A Literature Review of Factors Associated With Pain From Fine Needle Aspiration Biopsy of Thyroid Nodules.

OBJECTIVE: Thyroid nodules are common, being detected in 19% to 67% of the population. A fine needle aspiration biopsy (FNAB) is recommended for suspicious thyroid nodules to rule out malignancy; however, the procedure can be painful for subsets of patients. It remains unclear what factors are more likely to be associated with pain during FNAB. This literature review aimed to investigate patient-, procedure-, and analgesic-related factors that affect pain levels during thyroid nodule FNAB. METHODS: Predefined inclusion and exclusion criteria were set to search the Embase, MEDLINE, CINAHL, and Cochrane databases. The articles evaluating the factors affecting pain during FNAB were assessed for inclusion. The primary outcome of interest was scores evaluating pain level during FNAB. RESULTS: Twenty-two studies were included. The studies were a mix of cohort studies, randomized controlled trials, and clinical controlled trials. Under patient-related factor, nodule calcification was associated with increasing pain. The procedure-related factors potentially increasing pain included the number of needle passes and utilization of the aspiration technique (as opposed to capillary action), perpendicular needle placement (as opposed to parallel), and not using safety devices. Larger needle size, type of biopsy, operator expertise, and patient education did not appear to be correlated with pain. Subcutaneous lidocaine appeared to provide better pain relief than a topical analgesic. CONCLUSION: With increasing use of FNAB as the diagnostic test of choice for assessing thyroid nodules, understanding patient-, procedure-, and analgesic-related factors associated with optimal patient satisfaction is imperative.

Safety and Clinical Outcomes of Immune Checkpoint Inhibitors in Patients With Cancer and Preexisting Autoimmune Diseases.

Immunotherapy has revolutionized treatment outcomes in numerous cancers. However, clinical trials have largely excluded patients with autoimmune diseases (ADs) due to the risk of AD flares or predilection for developing organ-specific inflammation. The objective of this study was to evaluate the safety and efficacy of immunotherapy in patients with cancer and preexisting ADs. A retrospective, single-center study of patients with cancer initiated on immune checkpoint inhibitors between 2012 and 2019 was conducted. The primary outcome was the development of immune-related adverse events (irAEs) with respect to the presence of AD at baseline. Associations were assessed using Kaplan-Meier curves, bivariate and multivariable analyses. Of the 417 patients included in this study, 63 patients (15%) had preexisting ADs. A total of 218 patients (53%) developed at least 1 irAE. There was no association between the presence of baseline AD on the development, grade, or number of irAEs; time to irAE or irAE recovery; systemic corticosteroid or additional immunosuppressant treatment for irAEs; permanent treatment discontinuation; or overall response rate. Two smaller cohorts were studied, melanoma and non-small cell lung cancer, and there was no effect of baseline AD on overall survival on either cohort. However, a greater proportion of patients with baseline ADs had full recovery from their irAE (P=0.037). Furthermore, age below 65, baseline steroid use, and single-agent immunotherapy regimens were protective in terms of the development of irAEs. Our study suggests that immune checkpoint inhibitors have similar safety and efficacy profiles in patients with preexisting ADs.

Analysis of factors affecting Canadian medical students' success in the residency match.

BACKGROUND: In North America, there is limited data to support deliberate application strategies for post-graduate residency training. There is significant interest in determining what factors play a role in Canadian medical graduate (CMG) matching to their first choice discipline and heightened concern about the number of students going unmatched altogether. METHODS: We analyzed matching outcomes of CMGs based on seven years (2013-2019) of residency application data (n= 13,499) from the Canadian Residency Matching Service (CaRMS) database using descriptive and binary logistic regression modeling techniques. RESULTS: The sample was 54% female, with 60% between the ages of 26 and 29, and 60% attended medical schools in Ontario. Applicants who received more rankings from residency programs were more likely (OR = 1.185, p < 0.001) to match. Higher research activities (OR = 0.985, p < 0.001) and number of applications submitted (OR = 0.920, p < 0.001) were associated with a reduced likelihood of matching. Number of volunteer activities and self-report publications did not significantly affect matching. Being male (OR = 0.799, p < 0.05) aged <25 (OR = 0.756, p < 0.05), and from Eastern (OR = 0.497, p < 0.01), or Western (OR = 0.450, p < 0.001) Canadian medical schools were predictors of remaining unmatched. CONCLUSIONS: This study identified several significant associations of demographic and application factors that affected matching outcomes. The results will help to better inform medical student application strategies and highlight possible biases in the selection process.

