oral cavity cancer is associated with poorer survival and carries independent prognostic value in addition to tumor size, node status, and presence of distant metastasis (TNM) stage. Thus, histologic grade should be considered clinically when making treatment decisions, and multivariable models of survival should include grade as a covariate to improve prognostic accuracy. Level of Evidence 2b Laryngoscope, 124:688–694, 2014

Objective/Hypothesis To report data on death or permanent disability after tonsillectomy. Study Design Electronic mail survey. Methods A 32-question survey was disseminated via the American Academy of Otolaryngology–Head and Neck Surgery electronic newsletter. Recipients were queried regarding adverse events after tonsillectomy, capturing demographic data, risk factors, and detailed descriptions. Events were classified using a hierarchical taxonomy. Results A group of 552 respondents reported 51 instances of post-tonsillectomy mortality, and four instances of anoxic brain injury. These events occurred in 38 children (71%), 15 adults (25%), and two patients of unstated age (4%). The events were classified as related to medication (22%), pulmonary/cardiorespiratory factors (20%), hemorrhage (16%), perioperative events (7%), progression of underlying disease (5%), or unexplained (31%). Of unexplained events, all but one occurred outside the hospital. One or more comorbidities were identified in 58% of patients, most often neurologic impairment (24%), obesity (18%), or cardiopulmonary compromise (15%). A preoperative diagnosis of obstructive sleep apnea was not associated with increased risk of death or anoxic brain injury. Most events (55%) occurred within the first 2 postoperative days. Otolaryngologists who reported performing

Biomedical imaging techniques can provide a vast amount of anatomical information, enabling diagnosis and the monitoring of disease and treatment profile. MRI uniquely offers convenient, non-invasive, high resolution tomographic imaging. A considerable amount of effort has been invested, across several decades, in the design of non toxic paramagnetic contrast agents capable of enhancing positive MRI signal contrast. Recently, focus has shifted towards the development of agents capable of specifically reporting on their local biochemical environment, where a switch in image contrast is triggered by a specific stimulus/biochemical variable. Such an ability would not only strengthen diagnosis but also provide unique disease-specific biochemical insight. This feature article focuses on recent progress in the development of MRI contrast switching with molecular, macromolecular and nanoparticle-based agents.

Strong bidentate ligation of a fluorinated isophthalate with a binuclear lanthanide chelate results in the paramagnetic relaxation enhancement of 19F, providing a promising route to a generation of self-assembled 19F contrast agents.

Incidentalomas are findings on an imaging test done for other reasons, for which there are no matching symptoms in the patient. They are common in the adrenal gland, pancreas, liver, and thyroid, among other sites. Incidentalomas are a problem because we have a limited understanding of their natural history: it is difficult to know how much of a threat they pose to individual patients. An observational registry that would allow a systematic study of thyroid incidentalomas could reveal their natural history and the effect of detection on patients' lives, as well as document the cost to the healthcare system. A registry would help to determine which incidentalomas could be monitored and which require action.A cohort study was conducted, with case identification via radiology imaging reports with follow-up through a minimum of one year post-identification.In one year,109,000 imaging studies were performed that might reveal an incidental thyroid finding (computed tomography scans of the neck or chest, magnetic resonance imaging of the neck, plain x-ray of the chest, non-thyroid directed ultrasound of the neck, positron emission tomography scan, or myocardial perfusion scan). A total of 125 patients were identified as having a thyroid nodule, with a1% reporting rate among eligible imaging studies, much lower than other published estimates of incidental thyroid nodule prevalence on imaging. Of the 125 nodules, 46 had been previously identified (were not "new"). Of the 79 patients with new nodules, more than half (44; 53%) were not notified of the finding. The approved study design allowed contact only with those who had been clearly notified of their thyroid nodule. Among those who could be reached, many did not recall the finding (6/15; 40%). Of those who did recall the finding, none self-identified it as an incidentaloma.There are serious logistical and ethical hurdles to developing observational registries of incidentalomas, as well as threats to data validity because incidentalomas are incompletely identified, reported, and acted upon. Solutions commonly used to optimize data quality for registries would increase reporting, but could potentially overwhelm the healthcare system and harm patients. A novel interventional design that is proposed here for future work may facilitate both study and amelioration of the problem.

Gastroenteropancreatic neuroendocrine tumours (GEP-NET) represent a heterogeneous family of diseases of often challenging clinical management. Although many GEP-NET are slow progressing and frequently less aggressive than neoplasms of other origin, they can metastasise and reduce the life span of the patient. GEP-NET can be functioning (secreting hormones that may cause symptoms and organ damage), but some 60% are non-functioning. Thorough clinical assessment including family history, biochemical tests, radiology and nuclear medicine scans, and histological confirmation are important to tailor the optimal treatment of GEP-NET, which should be managed with a multidisciplinary approach and mainly guided by tumour grading and staging, functioning status, and location of the primary lesion.

To describe time trends in total laryngectomy health services utilization across the United States, such as rates of surgery, cost, length of stay, and insurance payer, and to compare this to important milestones in recommendations for laryngeal cancer treatment.Population-based cohort study.Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (HCUP-NIS) 1997-2008: stratified sample of all US hospital discharges.All patients with the principal procedure of complete laryngectomy. The unit of analysis was the discharge.Between 1997 and 2008, the number of laryngectomies done in the United States decreased by 48%. New cases of laryngeal cancer decreased 33% during the same time. The proportion of patients older than 65 years decreased from 48% to 43%. Mortality for the procedure was 1.4% in 1997 and 1.1% in 2008. Mean length of stay over the study period increased from 13 days to 14 days. Mean hospital charges rose from $58,000 in 1997 to $109,000 in 2008, consistent with the overall rise in US health care costs. Medicare was the dominant insurer throughout. Home health was ordered in 50% of 2008 discharges but only 32% in 1997.The rate of total laryngectomy has dropped more than the incidence of laryngeal cancer has dropped, consistent with the trend toward nonsurgical treatment. Lower surgical volumes and/or salvage laryngectomy surgeries are hypothesized to play a role in longer length of stay, stable mortality rates despite younger patient age, and increased need for home services after discharge.

The use of fibre-shaped nanomaterials in commercial applications has met with concern that they could cause health effects similar to those seen with pathogenic fibres such as certain forms of asbestos. Of the attributes which form the fibre pathogenicity paradigm, fibre length is thought to be a critical factor in determining fibre toxicity. We have previously shown that carbon nanotubes display such length-dependent pathogenicity but it remains unclear if other forms of fibrous nanomaterials conform to the fibre pathogenicity paradigm. As such, our aim is to determine the generality of this hypothesis by asking whether a radically different form of fibrous nanomaterial, nickel nanowires, show length-dependent pathogenicity. Our results indicate that nickel nanowires synthesised to be predominantly long (>20 mm) show the ability to elicit strong inflammation in the mouse peritoneal model in a dose-dependent manner; inflammation or fibrosis was not seen with the short (