BACKGROUND:The incidence of injury among older adults is rising in the United States, yet long-term outcomes after injury and their relationship to social health needs remain undescribed at a national level. The purpose of this study was to evaluate long-term physical, mental, financial, and social health outcomes among injured older adults, using matched controls. METHODS:We conducted a retrospective analysis of the nationally representative Health and Retirement Study linked with inpatient Medicare claims. Our cohort included individuals aged 65 and older who were admitted for injury from 1998 to 2018. Changes following injury were assessed using a difference-in-differences analysis using pre-/postinjury data in the Health and Retirement Study. RESULTS:We identified 1,754 injured patients and 3,244 non-injured controls. Injured patients required greater assistance with activities of daily living (mean difference: 1.1; P < .001), had higher odds of poor/fair self-rated health (odds ratio [OR], 1.7; 95% CI, 1.1-2.6), depression (OR, 1.5; 95% CI, 1.2-1.8), and cognitive impairment (OR, 1.2; 95% CI, 1.0-1.5). Injury was associated with greater odds of having unmet social health needs (OR, 1.7; 95% CI: 1.5-2.0). Among injured patients, those with preinjury unmet social health needs reported greater increases in outpatient visits (3.8 visits; 95% CI, 1.3-6.7), higher odds of poor/fair self-rated health (OR, 1.3; 95% CI 1.1-1.5) and cognitive impairment (OR, 1.4; 95% CI 1.2-1.8), and increased financial hardship compared with injured patients without unmet social health needs. CONCLUSIONS:Injury has enduring consequences on the physical, mental, financial, and social health of older patients Older adults with pre-existing unmet SHNs are particularly vulnerable to poor postinjury long-term outcomes.

BackgroundCancer diagnosis causes emotional distress, which can influence patients' treatment choice. This study aimed to investigate the effect of increased emotionally supportive surgeon communication in a virtual setting on treatment preference for thyroid cancer.DesignThis randomized trial (NCT05132478), conducted from November 2021 to February 2023, enrolled adults with ≤4-cm thyroid nodules not requiring surgery. Participants were randomized 1:1 to watch a virtual clinic visit depicting a patient-surgeon treatment discussion for low-risk thyroid cancer. Control and intervention videos were identical except for added emotionally supportive communication in the intervention. The primary outcome was treatment preference for total thyroidectomy or lobectomy. Secondary outcomes were perceived physician empathy, physician trust, decisional confidence, and disease-specific knowledge. An intention-to-treat analysis was performed using conditional regression to account for stratification by sex. Qualitative content analysis evaluated participants' open-ended responses about treatment choice and surgeon communication.ResultsOf 208 eligible patients, 118 (56.7%) participated. Participants were 85.6% female and 88.1% White. Overall, 89.0% (n = 105) of participants preferred lobectomy, which was similar between the intervention and control groups (90.0% v. 87.9%, respectively, P = 0.72). Compared with control, participants who viewed the consultation with enhanced communication perceived higher levels of physician empathy (34.5 ± 5.8 v. 25.9 ± 9.1, P < 0.001) and reported increased trust in the physician (12.0 ± 2.6 v. 10.4 ± 3.1, P < 0.001). The groups were similar in decisional confidence (7.6 ± 2.1 v. 7.7 ± 1.9, P = 0.74) and disease-specific knowledge. Prominent qualitative themes among participants choosing thyroid lobectomy included desire to avoid daily thyroid hormone (n = 53) and concerns about surgical complications (n = 25).ConclusionsIn this randomized controlled study, a significant proportion of participants preferred thyroid lobectomy if diagnosed with low-risk thyroid cancer. Participants perceived increased empathy when provided even in the virtual setting, which was associated with increased trust in the physician.HighlightsIn this single-site, randomized controlled trial, enhanced emotionally supportive surgeon communication had no effect on hypothetical treatment preference for low-risk thyroid cancer.Participants who experienced enhanced emotionally supportive surgeon communication perceived higher physician empathy and reported greater trust in the physician.The incorporation of empathetic communication during surgical consultation for low-risk thyroid cancer promotes patient trust and perception of empathy.

