Medical Management for the Treatment of Nontuberculous Mycobacteria Infection of the Parotid Gland: Avoiding Surgery May Be Possible

Infection with nontuberculous mycobacteria (NTM) is uncommon in the head and neck; therefore there is no clear consensus on treating these infections. Our objective was to report our experience with a unique case of NTM infection of the parotid in an immunocompetent patient, in order to determine appropriate management through our experience with this pathology. A 57-year-old man, known for numerous comorbid diseases, presented to our institution complaining of right parotid swelling and pain. A computed tomography (CT) of the neck showed a multiloculated collection in the inferior portion of the right parotid gland, compatible with abscess formation. This abscess was drained by interventional radiology (IR) but required repeat drainage twice due to lack of initial improvement. He was treated with several antibiotics as culture results initially indicated Gram-positive bacilli and then Mycobacterium species, with final identification by a reference laboratory as Mycobacterium abscessus. Imipenem was initiated with amikacin and clarithromycin. His infection clinically and radiologically resolved after 5 months of antibiotherapy. In our case, the patient improved following intravenous antibiotic therapy. Our experience demonstrates that appropriate antibiotherapy can lead to resolution of Mycobacterium abscessus infection in the parotid without the risks associated with surgical intervention

Une course sans répit : l’évolution des paramètres des candidats à la résidence en oto-rhino-laryngologie – chirurgie cervico-faciale au fil du temps

Background: There has been an increasing number of Canadian medical graduates who have gone unmatched in the residency selection process. Medical students have been engaging in extracurricular activities outside the formal curriculum which may help to distinguish themselves from their peers in the selection process. To understand how competitiveness in residency selection shapes applicant demographic characteristics and behaviours, this study set out to explore the demographic characteristics and prevalence of reported extra-curricular activities by applicants to Canadian Otolaryngology – Head & Neck Surgery (OTL-HNS) residency across time. Methods: A retrospective, descriptive study reviewed specific sections of the curriculum vitae (CV) of applicants to OTL-HNS programs in Canada.  These sections were self-reported, and included research productivity, involvement in volunteer and leadership activities, membership in associations, and honours or awards granted.  Data was quantified and analyzed descriptively. Results: Between 2013 to 2017, a total of 267 applicants reported a median of 12.6 research publications, 9.6 volunteer activities, six leadership activities, six association memberships and 9.8 honours/awards. Applicants were younger over time, with proportions of applicants over 30 years old decreasing from 56% in 2013 to 9% in 2017. Conclusion: Applicants to Canadian OTL-HNS residency programs are reporting consistently high numbers of extracurricular activities and were of increasingly younger ages. Medical students are investing significant time and energy to pursue these activities which are above and beyond the formal curriculum, possibly contributing to decreased diversity in applicants for competitive residencies, increasing the likelihood of misrepresentation in residency applications, and likely contributing to medical student burnout.Contexte : De plus en plus de diplômés en médecine canadiens demeurent non jumelés à l’issue du processus de sélection des résidents. Certains font des activités hors programme afin de se distinguer de leurs pairs dans le processus de sélection. Pour comprendre comment la compétition dans la sélection de résidents influence les caractéristiques démographiques et les comportements des candidats, cette étude visait à explorer l’évolution des caractéristiques démographiques et la prévalence d’activités hors programme déclarées par les candidats à la résidence en oto-rhino-laryngologie – chirurgie cervico-faciale (ORL-CCF) à travers le temps. Méthodes : Dans le cadre d’une étude rétrospective et descriptive, nous avons parcouru des sections pertinentes du curriculum vitae (CV) des candidats aux programmes d'oto-rhino-laryngologie et chirurgie cervico-faciale au Canada. Ces sections étaient auto-déclarées et comprenaient les activités de recherche, la participation à des activités de bénévolat et de leadership, l'appartenance à des associations et les prix et distinctions obtenus. Les données ont été quantifiées et analysées de manière descriptive. Résultats : Entre 2013 et 2017, un total de 267 candidats ont déclaré une médiane de 12,6 publications de recherche, 9,6 activités de bénévolat, 6 activités de leadership, 6 adhésions à des associations et 9,8 prix et distinctions. Au fil du temps, on observe que les candidats sont de plus en plus jeunes ; ainsi, la proportion de candidats âgés de 30 ans et plus a diminué de 56 % en 2013 à 9 % en 2017. Conclusion : Les candidats aux programmes de résidence en ORL-CCF au Canada déclarent d’une année à l’autre un nombre élevé d'activités hors programme et sont de plus en plus jeunes. Les étudiants en médecine investissent beaucoup de temps et d'énergie dans ces activités qui vont au-delà du programme d'études officiel. Cela pourrait nuire à la diversité des candidats aux programmes de résidence fortement contingentés, augmenter la probabilité de fausses déclarations dans les demandes de résidence et probablement contribuer à l'épuisement professionnel des étudiants en médecin

