With improved survival in cystic fibrosis (CF) patients, it is crucial to evaluate the impact of chronic co-morbidities such as chronic rhinosinusitis (CRS). The objectives were 1) To determine the ...prevalence of CRS with a large series of CF patients 2) To evaluate the impact of CRS on the Health-Related Quality of Life (HRQoL) of CF patients and 3) To compare CRS-specific, CF-specific and general HRQoL instruments.
Consecutive CF patients from the Toronto Adult Cystic Fibrosis Centre were recruited between March 2018 and January 2020. Participants completed the 22-Item Nasal Outcome Test (SNOT-22), Cystic Fibrosis Questionnaire-Revised for adolescents and adults over 14 years of age (CFQ-R), Cystic Fibrosis Quality of Life Evaluative Self-administered Test (CF-QUEST) and the 36-Item Short Form Survey (SF-36). HRQoL scores were correlated using Spearman's correlation coefficients.
Out of 195 patients eligible for analysis, the prevalence of CRS with positive endoscopic findings was 42.6% (95% confidence interval: 35.5–49.8%). CRS patients reported significantly lower HRQoL with higher SNOT-22 scores and lower scores in the respiratory domain of CFQ-R and physical health domains of CF-QUEST and SF-36. The physical (ρ= −0.63) and mental (ρ= −0.66) domains of SF-36 and CF-QUEST (ρ= −0.76) had a strong correlation with SNOT-22. Higher scores of SNOT-22 nasal subdomains correlated with lower scores of SF-36, CFQ-R and CF-QUEST.
CRS is a prevalent co-morbidity of CF patients, which significantly reduces HRQoL. SNOT-22, CFQ-R, CF-QUEST and SF-36 were strongly correlated. Severity of sinonasal symptoms have a strong correlation with HRQoL in CF patients.
Objectives/Hypothesis
Sonographic risk criteria may assist in further prognostication of indeterminate thyroid nodules (ITNs). Our aim was to determine whether sonographic criteria could further ...delineate the post‐test probability of malignancy in ITNs.
Study Design
Meta‐analysis of diagnostic test accuracy.
Methods
A systematic review of Web of Science, MEDLINE, EMBASE, and CINAHL was performed from inception to April 15, 2021. Eligible studies included those which reported ultrasonographic evaluations with the American Thyroid Association (ATA) or the Thyroid Imaging Reporting and Data System (TIRADS) in adult patients with ITNs. ATA or TIRADS were scored as low (negative) or high (positive) malignancy risk using a previously validated binary classification. Primary outcomes included pooled sensitivity, specificity, likelihood ratios, and diagnostic odds ratio for all sonographic criteria. Studies were appraised using Quality Assessment of Diagnostic Accuracy Studies and the data were pooled using bivariate random‐effects models.
Results
Seventeen studies were included in the analysis. For Bethesda III, ATA had a specificity (0.90, 95% confidence interval (CI): 0.74–0.94), but a sensitivity of 0.52 (95% CI: 0.25–0.77). Conversely, K‐TIRADS had the highest sensitivity (0.78, 95% CI: 0.62–0.89) with a specificity of 0.53 (95% CI: 0.31–0.74). Furthermore, American College of Radiology and EU TIRADS had specificities of 0.60 (95% CI: 0.36–0.80) and 0.81 (95% CI: 0.73–0.87) with sensitivities of 0.70 (95% CI: 0.37–0.90) and 0.38 (95% CI: 0.20–0.60), respectively. There were few studies with Bethesda IV nodules.
Conclusions
Though dependent on malignancy rates, Bethesda III nodules with low‐suspicion TIRADS features may benefit from clinical observation, whereas nodules with high‐suspicion ATA features may require molecular testing and/or surgery.
Level of Evidence
NA Laryngoscope, 132:242–251, 2022
The practices of head and neck surgical oncologists must evolve to meet the unprecedented needs placed on our health care system by the Coronavirus disease 2019 (COVID‐19) pandemic. Guidelines are ...emerging to help guide the provision of head and neck cancer care, though in practice, it can be challenging to operationalize such recommendations. Head and neck surgeons at Wuhan University faced significant challenges in providing care for their patients. Similar challenges were faced by the University of Toronto during the severe acute respiratory syndrome (SARS) pandemic in 2003. Herein, we outline our combined experience and key practical considerations for maintaining an oncology service in the midst of a pandemic.
Background
The cost utility of image‐guided surveillance using computed tomography (CT) and positron emission tomography (PET)‐CT to planned postradiation neck dissection (PRND) was compared for the ...management of advanced nodal human papillomavirus‐positive oropharyngeal cancer following chemoradiation.
