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Background/Objectives: Molecular testing is most commonly performed in evaluation of thyroid nodules with indeterminate Fine Needle Aspiration Biopsy (FNAB) results. However, in clinical practice, thyroidectomy may still be pursued in patients who present with clear clinical indications despite a benign molecular test result. The aim of this study is to identify clinical factors that influence the decision to proceed with surgery in the presence of a benign molecular test result. Methods: Patients who were evaluated in the outpatient clinic for thyroid nodules at one institution between January 2016 and January 2024 were retrospectively reviewed. Patients with FNAB results corresponding to Bethesda categories III or IV and a benign result on the Afirma molecular test were included. Demographic data, medical and family history, characteristics of thyroid nodules (including ultrasonographic features), surgical history, and postoperative pathology results were analyzed. Patients were divided into two groups based on clinical management—Observation (Group-1) or Thyroidectomy (Group-2)—and compared using Chi-square tests for bivariate analysis and multivariable logistic regression. Results: A total of 177 patients were included, with 87 (49.1%) in the observation group and 90 (50.9%) in the surgical group. Mean age was 55.9 ± 13.9 years and median nodule size (IQR) was 2.8 cm (1.95–4.0 cm). Bivariate analysis revealed the surgical group had significantly higher proportions of patients with compressive symptoms (p < 0.001), hyperthyroidism (p = 0.01), nodules >4 cm (p < 0.001) and documented nodule growth during follow-up (p < 0.001). Multivariate logistic regression identified the following factors as independently associated with the decision to proceed with surgery: compressive symptoms (OR: 23.2; 95%CI: 6.06–88.89; p < 0.001), hyperthyroidism (OR: 5.87; 95%CI: 1.63–21.20; p = 0.007), nodule size >4 cm (OR: 11.36; 95%CI: 3.90–33.12; p < 0.001), and increasing nodule size during follow-up (OR: 7.85; 95%CI: 2.72–22.65; p < 0.001). Conclusions: Despite a benign molecular test result, patients exhibiting compressive symptoms, hyperthyroidism, nodules larger than 4 cm, or evidence of nodule growth during follow-up are significantly more likely to undergo thyroidectomy. In such cases, molecular testing may offer limited clinical utility and could be omitted to optimize cost-effectiveness.

This study highlights the implications of surgical disparities on health care spending. The strengths of this study include pinning down the potential etiologies of how surgical disparities contribute to excessive spending. Prior studies have focused primarily on individual social factors, yet this study takes into consideration the financial implications of disparities from multiple levels.6 Black patients face more challenges in cancer care in part due to late stage presentation and diagnosis, as well as increased exposure to risk factors that place them under a disproportionate burden of disease and risk of post-operative complications.7 We commend the authors for broaching this rarely discussed and costly combination of minority race and dual eligibility contributing to a “multiple hit” phenomenon that our most vulnerable patients face.

Normocalcemic primary hyperparathyroidism (NPHPT), a variant of primary hyperparathyroidism (PHPT) characterized by persistently elevated parathyroid hormone (PTH) levels and normal serum calcium, has gained recognition as a substantial subset of PHPT cases. Despite its increasing prevalence, the precise pathophysiology and natural progression of NPHPT remain enigmatic. This in-depth literature review explores recent advancements in our understanding of NPHPT, encompassing pathophysiology, clinical presentation, diagnostic approaches, medical and surgical management options. By synthesizing this wealth of information, this review aims to contribute to a more nuanced and informed approach to the treatment of patients grappling with NPHPT. As our understanding of the condition continues to evolve, the knowledge gathered from this review has the potential to significantly enhance the quality of care and outcomes for individuals afflicted with NPHPT, ultimately improving their overall well-being and prognosis. •Normocalcaemic Primary Hyperparathyroidism (NPHPT) is a Distinct Clinical Entity.•Comprehensive Review of Diagnostic Criteria and Challenges.•Outlines Therapeutic Efficacy and Decision-making.

Abstract Context There are differences in diagnosis, treatment, and outcomes for thyroid between racial and ethnic groups that contribute to disparities. Identifying these differences and their causes are the key to understanding and reducing disparities in presentation and outcomes in endocrine disorders. Evidence Acquisition The present study reviews original studies identifying and exploring differences between benign and malignant thyroid diseases. A PubMed, Web of Science, and Scopus search was conducted for English-language studies using the terms “thyroid,” “thyroid disease,” “thyroid cancer,” “race,” “ethnicity,” and “disparities” from inception to December 31, 2022. Evidence Synthesis Many racial and ethnic disparities in the diagnosis, presentation, treatment, and outcomes of thyroid disease were found. Non-White patients are more likely to have a later time to referral, to present with more advanced disease, to have more aggressive forms of thyroid cancer, and are less likely to receive the appropriate treatment than White patients. Overall and disease-specific survival rates are lower in Black and Hispanic populations when compared to White patients. Conclusions Extensive disparities exist in thyroid disease diagnosis, treatment, and outcomes that may have been overlooked. Further work is needed to identify the causes of these disparities to begin to work toward equity in the care of thyroid disease.