CONTEXT:Little is known about how patients' emotions impact the choice between hemi- and total thyroidectomy (TT) for low-risk thyroid cancer (LR-TC) and how these emotions change after treatment. OBJECTIVE:To investigate thyroid cancer-specific fear and worry both before and after treatment of LR-TC with hemi- or TT. METHODS:This prospective cohort study enrolled adults with confirmed or likely LR-TC at 15 institutions. Participants completed measures of thyroid cancer-related fear and worry at the time of their treatment decision and 9 months later. Participants were categorized as having low, medium, or high levels of fear and worry in accordance with the literature. Those choosing hemithyroidectomy were compared to those choosing TT. RESULTS:Of 177 eligible patients, 125 (70.6%) enrolled and 114 completed both surveys (91.2% retention). Overall, 41 (36.0%) participants chose hemithyroidectomy and 73 (64.0%) chose TT. Across all participants, thyroid cancer-related fear and worry both decreased significantly after surgery (fear, 25.8 ± 6.4 to 23.1 ± 7.4; worry, 8.2 ± 2.4 to 5.4 ± 2.1, P < .001). The proportion of participants with high fear decreased from 64.9% to 50.9%, whereas the proportion with high worry decreased from 75.4% to 41.2% (P < .001 for both). At both time points, no differences existed between those choosing hemi- and TT in levels of worry or fear. CONCLUSION:Patients with LR-TC report lower levels of fear and worry 9 months after surgery regardless of the extent of surgery, suggesting that both surgeries provide an emotional benefit to some patients. Thyroid cancer-related fear and worry do not appear to influence patients' decisions to undergo hemi- or TT.

Sentinel lymph node biopsy (SLNB) is feasible in women with clinically node-positive breast cancer following neoadjuvant chemotherapy and a nodal pathologic complete response. Acceptable false negative rates are achieved through technical considerations such as removing three or more sentinel lymph nodes (SLNs); however, the variation that exists in adherence to this technique is unclear. This study aimed to evaluate recent trends in axillary surgery in women with cN1-cN2 disease who received neoadjuvant chemotherapy, adherence to removing three or more SLNs, and variation in SLN yield. We performed a cohort study using the National Cancer Database of women aged ≥18 years with cN1-cN2 disease who received neoadjuvant chemotherapy, including those without a pathologic complete response, from 2012 to 2020. Trends in axillary surgery and lymph node yield obtained during SLNB were evaluated. The cohort included 67,365 women (median age 54 years). The number of patients receiving SLNB alone increased from 14 to 39

INTRODUCTION:Thyroid cancer diagnosis often evokes strong negative emotions in patients, yet little is understood about such responses in those with benign thyroid nodules. This study explored the impact of a hypothetical cancer diagnosis, the provision of treatment information, and emotional support from surgeons on patients with benign nodules. METHODS:Patients within 30 d of a thyroid nodule biopsy were asked to imagine their nodule was cancerous and write down their feelings about this diagnosis. They then viewed a video depicting a patient-surgeon discussion of thyroid cancer treatment options, with or without added emotional support (1:1 randomized allocation). Validated measures assessed anxiety and thyroid cancer-related fear before and after video-viewing. Thematic analysis evaluated participants' feelings about the hypothetical diagnosis. RESULTS:Of 221 eligible patients, 118 participated (53.4%). While participants state anxiety increased after performing the thought exercise and watching the video (9 [6, 11]-12 [8, 14]; P < 0.001), thyroid cancer-related fear decreased over the same period (27 [22, 30]-25 [20, 29]; P < 0.001). Emotional support by the surgeon in the video did not affect anxiety or fear. Themes that emerged from participants imagining they have thyroid cancer included information seeking, trust in medicine, cancer experience, thyroid cancer knowledge, apprehension about surgery, and impact on family. CONCLUSIONS:Patients with recently diagnosed benign thyroid nodules experience heightened anxiety when contemplating thyroid cancer. Provision of treatment and disease information mitigates cancer-related fear, while emotional support does not. Offering patients with thyroid nodules information about thyroid cancer before biopsy may offer emotional benefits.