Radiomics strategies for risk assessment of tumour failure in head-and-neck cancer

Quantitative extraction of high-dimensional mineable data from medical images is a process known as radiomics. Radiomics is foreseen as an essential prognostic tool for cancer risk assessment and the quantification of intratumoural heterogeneity. In this work, 1615 radiomic features (quantifying tumour image intensity, shape, texture) extracted from pre-treatment FDG-PET and CT images of 300 patients from four different cohorts were analyzed for the risk assessment of locoregional recurrences (LR) and distant metastases (DM) in head-and-neck cancer. Prediction models combining radiomic and clinical variables were constructed via random forests and imbalance-adjustment strategies using two of the four cohorts. Independent validation of the prediction and prognostic performance of the models was carried out on the other two cohorts (LR: AUC = 0.69 and CI = 0.67; DM: AUC = 0.86 and CI = 0.88). Furthermore, the results obtained via Kaplan-Meier analysis demonstrated the potential of radiomics for assessing the risk of specific tumour outcomes using multiple stratification groups. This could have important clinical impact, notably by allowing for a better personalization of chemo-radiation treatments for head-and-neck cancer patients from different risk groups.Comment: (1) Paper: 33 pages, 4 figures, 1 table; (2) SUPP info: 41 pages, 7 figures, 8 table

High-frequency ultrasound: A novel diagnostic tool to measure pediatric tonsils in three dimensions

ObjectiveVarious pathologies can affect the palatine tonsils. Ultrasound is a commonly used modality for assessing head and neck masses in children, however its use in tonsillar evaluation has not been widely explored. The objective of this thesis was to measure three-dimensional tonsillar size with ultrasound, in centimeters, and correlate these measurements with actual ex-vivo dimensions on pathology specimens.Study DesignA prospective cohort study was done.SettingThe study was set in a tertiary care children’s hospital.Subjects and MethodsChildren undergoing tonsillectomy were included in the study. Transcervical high-frequency ultrasound (HFU) was performed prior to surgery to obtain three-dimensional measurements of the right and left palatine tonsils. Mean sizes were compared to ex-vivo tonsil measurements and correlations were obtained.ResultsSeventy-five consecutive children underwent a transcervical HFU, yielding a total of 150 tonsils analyzed. The mean differences between HFU and pathology measurements were -0.08 cm and -0.24 cm for the right and left cranio-caudal axes, -0.19 cm and -0.18 cm for the right and left medio-lateral axes, and 0.05 cm and 0.03 cm for the right and left antero-posterior axes. Correlation coefficients between ultrasound and pathology measurements were all above 0.5. ConclusionHFU can accurately measure the size of pediatric tonsils in three dimensions.ObjectifUne grande variété de pathologies peut affecter les amygdales palatines. L'échographie est une modalité couramment utilisée pour évaluer les masses cervico-faciales chez les enfants. Cependant, son utilisation dans l'évaluation des amygdales n'a pas été largement explorée. L'objectif de cette étude était de mesurer la taille des amygdales en trois dimensions avec l’échographie, en centimètres, et de corréler ces mesures avec les dimensions réelles ex-vivo sur des spécimens pathologiques.Type d’étudeNous avons réalisé une étude de cohorte prospective.RéglageL’étude a été réalisée dans un hôpital pour enfants en soins tertiaires.Sujets et méthodesLes enfants ayant subi une amygdalectomie ont été inclus dans l'étude. Une échographie transcervicale à haute fréquence (EHF) a été réalisée avant l'opération afin d'obtenir des mesures en trois dimensions des amygdales palatines. Les tailles moyennes ont été comparées aux mesures ex-vivo des amygdales et des corrélations ont été obtenues.Résultats75 enfants consécutifs ont subi une EHF transcervicale, avec un total de 150 amygdales analysées. Les différences moyennes entre les mesures de EHF et de pathologie étaient de -0,08 cm et -0,24 cm pour les axes cranio-caudaux droit et gauche, de -0,19 cm et -0,18 cm pour les axes médio-latéraux droit et gauche, et de 0,05 cm et 0,03 cm pour les axes antéro-postérieurs droit et gauche. Les coefficients de corrélation entre les mesures obtenues en échographie et en pathologie étaient tous supérieurs à 0,5.ConclusionL’EHF peut mesurer avec précision la taille des amygdales pédiatriques en trois dimensions

