Jeannette Goguen

The Impact of Thyroid Cancer and Post-Surgical Radioactive Iodine Treatment on the Lives of Thyroid Cancer Survivors: A Qualitative Study

Background Adjuvant treatment with radioactive iodine (RAI) is often considered in the treatment of well-differentiated thyroid carcinoma (WDTC). We explored the recollections of thyroid cancer survivors on the diagnosis of WDTC, adjuvant radioactive iodine (RAI) treatment, and decision-making related to RAI treatment. Participants provided recommendations for healthcare providers on counseling future patients on adjuvant RAI treatment. Methods We conducted three focus group sessions, including WDTC survivors recruited from two Canadian academic hospitals. Participants had a prior history of WDTC that was completely resected at primary surgery and had been offered adjuvant RAI treatment. Open-ended questions were used to generate discussion in the groups. Saturation of major themes was achieved among the groups. Findings There were 16 participants in the study, twelve of whom were women (75%). All but one participant had received RAI treatment (94%). Participants reported that a thyroid cancer diagnosis was life-changing, resulting in feelings of fear and uncertainty. Some participants felt dismissed as not having a serious disease. Some participants reported receiving conflicting messages from healthcare providers on the appropriateness of adjuvant RAI treatment or insufficient information. If RAI-related side effects occurred, their presence was not legitimized by some healthcare providers. Conclusions The diagnosis and treatment of thyroid cancer significantly impacts the lives of survivors. Fear and uncertainty related to a cancer diagnosis, feelings of the diagnosis being dismissed as not serious, conflicting messages about adjuvant RAI treatment, and treatment-related side effects, have been raised as important concerns by thyroid cancer survivors.

Natural Health Products

Seventy-eight percent of patients with diabetes reported taking a natural health product (NHP) for various indications. Some NHPs have shown a lowering of A1C by 0.5% in trials lasting 3months in adults with type 2 diabetes, but most are single small trials so it would be premature to recommend their widespread use. Healthcare providers should always ask about the use of NHPs since some may result in side effects or drug interactions.

Impact of technique on cushing disease outcome using strict remission criteria.

BACKGROUND Cushing disease (CD) constitutes a challenging condition for the pituitary surgeon. Given the variety of factors affecting outcomes in CD, it is uncertain whether the newer endoscopic technique improves the results of surgery. METHODS A review was conducted of CD cases at our institution between 2000 and 2010. Analysis was done to: determine if surgical technique had an effect on outcome, identify the predictors of outcome and provide details of failed cases. Remission was defined as normal postoperative 24-hour urinary free cortisol (24-h UFC), suppression of morning serum cortisol to <50 nmol/L after 1mg of dexamethasone or being dependent on steroid replacement. RESULTS Forty-two patients met our inclusion criteria. Average follow-up period was 33 months. There were 15 macroadenomas and 27 microadenomas. Seventeen patients had an endoscopic transsphenoidal surgery and twenty-five patients had a microscopic transsphenoidal procedure. Long-term overall remission was achieved in 26 (62%) patients. There was no significant difference in remission rates between the two techniques (p value 0.757). Patients subjective symptomatic improvement and drop of morning serum cortisol in the postoperative period to less than 100 nmol/L correlated with long-term remission (p value 0.0031 and 0.0101, respectively) while repeat surgery was the only predictor of the lack of postoperative remission (p value 0.0008). CONCLUSIONS Revision surgery predicted poor remission rate for CD. Within the power of our study size, there was no difference in outcome between the endoscopic and microscopic approaches. Surgical outcomes should be reviewed in association with remission criteria used in a study.

Persistent posttreatment fatigue in thyroid cancer survivors: a scoping review.

The relevance of persistent posttreatment fatigue (PPF) to thyroid cancer (TC) survivor populations is not known. This article presents a scoping review, which is an overview of published research activity. Uncontrolled data suggest that PPF is one of the most common complaints in TC survivors. Furthermore, statistically significantly worse levels of fatigue were reported in TC survivors, compared with the general population or healthy controls. There was some inconsistency among PPF risk factors. More research is needed on PPF in TC survivors, including long-term prospective cohort studies, research on fatigue severity prevalence, and randomized controlled trials of treatment strategies.

Deliberate practice as a framework for evaluating feedback in residency training

Abstract Objective: Using the theory of deliberate practice, a key component of Ericsson’s theory of expertise development, this study aims to evaluate the quality of written feedback given to learners. Methods: The authors created a feedback scoring system based on the key elements of deliberate practice and used it to assess the quality of written feedback provided to residents in 205 mini-CEX encounter forms. Scores were assigned to each feedback entry for identification of the following: Task, performance gap and action plan. Results: The scoring system allowed for reliable identification of the components that facilitate deliberate practice in written feedback provided to trainees. However, only one of these components was identified in 70% of the feedback entries. A specific task was identified in 56%, whereas specific performance gaps and action plans were identified in only 3.9% and 13.7% of encounters, respectively. Conclusions: Scoring written feedback identified that tasks were often specifically described, but performance gaps and action plans were less frequently and specifically mentioned. Educators might improve feedback effectiveness by better articulating to trainees the gap between their performance and an expert standard, as well as by providing them with specific learning plans.