Methods
A universal payer perspective was adopted. A Markov model was designed to simulate four treatment approaches with 3‐month cycles over a lifetime horizon: 1) CT surveillance, 2) standard PET‐CT surveillance, 3) a novel PET‐CT approach with repeat PET at 6 months postchemoradiation for equivocal responders, and 4) PRND. Parameters including probabilities of CT nodal progression/resolution, PET avidity, recurrence, and survival were obtained from the literature. Costs were reported in 2019 Canadian dollars and utilities were expressed in quality‐adjusted life years (QALYs). Deterministic and probabilistic sensitivity analyses were performed to evaluate model uncertainty.
Results
PET‐CT surveillance dominated CT surveillance and PRND in the base case scenario, and the novel PET‐CT approach was the most cost‐effective strategy across a wide range of variables tested in one‐way sensitivity analysis. On probabilistic sensitivity analysis, novel PET‐CT surveillance was the most cost‐effective strategy in 78.1% of model iterations at a willingness‐to‐pay of $50,000/QALYs. Novel PET‐CT surveillance resulted in a 49% lower rate of neck dissection compared with traditional PET‐CT, and yielded an incremental benefit of 0.14 QALYs with average cost savings of $1309.
Conclusions
Image‐guided surveillance including PET‐CT and CT are more cost effective than PRND. The novel PET‐CT approach with repeat PET for equivocal responders was the dominant strategy and yielded both higher benefit and lower costs compared with standard PET‐CT surveillance.
Image‐guided surveillance with positron emission tomography‐computed tomography (PET‐CT) and CT is more cost effective than planned postradiation neck dissection for advanced nodal human papillomavirus‐positive oropharyngeal cancer. A novel PET‐CT surveillance approach involving repeat imaging at 6 months postchemoradiation was the most cost‐effective strategy for managing advanced nodal human papillomavirus‐positive oropharyngeal cancer.
The ocular status of homeless populations remains largely unknown. Given that visual acuity has been shown to be heavily correlated with reduced well-being and decreased earning potential, findings ...of poor vision could have important health implications for people experiencing homelessness.
To assess the prevalence of visual impairment and to identify unmet eye care needs in an adult homeless population.
For this cross-sectional study, we recruited 100 homeless persons using a stratified random sampling technique from January to March 2014. Recruitment took place at 10 randomly selected adult shelters in Toronto, Ontario, Canada. All English-speaking persons older than 18 years of age were eligible to participate. Information was obtained on sociodemographic characteristics, ocular history, and subjective visual acuity. A comprehensive vision screening and an undilated retinal examination were performed for each participant.
Rates of functional visual impairment and prevalence of nonrefractive eye pathology.
The median age of participants was 48 years (interquartile range, 36-56 years), and 62% were men. The median lifetime duration of homelessness was 12 months (interquartile range, 5-36 months). Based on the participants' presenting visual acuity, the age-standardized rate of visual impairment was 25.2% (95% CI, 16.7%-33.7%). After pinhole occlusion, this number decreased to 15.2% (95% CI, 7.7%-22.7%). In total, 13.0% (95% CI, 7.8%-20.0%) of participants experienced visual impairment secondary to a correctable refractive error. Although the major problem for this demographic was limited access to refractive correction, a large degree of nonrefractive pathology was also observed. Of all the participants, 34.0% (95% CI, 24.7%-43.3%) had 1 or more abnormal findings during the vision screening, and 8% (95% CI, 2.7%-13.3%) required urgent referral to an ophthalmologist. A large majority of participants (89.0%) indicated interest in accessing free eye examinations.
These data suggest that homeless adults have a high prevalence of visual impairment, even when living within a system of universal health insurance. Given the high level of interest in eye care among homeless persons, ongoing vision-screening programs and readily accessible free eye clinics may help address this need.
Objectives/Hypothesis
Performance of thyroidectomy on an outpatient basis has gained popularity although many jurisdictions have not shifted their practice despite a strong safety profile. We sought ...to assess the uptake and safety of outpatient thyroidectomy in Ontario.
Study Design
Retrospective cohort study.
Methods
This was a population‐based retrospecive cohort of adult patients undergoing hemithyroidectomy or total thyroidectomy between 1993 and 2017 in Ontario, Canada. Outpatient surgery was defined as discharge home on the same day of surgery. Outcomes of interest include 30‐day all cause death, hematoma, emergency department use, and readmission. To adjust for confounding, propensity scores were calculated. Logistic regression models with inverse probability of treatment weighting (IPTW) were then used to estimate the exposure‐outcome relationship.
Results
The final cohort consisted of 81,199 patients: 8,442 underwent same day surgery and 72,757 were admitted. The proportion of patients undergoing outpatient thyroidectomy increased overtime (2.3% in 1993–1994 to 17.8% in 2016–2017). Factors associated with higher odds of outpatient thyroidectomy included: younger age, less material deprivation, less comorbidities, and higher surgeon volume. The absolute number of deaths (≤5) and hematomas (64, 0.8%) in the outpatient cohort was low. After IPTW adjustment, patients with outpatient management had lower odds of neck hematoma (OR 0.7395CI% 0.58–0.93), but higher odds of emergency department use (OR 1.6795%CI 1.56–1.79).
