Thyroid Nodule Evaluation and Management in Older Adults: A Review of Practical Considerations for Clinical Endocrinologists

ObjectiveContextualizing the evaluation of older adults with thyroid nodules is necessary to fully understand which management strategy is the most appropriate. Our goal was to summarize available clinical evidence to provide guidance in the care of older adults with thyroid nodules and highlight special considerations for thyroid nodule evaluation and management in this population.MethodsWe conducted a literature search of PubMed and Ovid MEDLINE from January 2000 to November 2020 to identify relevant peer-reviewed articles published in English. References from the included articles as well as articles identified by the authors were also reviewed.ResultsThe prevalence of thyroid nodules increases with age. Although thyroid nodules in older adults have a lower risk of malignancy, identified cancers are more likely to be of high-risk histology. The goals of thyroid nodule evaluation and the tools used for diagnosis are similar for older and younger patients with thyroid nodules. However, limited evidence exists regarding thyroid nodule evaluation and management to guide personalized decision making in the geriatric population.ConclusionConsidering patient context is significant in the diagnosis and management of thyroid nodules in older adults. When making management decisions in this population, it is essential to carefully weigh the risks and benefits of thyroid nodule diagnosis and treatment, in view of older adults’ higher prevalence of high-risk thyroid cancer as well as increased risk for multimorbidity, functional and cognitive decline, and treatment complications.     

Context-dependent persistency as a coding mechanism for robust and widely distributed value coding

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Patch choice from a distance and use of habitat information during foraging by the parasitoid Ibalia leucospoides

1. In environments in which resources are distributed heterogeneously, patch choice and the length of time spent on a patch by foragers are subject to strong selective pressures. This is particularly true for parasitoids because their host foraging success translates directly into individual fitness. 2. The aim of this study was to test whether: (i) females of the parasitoid Ibalia leucospoides (Hymenoptera: Ibaliidae) can discriminate among patches according to host numbers; (ii) the surrounding context affects the initial choice of patch, as well as time spent on patch; and (iii) the perceived quality of a given patch is affected by the quality of the surrounding patches. 3. Each female was randomly exposed to one of three different three‐patch environments which differed in host number per patch, mean environment host number and host distribution among patches. For each treatment level, the first patch chosen and the time allocated to each patch visited by the female were recorded. 4. Females of I. leucospoides were able to discriminate different levels of host numbers among patches from a distance. The patch bearing the highest number of hosts was, predominantly, the first choice. Patch host number in association with mean habitat profitability influenced the length of time spent on the first patch visited. By contrast, variance in habitat profitability did not influence time allocation decisions. Contrary to the study prediction, there were no significant habitat‐dependent time allocation differences among patches holding the same number of hosts. 5. The results indicate that, for I. leucospoides, patch exploitation decisions are partially influenced by information obtained from the habitat as a whole, a behaviour that may prove to indicate adaptive ability in highly patchy environments, as well as suggesting the presence of good cognitive abilities in this parasitoid species.     

To be or not to be faithful: flexible fidelity to foraging trails in the leaf‐cutting ant Acromyrmex lobicornis

1. Ants using trails to forage have to select between two alternative routes at bifurcations, using two, potentially conflicting, sources of information to make their decision: individual experience to return to a previous successful foraging site (i.e. fidelity) and ant traffic. In the field, we investigated which of these two types of information individuals of the leaf‐cutting ant Acromyrmex lobicornis Emery use to decide which foraging route to take. 2. We measured the proportion of foraging ants returning to each trail of bifurcations the following day, and for 4–7 consecutive days. We then experimentally increased ant traffic on one trail of the bifurcation by adding additional food sources to examine the effect of increased ant traffic on the decision that ants make. 3. Binomial tests showed that for 62% of the trails, ant fidelity was relatively more important than ant traffic in deciding which bifurcation to follow, suggesting the importance of previous experience. 4. When information conflict was generated by experimentally increasing ant traffic along the trail with less foraging activity, most ants relied on ant traffic to decide. However, in 33% of these bifurcations, ants were still faithful to their trail. Thus, there is some degree of flexibility in the decisions that A. lobicornis make to access food resources. 5. This flexible fidelity results in individual variation in the response of workers to different levels of ant traffic, and allows the colony to simultaneously exploit both established and recently discovered food patches, aiding efficient food gathering.     

Modeling seasonality in space‐time infectious disease surveillance data

Infectious disease data from surveillance systems are typically available as multivariate times series of disease counts in specific administrative geographical regions. Such databases are useful resources to infer temporal and spatiotemporal transmission parameters to better understand and predict disease spread. However, seasonal variation in disease notification is a common feature of surveillance data and needs to be taken into account appropriately. In this paper, we extend a time series model for spatiotemporal surveillance counts to incorporate seasonal variation in three distinct components. A simulation study confirms that the different types of seasonality are identifiable and that a predictive approach suggested for model selection performs well. Application to surveillance data on influenza in Southern Germany reveals a better model fit and improved one‐step‐ahead predictions if all three components allow for seasonal variation.     

Sink or swim: Risk stratification of preweaning mortality in harbor seal pups (Phoca vitulina richardii) admitted for rehabilitation

To date, few consistent relationships between survival in rehabilitation programs and diagnostic measures recorded upon admission have been identified for harbor seal pups. Veterinary records for 718 unweaned Pacific harbor seal pups (Phoca vitulina richardii) admitted to a rehabilitation center were examined to identify clinical factors associated with preweaning survival and develop a triage tool to stratify pups according to their risk of mortality. Physical, serum chemical, and hematological variables were examined and their relationship with survival to weaning was assessed by logistic regression and classification and regression tree (CART) analysis. Survival to weaning was 85.1% and many clinical variables reflecting the pups’ age, size, growth, injuries, and blood parameters were associated with the likelihood of survival. A decision tree model, consisting of serum concentrations of phosphorus, sodium, and calcium, successfully stratified harbor seal pups into clinical subgroups according to their preweaning mortality risk. For both the derivation and validation cohorts, pups classified as “high risk” had significantly lower odds of survival, while those classified as “low risk” had significantly greater odds of survival. This simple decision tree could serve as a practical triage tool to help identify and direct care towards pups at higher risk of preweaning mortality.     

COUNTERFACTUAL REASONING IN SURROGATE DECISION MAKING – ANOTHER LOOK

Incompetent patients need to have someone else make decisions on their behalf. According to the Substituted Judgment Standard the surrogate decision maker ought to make the decision that the patient would have made, had he or she been competent. Objections have been raised against this traditional construal of the standard on the grounds that it involves flawed counterfactual reasoning, and amendments have been suggested within the framework of possible worlds semantics. The paper shows that while this approach may circumvent the alleged problem, the way it has so far been elaborated reflects insufficient understanding of the moral underpinnings of the idea of substituted judgment. Proper recognition of these moral underpinnings has potentially far‐reaching implications for our normative assumptions about accuracy and objectivity in surrogate decision making.     

Extracting the dynamics of behavior in sensory decision-making experiments

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