Medical Management for the Treatment of Nontuberculous Mycobacteria Infection of the Parotid Gland: Avoiding Surgery May Be Possible

Infection with nontuberculous mycobacteria (NTM) is uncommon in the head and neck; therefore there is no clear consensus on treating these infections. Our objective was to report our experience with a unique case of NTM infection of the parotid in an immunocompetent patient, in order to determine appropriate management through our experience with this pathology. A 57-year-old man, known for numerous comorbid diseases, presented to our institution complaining of right parotid swelling and pain. A computed tomography (CT) of the neck showed a multiloculated collection in the inferior portion of the right parotid gland, compatible with abscess formation. This abscess was drained by interventional radiology (IR) but required repeat drainage twice due to lack of initial improvement. He was treated with several antibiotics as culture results initially indicated Gram-positive bacilli and then Mycobacterium species, with final identification by a reference laboratory as Mycobacterium abscessus. Imipenem was initiated with amikacin and clarithromycin. His infection clinically and radiologically resolved after 5 months of antibiotherapy. In our case, the patient improved following intravenous antibiotic therapy. Our experience demonstrates that appropriate antibiotherapy can lead to resolution of Mycobacterium abscessus infection in the parotid without the risks associated with surgical intervention

The T4/T3 quotient as a risk factor for differentiated thyroid cancer: a case control study

Abstract Background The incidence of thyroid nodules is increasing among patients in North America. Few of these nodules harbour malignancy, thus further research is required to identify predictive markers of malignant thyroid disease. This study set out to understand the relationship between the levels of fT4 and fT3 and differentiated thyroid cancer. Methods A case-control study was conducted with 142 cases and 86 controls from the McGill University Teaching Hospitals. All patients underwent thyroid surgery. Cases were defined as patients with malignant nodules confirmed on final pathology and controls were defined as patients with benign nodules. The serological levels of TSH, fT4 and fT3 were measured preoperatively. Odds ratios were determined for each parameter and logistic regressions were calculated between markers and probability of malignancy. Additionally, fT4 values were divided by fT3 values (fT4/fT3 quotient) for each patient and an odds ratio was calculated. Results Amongst cases, the mean TSH was 2.25 ± 0.360U/mL, fT4 was 14.8 ± 0.689pmol/L, and fT3 was 4.65 ± 0.463pmol/L. Amongst controls, the mean TSH was 2.36 ± 1.68U/mL, fT4 was 14.3 ± 1.71pmol/L, and fT3 was 5.27 ± 0.957pmol/L. Patients in the control group were more likely to have low TSH, while patients in the case group would have high fT4 and patients in the control group were more likely to have a low fT4. The OR for patients with TSH >4.4U/mL was 2.13 (0.97, 4.65), and for patients with TSH  16pmol/L was 2.10 (1.09, 4.06), and for patients with fT4  5.5pmol/L was 0.39 (0.14, 1.28). The OR for patients with fT3 3.3 (OR =6.00 (2.94, 12.25)). Conclusion In this study, a direct relationship between high levels of fT4 and malignancy was uncovered. Furthermore, low levels of TSH and fT4 increased the likelihood that a nodule was benign. In this study a fT4/fT3 ratio >3.3 increased the risk of malignancy by 3.6 times (p-value =0.0013)