Importance The implications of new-onset depressive symptoms during residency, particularly for first-year physicians (ie, interns), on the long-term mental health of physicians are unknown. Objective To examine the association between and persistence of new-onset and long-term depressive symptoms among interns. Design, Setting, and Participants The ongoing Intern Health Study (IHS) is a prospective annual cohort study that assesses the mental health of incoming US-based resident physicians. The IHS began in 2007, and a total of 105 residency programs have been represented in this national study. Interns enrolled sequentially in annual cohorts and completed follow-up surveys to screen for depression using the 9-item Patient Health Questionnaire-9 (PHQ-9) throughout and after medical training. The data were analyzed from May 2023 to March 2024. Exposure A positive screening result for depression, defined as an elevated PHQ-9 score of 10 or greater (indicating moderate to severe depression) at 1 or more time points during the first postgraduate year of medical training (ie, the intern year). Main Outcomes and MeasuresThe main outcomes assessed were mean PHQ-9 scores (continuous) and proportions of physicians with an elevated PHQ-9 score (>= 10; categorical or binary) at the time of the annual follow-up survey. To account for repeated measures over time, a linear mixed model was used to analyze mean PHQ-9 scores and a generalized estimating equation (GEE) was used to analyze the binary indicator for a PHQ-9 score of 10 or greater. Results This study included 858 physicians with a PHQ-9 score of less than 10 before the start of their internship. Their mean (SD) age was 27.4 (9.0) years, and more than half (53.0% [95% CI, 48.5%-57.5%]) were women. Over the follow-up period, mean PHQ-9 scores did not return to the baseline level assessed before the start of the internship in either group (those with a positive depression screen as interns and those without). Among interns who screened positive for depression (PHQ-9 score >= 10) during their internship, mean PHQ-9 scores were significantly higher at both 5 years (4.7 [95% CI, 4.4-5.0] vs 2.8 [95% CI, 2.5-3.0]; P < .001) and 10 years (5.1 [95% CI, 4.5-5.7] vs 3.5 [95% CI, 3.0-4.0]; P < .001) of follow-up. Furthermore, interns with an elevated PHQ-9 score (>= 10) demonstrated a higher likelihood of meeting this threshold during each year of follow-up. Conclusions and Relevance In this cohort study of IHS participants, a positive depression screening result during the intern year had long-term implications for physicians, including having persistently higher mean PHQ-9 scores and a higher likelihood of meeting this threshold again. These findings underscore the pressing need to address the mental health of physicians who experience depressive symptoms during their training and to emphasize the importance of interventions to sustain the health of physicians throughout their careers.

OBJECTIVE:To evaluate the relative importance of treatment outcomes to patients with low-risk thyroid cancer (TC). BACKGROUND:Overuse of total thyroidectomy (TT) for low-risk TC is common. Emotions from a cancer diagnosis may lead patients to choose TT, resulting in outcomes that do not align with their preferences. METHODS:Adults with clinically low-risk TC enrolled in a prospective, multi-institutional, longitudinal cohort study from November 2019 to June 2021. Participants rated treatment outcomes at the time of their surgical decision and again 9 months later by allocating 100 points among 10 outcomes. t tests and Hotelling T 2 statistic compared outcome valuation within and between subjects based on chosen extent of surgery (TT vs lobectomy). RESULTS:Of 177 eligible patients, 125 participated (70.6% response) and 114 completed the 9-month follow-up (91.2% retention). At the time of the treatment decision, patients choosing TT valued the risk of recurrence more than those choosing lobectomy and the need to take thyroid hormone less ( P <0.05). At repeat valuation, all patients assigned fewer points to cancer being removed and the impact of treatment on their voice and more points to energy levels ( P <0.05). The importance of the risk of recurrence increased for those who chose lobectomy and decreased for those choosing TT ( P <0.05). CONCLUSIONS:The relative importance of treatment outcomes changes for patients with low-risk TC once the outcome has been experienced to favor quality of life over emotion-related outcomes. Surgeons can use this information to discuss the potential for asthenia or changes in energy levels associated with total thyroidectomy.