Conclusions
Outpatient thyroidectomy is not associated with an increased mortality risk. Less than one in five patients undergo outpatient thyroidectomy in Ontario, despite a well‐established safety profile.
Level of Evidence
3 Laryngoscope, 131:2625–2633, 2021
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•Close symptom management is a cornerstone of cancer care.•The Edmonton Symptom Assessment System (ESAS) is one of the most commonly used symptom scales in cancer patients across the ...world.•Despite being a generic symptom scale, the ESAS has good discriminative and evaluative properties in a head and neck population.•ESAS scores are strongly correlated with emergency department use in head and neck oncology and may be a good tool for risk stratification.
Symptom burden is common in head and neck cancer patients though it frequently remains undetected and untreated. The Edmonton Symptom Assessment System - revised version (ESAS-r) is a generic symptom scale deployed in many outpatient settings worldwide. The ESAS-r is meant to improve symptom detection and management. We sought to review the ESAS-r and its psychometric properties in a head and neck oncology population.
Narrative Review.
Over the past 30 years, the ESAS-r has emerged as one of the most used symptom scales for cancer patients. Its psychometric properties in a heterogenous cancer population are well supported, proving to be reliable and valid in a variety of settings. The linking of ESAS-r scores with Ontario administrative health data has led to a detailed assessment of validity in head and neck cancer. The ESAS-r can discriminate between high and low levels of symptom burden and is responsive to change over time in this patient population. ESAS-r scores have also been shown to be a strong predictor of future emergency department use and unplanned hospitalization in head and neck cancer patients.
The ESAS-r is reliable and valid in the head and neck cancer population and may serve as a useful clinical endpoint in research studies.
Background
This study aimed to assess whether surgical case volume for lateral neck dissection has an impact on the survival of patients who have well-differentiated thyroid cancer (WDTC) with ...lateral cervical node metastases. The authors used a population-based cohort study design.
Methods
The study cohort consisted of WDTC patients in Ontario Canada who underwent thyroidectomy and lateral neck dissection. These patients were identified using both hospital- and surgeon-level administrative data between 1993 and 2017 (
n
= 1832). Surgeon and hospital volumes were calculated based on the number of cases managed in the year before the procedure by the physician and at the institution managing each case, respectively, and divided into tertiles. Multilevel Cox regression models were used to estimate the effect of volume on disease-free survival (DFS).
Results
A crude model without patient or treatment characteristics demonstrated that DFS was associated with both higher surgeon volume tertiles (
p
< 0.01) and higher hospital volume tertiles (
p
< 0.01). After control for clustering, patient/treatment covariates, and hospital volume, the lowest surgeon volume tertile (range, 0–20/year; mean, 6.5/year) remained an independent statistically significant negative predictor of DFS (hazard ratio, 1.71; 95 % confidence interval, 1.22–2.4;
p
< 0.01).
Conclusion
Surgeon lateral neck dissection case volume is a predictor of better DFS for thyroid cancer patients, with the lowest surgeon volume tertile (<20 neck dissections per year) demonstrating poorer DFS.
Healthcare systems generate substantial carbon footprints that may be targeted to decrease greenhouse gas emissions. Outreach clinics may represent tools to assist in this reduction by optimizing ...patient related travel. Therefore, we sought to estimate the carbon footprint savings associated with a head and neck surgery outreach clinic.
This study was a cross-sectional survey of patient travel patterns to a surgical outreach clinic compared to a regional cancer treatment centre from December 2019 to February 2020. Participants completed a self-administered survey of 12 items eliciting travel distance, vehicle details, and ability to combine medical appointments. Canadian datasets of manufacturer provided vehicular efficiency were used to estimate carbon emissions for each participant. Geographic information systems were used for analyses.
One hundred thirteen patients were included for analysis. The majority of patients (85.8%) used their own personal vehicle to travel to the outreach clinic. The median distance to the clinic and regional centre were 29.0 km (IQR 6.0-51.9) and 327.0 km (IQR 309.0-337.0) respectively. The mean carbon emission reduction per person was therefore 117,495.4 g (SD: 29,040.0) to 143,570.9 g (SD: 40,236.0). This represents up to 2.5% of an average individual's yearly carbon footprint. Fewer than 10% of patients indicated they were able to carpool or group their appointments.
Surgical outreach clinics decrease carbon footprints associated with patient travel compared to continued care at a regional centre. Further research is needed to determine possible interventions to further reduce carbon emissions associated with the surgical care of patients.
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