Primary hyperparathyroidism (HPT) is typically characterized by elevated parathyroid hormone (PTH) and hypercalcemia; however, some patients develop normocalcemic hyperparathyroidism. Patients with normocalcemic HPT have an elevated PTH with normal calcium levels and no other secondary causes of elevated PTH, and therefore have a unique biochemical profile. The aim of this project is to compare the demographics, presentation, and outcomes for patients with normocalcemic HPT versus patients with hypercalcemic HPT undergoing parathyroidectomy. A single institution, retrospective review was conducted between January 2016 and June 2022. Patients were classified as either having hypercalcemic (calcium >10.4 ​mg/dL) or normocalcemic (calcium ≤10.4 ​mg/dL) HPT. Cure was defined as normal calcium for 6 months post-operatively in the hypercalcemic HPT group and normal PTH (<88 ​pg/mL) for 6 months post-operatively in the normocalcemic HPT group. Of the 701 patients included in the study, 566 (80.7 ​%) had hypercalcemic HPT and 135 (19.3 ​%) had normocalcemic HPT. The preoperative Ca was 11 ​± ​0.7 ​mg/dL in the hypercalcemic group and 9.8 ​± ​0.4 ​mg/dL in the normocalcemic group (p ​< ​0.001). The preoperative PTH was 148.2 ​± ​180 ​pg/dL in the hypercalcemic group and 117.4 ​± ​105.3 ​pg/dL in the normocalcemic group (p ​= ​0.06). The average age of normocalcemic patients was 56 ​± ​15 years, compared to 59 ​± ​15 years in the hypercalcemic group (p ​= ​0.07). There was no significant difference in sex (p ​= ​0.42). African American patients were more likely to present with hypercalcemic HPT (19.1 ​%) than with normocalcemic HPT (9.6 ​%, p ​= ​0.01). Normocalcemic patients were more likely to report pre-operative symptoms of kidney stones compared to patients with hypercalcemia (53.3 ​% versus 30.4 ​%, p ​< ​0.001). There was no significant difference in pre-operative symptoms of fatigue, bone pain, or fractures. Patients with hypercalcemic HPT were more likely to present with adenoma (64.3 ​%); whereas patients with normocalcemic HPT were more likely to present with hyperplasia (43.3 ​%, p ​< ​0.001). More patients with normocalcemic HPT underwent thymectomy compared to patients with hypercalcemia (39.3 ​% versus 20.8 ​% respectively, p ​< ​0.001). 92.0 ​% of normocalcemic patients achieved cure post-operatively, which was significantly less than in the hypercalcemic group (97.0 ​%, p ​= ​0.02). The 8.0 ​% of normocalcemic patients that did not achieve cure had a mean PTH level of 147.9 ​± ​159 ​pg/mL at 6 months post-operative. Four patients with normocalcemic HPT had recurrence of disease (3 ​%), and three of the four patients underwent bilateral exploration. Patients with normocalcemic HPT present with different symptoms compared to patients with hypercalcemic HPT prior to surgery. Additionally, patients with normocalcemic HPT are less likely to achieve cure after surgery, which warrants further investigation. •Hyperparathyroidism.•Normocalcemic hyperparathyroidism.•Mild hyperparathyroidism.•Endocrine surgery.

Primary hyperparathyroidism (PHPT) can be cured through surgery, but referral for treatment is often provider dependent. A conjoint analysis was performed to identify factors influencing referral for surgery. Online survey assessed endocrinologists and other physicians who reviewed 10 patient scenarios. They decided whether to refer for surgery or medical management based on clinical (age, comorbidities, etc) and biochemical factors (mild or classic disease). Classic PHPT, age below 50, absence of comorbidities, presence of osteoporosis, and seeing a surgical provider significantly increased the likelihood of surgery referral (p < 0.001). Physician characteristics such as gender, practice duration, and setting did not have a significant influence. Despite published benefits of surgery, non-surgical physicians were less likely to refer PHPT patients for surgical treatment if patients were older (age ≥ 50), had comorbid conditions, or had mild disease. More education and advocacy are needed for improved access to surgery. •Factors impacting surgery referral in PHPT determined via conjoint analysis.•Age, comorbidities, disease severity impact likelihood of surgical referral for PHPT patients.•Classic PHPT, age <50, no comorbidities, osteoporosis increase odds of surgery referral.•Physician traits like gender, experience, and setting have no impact on referral choices.•Advocacy for surgery access in older, comorbid, mild PHPT patients by medical providers.