Erin Grady

Defining scholarly activity in graduate medical education.

BACKGROUND Scholarly activity is a requirement for accreditation by the Accreditation Council for Graduate Medical Education. There is currently no uniform definition used by all Residency Review Committees (RRCs). A total of 6 of the 27 RRCs currently have a rubric or draft of a rubric to evaluate scholarly activity. OBJECTIVE To develop a definition of scholarly activity and a set of rubrics to be used in program accreditation to reduce subjectivity of the evaluation of scholarly activity at the level of individual residency programs and across RRCs. METHODS We performed a review of the pertinent literature and selected faculty promotion criteria across the United States to develop a structure for a proposed rubric of scholarly activity, drawing on work on scholarship by experts to create a definition of scholarly activity and rubrics for its assessment. RESULTS The literature review showed that academic institutions in the United States place emphasis on all 4 major components of Boyers definition of scholarship: discovery, integration, application, and teaching. We feel that the assessment of scholarly activity should mirror these findings as set forth in our proposed rubric. Our proposed rubric is intended to ensure a more objective evaluation of these components of scholarship in accreditation reviews, and to address both expectations for scholarly pursuits for core teaching faculty and those for resident and fellow physicians. CONCLUSION The aim of our proposed rubric is to ensure a more objective evaluation of these components of scholarship in accreditation reviews, and to address expectations for scholarly pursuits for core teaching faculty as well as those for resident and fellow physicians.

Efficacy of thyroid blockade on thyroid radioiodine uptake in 123I-mIBG imaging.

Although iodinated radiopharmaceuticals usually contain a small quantity of unbound iodine, it is difficult to establish the degree to which thyroid activity on scintigraphic images reflects uptake of free radioiodine. The objective of the present study was to examine the effectiveness of thyroid blockade in subjects undergoing 123I-meta-iodobenzylguanidine (mIBG) imaging and to estimate the relative contribution of bound and unbound radioiodine to imaging findings. Methods: All subjects were participants in prospective trials of 123I-mIBG cardiac imaging in which pretreatment with thyroid blockade was optional unless locally required. In a pilot project, 15 subjects (6 blocked) had thyroid uptake measured at 4 h using a probe system. Fifteen-minute (early) and 4-h (late) anterior planar chest images that included the thyroid region were visually scored for thyroid uptake (scale of 0–4) in another group of 152 subjects (98 blocked). Quantitative analysis based on thyroid regions of interest was performed on anterior planar images from a further sample of 669 subjects (442 blocked). For all 3 investigations, quantitative comparisons of thyroid uptake were made between the blocked and nonblocked subjects. Results: There was no statistical difference between probe uptake of the 6 blocked and 9 nonblocked subjects. However, in the second series, mean visual score on the late images was significantly lower for blocked than nonblocked subjects (P < 0.001). In the region-of-interest analyses, net thyroid counts were significantly higher on the late images of nonblocked subjects (P < 0.0001), and compared with early images, 87% of subjects who received blockade showed decreased or unchanged counts whereas 75% of nonblocked subjects had increased net thyroid activity. In nonblocked subjects, an estimated 79% of thyroid counts on late images could be attributed to unbound 123I. Conclusion: On the basis of 3 different methods for assessing thyroid uptake of 123I, use of thyroid blockade pretreatment in 123I-mIBG imaging prevents increase of thyroid activity over time because of uptake of unbound 123I. In most subjects, there is a low level of 123I-mIBG thyroid activity that probably represents specific uptake in sympathetic nerve terminals.