CONTEXTE: En Amérique du Nord, les données qui soutiennent les stratégies délibérées de candidature pour la formation en résidence postdoctorale sont limitées. Il existe un intérêt important dans la détermination des facteurs qui jouent un rôle dans le jumelage des diplômés canadiens en médecine (DCM) à leur discipline de premier choix et dans les préoccupations croissantes au sujet du nombre d'étudiants non jumelés. MÉTHODES: Nous avons analysé les résultats des DCM sur une période de sept ans (2013-2019) à partir de données de demandes de résidence (n = 13 499) tirées de la base de données du Service canadien de jumelage des résidents (CaRMS) en utilisant des techniques de modélisation par régression logistique binaire. RÉSULTATS: L'échantillon comportait 54 % de femmes, avec 56 % âgées de 26 à 29 ans, et 60 % qui allaient à des facultés de médecine en Ontario. Les candidats qui avaient reçu plus de classements des programmes de résidences étaient plus susceptibles d'être jumelés (RC = 1,185, p < 0,001). Les activités scientifiques de pointe (RC = 0,985, p < 0,001) et un certain nombre de candidatures soumises (RC = 0,90, p < 0,001) étaient associées avec une probabilité réduite de jumelage. Un certain nombre d'activités bénévoles et des publications autodéclarées ne modifiaient pas le jumelage de manière importante. Être un homme (RC = 0,799, p < 0,05) âgé de moins de 25 ans (RC = 0,756, p < 0,05) et de facultés canadiennes de médecine de l'Est (RC = 0,497, p < 0,01) et de l'Ouest (RC = 0,450, p < 0,001) étaient des prédicteurs des candidatures non jumelées. CONCLUSIONS: Cette étude a établi plusieurs associations importantes de facteurs démographiques et de candidatures qui touchaient les résultats des jumelages. Les résultats aideront à mieux informer les stratégies de candidatures des étudiants en médecine et montrent les biais possibles dans le processus de sélection.

THYROID NODULE GROWTH AS A PREDICTOR OF MALIGNANCY.

Objective: To assess which measure of thyroid nodule growth on serial neck ultrasound, if any, is associated with malignancy. Methods: Retrospective exploratory chart review of malignant thyroid nodules assessed at Kingston Health Sciences Centre (2006-2016) and benign thyroid nodules (2016), at least 1 cm in diameter and with 2 ultrasounds completed at least 30 days apart. Groups were compared using independent samples Student's t test, chi-square test, or Mann-Whitney U test as appropriate, as well as multivariable logistic and linear regression modelling to adjust for age and baseline volume. Results: One hundred and seventy-eight nodules were included in the study. When growth was defined as >20% increase in 2 dimensions (minimum 2 mm), malignant nodules (MNs) underwent significantly more growth than benign nodules (BNs) (16.8% BN versus 29.8% MN [P = .026]; odds ratio = 2.49; 95% confidence interval = 1.12 to 5.56). There was no significant difference between the groups when growth was defined as >2 mm/year or ≥50% volume growth. Nodules shrank >2 mm/year in each group and the difference was not statistically significant (24.2% BN versus 20.7% MN [P = .449]). The median doubling time for the nodules that grew was 1022.1 days in the BN group and 463.2 days in the MN group (P = .036). The median doubling time for all nodules was 456.5 days in the BN group and 244.2 days in the MN group (P = .015). Conclusion: Thyroid nodule growth defined as >20% increase in 2 dimensions (minimum 2 mm) is associated with risk of malignancy. Nodule shrinkage did not distinguish between BNs and MNs. Abbreviations: BN = benign nodule; CI = confidence interval; FNA = fine needle aspiration; KHSC = Kingston Health Science Centre; MN = malignant nodule; OR = odds ratio; ROC = receiver operating characteristic.

The efficacy and toxicity of immune checkpoint inhibitors in a real-world older patient population.