IMPORTANCE The American College of Surgeons (ACS) operative standards were established to detail critical elements of cancer surgery, reduce technical variation, and improve outcomes. Two of the 6 operative standards target adequate axillary surgery for breast cancer. The potential association of the operative standards with short-term oncologic outcomes, such as nodal yield and nodal positivity rates, is currently unknown. OBJECTIVE To evaluate the potential association of the ACS operative standards with short-term oncologic outcomes in breast cancer. DESIGN, SETTING, AND PARTICIPANTS A cohort study was performed using data on 1201317 women 18 years or older who underwent sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND) for invasive breast cancer from January 1, 2012, to December 31, 2020. Patients were identified using the National Cancer Database (NCDB), a clinical oncology database encompassing approximately 70% of new cancer diagnoses, sourced from hospital registry data from 1317 facilities. Statistical analysis was performed from October 2023 to June 2024. EXPOSURE Sentinel lymph node biopsy or ALND. MAIN OUTCOMES AND MEASURES Reliability-adjusted facility-level lymph node yield and nodal positivity rate for each procedure were calculated using generalized linear mixed models, Poisson regression, and logistic regression with facility-level random intercepts. RESULTS The cohort included 1201317 women with a median age of 62 years (IQR, 53-70 years). Facility-level nodal yield ranged from 1 to 6 for SLNB and from 6 to 22 for ALND. Median facility-level nodal yield for SLNB was 2.6 (IQR, 2.3-3.0) and the nodal positivity rate for SLNB was 12.2% (IQR, 11.0%-13.7%), with rates ranging from 6% to 21%. A weak correlation between facility-level lymph node yield and nodal positivity was observed (Spearman correlation coefficient, 0.17). Median nodal upstaging rate (>= 4 positive nodes) for ALND was 30.5% (IQR, 26.5%-35.0%), with rates ranging from 11% to 54%; median nodal yield was 12.2 (IQR, 10.9-13.6). A strong correlation between nodal yield and nodal upstaging rates was observed (Spearman correlation coefficient, 0.53). CONCLUSIONS AND RELEVANCE In this cohort study of women undergoing axillary surgery for invasive breast cancer, facility-level variation in lymph node yield was present for both SLNB and ALND, which could potentially be improved through the ACS operative standards. However, this variation had mixed associations with nodal positivity and upstaging rates, suggesting the association of the ACS operative standards with oncologic outcomes may be mixed.

This study examines how racialization processes (conceptualized as multilevel and dynamic processes) shape prenatal mental health by testing the association of discrimination and the John Henryism hypothesis on depressive symptoms for pregnant Mexican-origin immigrant women. We analyzed baseline data (n = 218) from a healthy lifestyle intervention for pregnant Latinas in Detroit, Michigan. Using separate multiple linear regression models, we examined the independent and joint associations of discrimination and John Henryism with depressive symptoms and effect modification by socioeconomic position. Discrimination was positively associated with depressive symptoms (β = 2.84; p < .001) when adjusting for covariates. This association did not vary by socioeconomic position. Women primarily attributed discrimination to language use, racial background, and nativity. We did not find support for the John Henryism hypothesis, meaning that the hypothesized association between John Henryism and depressive symptoms did not vary by socioeconomic position. Examinations of joint associations of discrimination and John Henryism on depressive symptoms indicate a positive association between discrimination and depressive symptoms (β = 2.81; p < .001) and no association of John Henryism and depressive symptoms (β = -0.83; p > .05). Results suggest complex pathways by which racialization processes affect health and highlight the importance of considering experiences of race, class, and gender within racialization processes.