Utility of Diagnostic Whole-Body Iodine Scanning in High-Risk Differentiated Thyroid Carcinoma

TO THE EDITOR: de Meer et al. recently published a retrospective study comparing diagnostic whole-body scintigraphy (DxWBS) to stimulated thyroglobulin measurement in patients with high-risk differentiated thyroid cancer (1). The authors concluded that DxWBS offered no additional information compared with recombinant human thyroid-stimulating hormone (rhTSH)–stimulated thyroglobulin levels for this cohort of patients. We would argue that shortcomings in the study design and DxWBS methodology invalidate the authors’ conclusion. The authors defined high-risk patients as those with either T3 or T4 tumors or cervical lymph node metastases (N1) based on American Joint Committee on Cancer (AJCC) TNM version 7 (2). Interestingly, they chose to exclude all patients with distant metastases (M1). However, the authors’ high-risk definition is inconsistent with both American and European guidelines, which include patients with M1 disease in their definitions of high-risk patients (3,4). Moreover, the inclusion and exclusion criteria may have been stated incorrectly: we were surprised to see AJCC TNM stage II patients listed in Table 1 of the article. AJCC TNM stage II is defined as either M1 disease in patients less than 45 y old or T2N0M0 for patients more than 45 y old. Since both of these subsets of patients were purportedly excluded, stage II patients should not have appeared in the group analyzed. This inconsistency warrants explanation or correction. The authors did not take into account age when risk stratifying their patients since European treatment guidelines are independent of age. However, age is considered the most important prognostic variable for mortality by the American National Comprehensive Cancer Network guidelines, with higher mortality in patients over 40 y old (5). For papillary and follicular thyroid carcinoma, AJCC TNM staging defines all patients less than 45 y old as either stage I or stage II, including patients with distant metastases. In a study validating AJCC TNM classification and group staging for patients with papillary thyroid carcinoma, age was an independent predictor of both disease-free survival and cause-specific survival (6). Not using the age for risk stratification in such a study renders the results irrelevant to nuclear medicine practices in the United States. In their study, the authors performed DxWBS with thyroid hormone withdrawal (THW) between January 1998 and December 2004 and then switched to rhTSH exclusively from January 2005 to January 2009. However, the original phase III clinical trial comparing rhTSH and THW preparation for DxWBS concluded that rhTSH DxWBS was less sensitive than DxWBS using THW (7). In this phase III trial, rhTSH DxWBS was inferior to THW DxWBS in 18 (29%) of 62 patients and failed to detect metastatic disease in 8 (13%) of 62 patients with positive scans. A second phase III clinical trial, again comparing rhTSH and THW preparation for DxWBS, also showed that rhTSH DxWBS was inferior to THW DxWBS in 8 (16%) of 49 of patients with metastatic disease (8). Although this difference was not statistically significant (p 5 0.109), the trend favored THW DxWBS. As a result, we believe that rhTSH DxWBS should be reserved for low-risk patients only, an approach supported by the package insert for rhTSH itself. Moreover, the authors waited 7 d after 131I administration to perform the DxWBS (European guidelines recommend between 2 and 5 d) and used twice the recommended 131I activity; these factors make their technique impossible to compare with standard practices. Relying on rhTSH-stimulated thyroglobulin for detection of recurrence has its perils. Comparing 131I rhTSH-stimulated DxWBS to thyroglobulin during routine follow-up evaluations, Robbins et al. found metastatic thyroid carcinoma on DxWBS in 13.7% of patients of all risk categories with stimulated thyroglobulin of 2 mg/L or less (9). The authors of the present paper mentioned the conclusion of Robbins et al. but left a huge gap in the discussion by offering no explanation as to why their own results and conclusions were so different from those of Robbins et al. Only the DxWBS can show iodine avidity and guide the decision on whether to treat the patients with 131I or with surgery. In the United States, DxWBS remains the gatekeeper to more advanced imaging with 18F-FDG PET, as most insurance companies require both elevated thyroglobulin levels and negative DxWBS findings to reimburse PET. Omitting the DxWBS would make 18F-FDG PET unavailable to patients in the United States. The deMeer et al. study addressed a very narrow segment of high-risk thyroid carcinoma patients, did not follow accepted risk stratification guidelines, and does not help many of us who use age in this stratification. The striking deficiencies of this work are the application of rhTSH-stimulated DxWBS to a high-risk group in which it is considered to be inferior to THW DxWBS, the use of nonstandard imaging techniques, and the notion that disease location and iodine avidity are irrelevant to patient management. The readers are encouraged to keep these issues in mind as they evaluate high-risk thyroid cancer patients.