IMPORTANCE: Immunotherapy has emerged as an effective treatment option for the management of advanced cancers. The effects of these immune checkpoint inhibitors in the older patient population has not been adequately assessed. OBJECTIVE: To understand the impact of aging on CTLA-4 and PDL-1 inhibitors efficacy and immune-related adverse events (irAE) in the context of real-world management of advanced solid cancers. DESIGN, SETTING, AND PARTICIPANTS: This retrospective study involved all non-study patients with histologically-confirmed metastatic or inoperable solid cancers receiving immunotherapy at Kingston Health Sciences Centre. We defined 'older patient' as age ≥ 75. All statistical analyses were conducted under SPSS IBM for Windows version 24.0. MAIN OUTCOMES AND MEASURES: Study outcomes included immunotherapy treatment response, survival, as well as number, type, and severity of irAEs. RESULTS: Our study (N = 78) had 29 (37%) patients age <65, 26 (33%) patients age 65-74, and 23 (30%) patients age ≥75. Melanoma, non-small cell lung cancer, and renal cell carcinoma accounted for 70%, 22%, and 8% of the study population, respectively. Distributions of ipilimumab (32%), nivolumab (33%), and pembrolizumab (35%) were similar in the study. The response rates were 28%, 27%, and 39% in the age <65, age 64-74, age ≥75 groups, respectively (P = 0.585). Kaplan-Meier curve showed a median survival of 28 months (12.28-43.9, 95% CI) and 17 months (0-36.9, 95% CI) in the age <65 and age 64-74 groups, respectively; the estimated survival probability did not reach 50% in the age ≥75 group (P = 0.319). There were no statistically significant differences found in terms of irAEs, multiple irAEs, severity of grade 3 or higher, types of irAEs, and irAEs resolution status when comparing between different age groups. CONCLUSION AND RELEVANCE: Our results suggest that patients age ≥75 are able to gain as much benefit from immunotherapy as younger patients, without excess toxicity. Our findings suggest that single agent immunotherapy is generally well-tolerated across different age groups with no significant difference in the type, frequency or severity of irAEs. Future studies evaluating aging and combination immunotherapy are warranted.

Cause of death in patients awaiting bariatric surgery.

BACKGROUND: Obesity is associated with increased mortality. Bariatric surgery is becoming an important treatment modality for obesity, with an associated reduction in mortality. There are few data available on the incidence and cause of death in referred patients while they are waiting for bariatric surgery. METHODS: We retrospectively examined all cases of death in patients who were referred for bariatric surgery assessment but who had not yet undergone bariatric surgery at a tertiary care centre in Halifax, Nova Scotia. The wait list comprised patients referred for surgery between March 2008 and May 2013. All cases of death were reviewed to determine age, sex, time of referral, time spent on the wait list, cause of death, comorbidities and body mass index (BMI). RESULTS: Of the 1399 patients referred, 22 (1.57%) died before receiving surgery. The mean age of these patients was 62.7 (range of 32-70) years. The average time from referral to death was 21.6 months, and the average BMI was 51.5. The most frequent cause of death was cancer, followed by cardiac and infectious causes. CONCLUSION: This study provides useful information about mortality and causes of death among patients awaiting bariatric surgery at our centre. Our results will help guide the development of a judicious system for triage in light of long wait times.

CONTEXTE: L'obésité est associée à une mortalité accrue. La chirurgie bariatrique devient une modalité thérapeutique importante pour traiter l'obésité et elle est associée à une réduction de la mortalité. On dispose de peu de données sur l'incidence et la cause du décès chez les patients référés qui sont en attente d'une chirurgie bariatrique. MÉTHODES: Nous avons examiné rétrospectivement tous les cas de patients référés qui sont décédés en attente d'une chirurgie bariatrique dans un centre de soins tertiaires de Halifax (Nouvelle-Écosse). La liste d'attente comprenait des patients référés pour chirurgie entre mars 2008 et mai 2013. Nous avons passé en revue tous les décès pour déterminer l'âge, le sexe, la date de la référence, le temps passé sur la liste d'attente, la cause du décès, les comorbidités et l'indice de masse corporelle (IMC). RÉSULTANTS: Parmi les 1399 patients référés, 22 (1,57 %) sont décédés avant de subir leur chirurgie. L'âge moyen de ces patients était de 62,7 ans (entre 32 et 70 ans). L'intervalle moyen entre la référence et le décès a été de 21,6 mois et l'IMC moyen était de 51,5. La cause de décès la plus fréquente était le cancer, suivi des causes cardiaques et infectieuses. CONCLUSION: Cette étude procure des renseignements utiles sur la mortalité et les causes de décès chez les patients en attente d'une chirurgie bariatrique dans notre établissement. Ces résultats permettront de mieux orienter la création d'un système de triage adéquat, compte tenu de la longueur des temps d'attente.