Objective: To evaluate the relative importance of treatment outcomes to patients with low-risk thyroid cancer (TC). Summary Background Data: Overuse of total thyroidectomy (TT) for low-risk TC is common. Emotions from a cancer diagnosis may lead patients to choose TT resulting in outcomes that do not align with their preferences. Methods: Adults with clinically low-risk TC enrolled in a prospective, multi-institutional, longitudinal cohort study from 11/2019-6/2021. Participants rated treatment outcomes at the time of their surgical decision and again 9 months later by allocating 100 points amongst 10 outcomes. T-tests and Hotelling’s T 2 statistic compared outcome valuation within and between subjects based on chosen extent of surgery (TT vs. lobectomy). Results: Of 177 eligible patients, 125 participated (70.6% response) and 114 completed the 9-month follow-up (91.2% retention). At the time of the treatment decision, patients choosing TT valued the risk of recurrence more than those choosing lobectomy and the need to take thyroid hormone less ( P <0.05). At repeat valuation, all patients assigned fewer points to cancer being removed and the impact of treatment on their voice, and more points to energy levels ( P <0.05). The importance of the risk of recurrence increased for those who chose lobectomy and decreased for those choosing TT ( P <0.05). Conclusion: The relative importance of treatment outcomes changes for patients with low-risk TC once the outcome has been experienced to favor quality of life over emotion-related outcomes. Surgeons can use this information to discuss the potential for asthenia or changes in energy levels associated with total thyroidectomy.

Objective: To evaluate the relative importance of treatment outcomes to patients with low-risk thyroid cancer (TC). Summary Background Data: Overuse of total thyroidectomy (TT) for low-risk TC is common. Emotions from a cancer diagnosis may lead patients to choose TT resulting in outcomes that do not align with their preferences. Methods: Adults with clinically low-risk TC enrolled in a prospective, multi-institutional, longitudinal cohort study from 11/2019-6/2021. Participants rated treatment outcomes at the time of their surgical decision and again 9 months later by allocating 100 points amongst 10 outcomes. T-tests and Hotelling’s T2 statistic compared outcome valuation within and between subjects based on chosen extent of surgery (TT vs. lobectomy). Results: Of 177 eligible patients, 125 participated (70.6% response) and 114 completed the 9-month follow-up (91.2% retention). At the time of the treatment decision, patients choosing TT valued the risk of recurrence more than those choosing lobectomy and the need to take thyroid hormone less (P<0.05). At repeat valuation, all patients assigned fewer points to cancer being removed and the impact of treatment on their voice, and more points to energy levels (P<0.05). The importance of the risk of recurrence increased for those who chose lobectomy and decreased for those choosing TT (P<0.05). Conclusion: The relative importance of treatment outcomes changes for patients with low-risk TC once the outcome has been experienced to favor quality of life over emotion-related outcomes. Surgeons can use this information to discuss the potential for asthenia or changes in energy levels associated with total thyroidectomy.

BACKGROUND AND OBJECTIVES:The importance of the radial margin for rectal cancer resection is well understood. However, surgeons have deemphasized the distal margin, accepting very close distal margins to perform sphincter-preserving surgery. We hypothesized that distal margins < 1 cm would be an independent risk factor for locoregional recurrence. The objective was to determine whether close distal margins are associated with increased locoregional recurrence risk. METHODS:This was a multi-institutional retrospective cohort study conducted at six academic medical centers including patients who received low anterior resection surgery for primary rectal cancer between 2007 and 2018. RESULTS:Of 556 low anterior resection patients, the rate of close distal margin was 12.8% (n = 71), and the locoregional recurrence rate was 5.0% (n = 28). The locoregional recurrence rate for close distal margin cases was 9.9% (n = 7) compared to 4.3% (n = 21) for distal margins ≥1.0 cm. In multivariable analysis, the only factor significantly associated with locoregional recurrence was close distal margin (adjusted odds ratio: 2.80, confidence interval: 1.08-7.25, p = 0.035). CONCLUSIONS:Rectal cancer patients with close distal margins (<1 cm) following low anterior resection had a significantly higher risk for locoregional recurrence. Therefore, the decision to perform low anterior resection with margins < 1 cm should be taken with caution.