Epistemology, culture, justice and power: non‐bioscientific knowledge for medical training

While medical curricula were traditionally almost entirely comprised of bioscientific knowledge, widely accepted competency frameworks now make clear that physicians must be competent in far more than biomedical knowledge and technical skills. For example, of the influential CanMEDS roles, six are conceptually based in the social sciences and humanities (SSH). Educators frequently express uncertainty about what to teach in this area. This study concretely identifies the knowledge beyond bioscience needed to support the training of physicians competent in the six non‐Medical Expert CanMEDS roles.

Examining the “Killer K” of Diabetic Ketoacidosis at a Tertiary Care Hospital: An Exploratory Study

OBJECTIVES Hypokalemia, a frequently cited complication of diabetic ketoacidosis (DKA) treatment, can have critical implications, including arrhythmias and death. We assessed the prevalence of hypokalemia and its associated factors in patients with DKA at our tertiary-care centre and identified opportunities to improve care. METHODS We conducted a retrospective chart review to establish the prevalence of hypokalemia in patients diagnosed with DKA between July 2012 and July 2013. A focused root-cause analysis was subsequently performed to identify Canadian Diabetes Association DKA clinical practice guideline deviations and preventable errors that resulted in significant hypokalemia (K<3.3 mmol/L) during the first 48 hours of management. Clinical and management details were reviewed to determine the type, preventability and root cause(s) of each error. RESULTS We identified 40 cases of DKA during the study period. The overall prevalence of hypokalemia during DKA treatment was 38% (15/40), with 25% in type 1 and 56% in type 2 diabetes. Males were more likely to experience hypokalemia (87%), and 47% of hypokalemic incidents occurred in the first presentation of diabetes. All 10 cases of significant hypokalemia were reviewed. We identified 23 errors in 6 (60%) cases, of which 87% were deemed to be preventable. The most common errors were noncessation of insulin infusion during hypokalemia (60%), inadequate potassium supplementation (50%) and infrequent biochemical monitoring (50%). CONCLUSIONS Hypokalemia occurs frequently during acute DKA management and is often preventable. Our findings suggest that interventions targeted at enhancing awareness of guidelines may reduce hypokalemia rates.

Tools for Enhancement and Quality Improvement of Peer Assessment and Clinical Care in Endocrinology and Metabolism

Members of the College of Physicians and Surgeons of Ontario Endocrinology and Metabolism Peer Review Network have been involved in a quality improvement project to help standardize the peer assessment of physicians practicing in endocrinology and metabolism. This has included developing state-of-the-art summaries of common endocrine problems by Canadian experts in endocrinology and metabolism. These tools have been developed in response to the educational needs, as identified by peer reviewers, of practicing endocrinologists in Ontario. These pedagogical tools aim not only to standardize the documentation of the clinical performance of endocrinologists but also to make the process more transparent and to improve the quality of patient care in Ontario. This article summarizes the project and also provides the tools developed for the endocrinology and metabolism section of the College of Physicians and Surgeons of Ontario.

A QEye Project: Improving the Quality of Surveillance for Diabetes-related Eye Disease by Endocrinologists

decisions about their diabetes management. This study assessed differences between self-reported, estimated BG values and those measured on a BG meter. Subjects aged 18 years with type 2 diabetes (N1⁄4297) attending 1 of 2 Taking Control of Your Diabetes (TCOYD.org) conferences were asked questions about their diabetes management. 77%of subjects reported their body tells themwithout testing if their BG is lowor high, and 71%made decisions about their diabetes without testing. Study staff then performed a fingerstick to measure the BG value on a BG meter. 46% of subjects estimated BG values to be more than 15 mg/dL (0.83 mmol/L) or 20% of meter glucose values <75 and 75 mg/dL (4.2 mmol/L), respectively (current ISO accuracy criteria); 58% estimated BG values to be more than 15 mg/dL (0.83 mmol/L) or 15% of meter values <100 and 100mg/dL (5.6 mmol/L), respectively (proposed new ISO criteria). The percentage of inaccurate BG estimates across various glucose ranges is shown (Figure). Timesince last BG test, time since lastmeal, testing frequency, and A1c ( 12%) had no effect on the results. After BG testing, nearly all (99%) indicated that knowing their BG by checking with a BG meter could help them make different diabetes decisions. These findings suggest the importance of BG testing versus estimation of BG values to help people with diabetes make informed decisions for effective diabetes management.