Resuscitation of the exsanguinating trauma patient: Prioritize circulation

BACKGROUND:The operating room (OR) is a complex environment for medical students. Little is known about the OR staff's perception of medical students.METHODS:We utilized an embedded mixed methods design to characterize surgical staff perceptions of students at an academic institution. We surveyed 408 OR nursing/technician staff with 16 follow-up interviews.RESULTS:139 respondents. 91.3% reported having daily-to-weekly interactions with medical students. Yet, only 37.9% agreed that "patient care is better when medical students are part of the team." 25.2% felt confident that they knew what a student's education entails outside the OR. 93.5% agreed that interprofessional training between physicians and OR staff should be included in educational programs. 54% agreed that their responsibilities include medical student training in the OR setting.CONCLUSIONS:Despite an overall desire for teamwork, this study highlights a lack of knowledge of each others' roles. To improve OR culture and team dynamics, concerted efforts need to be made around interprofessional training.

Intolerance of uncertainty has been implicated in the development and maintenance of depression and anxiety (McEvoy & Mahoney, 2012). Given that, promoting positive experiences of uncertainty through improvisational theater training (Napier, 2004) may have psychological benefits such as reductions in anxiety and depression (Krueger, Murphy, & Bink, 2017; Felsman, Seifert, & Himle, 2019). This study tests whether intolerance of uncertainty changes with participation in improvisational theater class for adolescents, and whether that change can explain changes in social anxiety. Surveys were collected on weeks one (n = 350) and ten (n = 339) of an improvisational theater program across 14 urban public schools, grades 8-12, measuring social anxiety (the Mini-SPIN; Connor, Kobak, Churchill, Katzelnick, & Davidson, 2001) and intolerance of uncertainty (Brief-IUS; Fialko, Bolton, & Perrin, 2012). Participating in the program was associated with significant reductions in social anxiety and intolerance of uncertainty. In our linear mixed model, change in intolerance of uncertainty was associated with greater reductions in social anxiety. This study provides the first evidence that participating in improvisational theater is associated with reductions in intolerance of uncertainty and adds to the argument that improvisational theater training may indirectly provide a low stigma, accessible mental health intervention (Felsman et al., 2019).

Objective: The aim of this study was to determine overall trends and center-level variation in utilization of completion lymph node dissection (CLND) and adjuvant systemic therapy for sentinel lymph node (SLN)-positive melanoma. Summary Background Data: Based on recent clinical trials, management options for SLN-positive melanoma now include effective adjuvant systemic therapy and nodal observation instead of CLND. It is unknown how these findings have shaped practice or how these contemporaneous developments have influenced their respective utilization. Methods: We performed an international cohort study at 21 melanoma referral centers in Australia, Europe, and the United States that treated adults with SLN-positive melanoma and negative distant staging from July 2017 to June 2019. We used generalized linear and multinomial logistic regression models with random intercepts for each center to assess center-level variation in CLND and adjuvant systemic treatment, adjusting for patient and disease-specific characteristics. Results: Among 1109 patients, performance of CLND decreased from 28% to 8% and adjuvant systemic therapy use increased from 29 to 60%. For both CLND and adjuvant systemic treatment, the most influential factors were nodal tumor size, stage, and location of treating center. There was notable variation among treating centers in management of stage IIIA patients and use of CLND with adjuvant systemic therapy versus nodal observation alone for similar risk patients. Conclusions: There has been an overall decline in CLND and simultaneous adoption of adjuvant systemic therapy for patients with SLN-positive melanoma though wide variation in practice remains. Accounting for differences in patient mix, location of care contributed significantly to the observed variation.