The first Canadian experience with the Afirma® gene expression classifier test

Abstract Background Thyroid nodules are common and often benign, although prove to be malignant upon surgical pathology in 5–15% of cases. When assessed with ultrasound-guided fine-needle aspiration (USFNA), 15–30% of the nodules yield an indeterminate result. The Afirma® gene expression classifier (AGEC) was developed to improve management of indeterminate thyroid nodules (ITNs) by classifying them as “benign” or “suspicious.” Objectives were (1) to assess the performance of the AGEC in two Canadian academic medical centres (2), to search for inter-institutional variation and (3) to compare AGEC performance in Canadian versus American institutions. Methods We undertook a retrospective cohort study of patients with indeterminate cytopathology (Bethesda Class III or IV) as per USFNA who underwent AGEC testing. We reviewed patient demographics, cytopathological results, AGEC data and, if the patient underwent surgery, results from their final pathology. Results In total, we included 172 patients with Bethesda Class III or IV thyroid nodules underwent AGEC testing, 109 in Montreal, Quebec and 63 in St. John’s, Newfoundland, in this study. Among the nodules sent for testing, 55% (60/109) in Montreal and 46% (29/63) in St. John’s returned as “benign.” None of these patients underwent surgery. On the other hand, 45% (49/109) nodules in Montreal and 54% (34/63) in St. John’s were found to be “suspicious,” for a total of 83 specimens. Seventy seven of these patients underwent surgery. Both in Montreal and St. John’s, the final pathology yielded malignant thyroid disease in approximately 50% of the specimens categorized as “suspicious.” Since 2013, no patient diagnosed with a benign nodule as per AGEC testing was found to harbor a malignant thyroid nodule on follow-up. Conclusions Molecular analysis is increasingly used in the management of indeterminate thyroid nodules. This study highlights the experience of two Canadian centres with AGEC testing. We found inter-institutional variability in the rate of nodules returning as “benign,” however we found similar rates of confirmed malignancy in nodules returning as “suspicious.” According the literature, results for AGEC testing in two Canadian institutions align with results reported in American centres

Health-status outcomes with invasive or conservative care in coronary disease

BACKGROUND In the ISCHEMIA trial, an invasive strategy with angiographic assessment and revascularization did not reduce clinical events among patients with stable ischemic heart disease and moderate or severe ischemia. A secondary objective of the trial was to assess angina-related health status among these patients. METHODS We assessed angina-related symptoms, function, and quality of life with the Seattle Angina Questionnaire (SAQ) at randomization, at months 1.5, 3, and 6, and every 6 months thereafter in participants who had been randomly assigned to an invasive treatment strategy (2295 participants) or a conservative strategy (2322). Mixed-effects cumulative probability models within a Bayesian framework were used to estimate differences between the treatment groups. The primary outcome of this health-status analysis was the SAQ summary score (scores range from 0 to 100, with higher scores indicating better health status). All analyses were performed in the overall population and according to baseline angina frequency. RESULTS At baseline, 35% of patients reported having no angina in the previous month. SAQ summary scores increased in both treatment groups, with increases at 3, 12, and 36 months that were 4.1 points (95% credible interval, 3.2 to 5.0), 4.2 points (95% credible interval, 3.3 to 5.1), and 2.9 points (95% credible interval, 2.2 to 3.7) higher with the invasive strategy than with the conservative strategy. Differences were larger among participants who had more frequent angina at baseline (8.5 vs. 0.1 points at 3 months and 5.3 vs. 1.2 points at 36 months among participants with daily or weekly angina as compared with no angina). CONCLUSIONS In the overall trial population with moderate or severe ischemia, which included 35% of participants without angina at baseline, patients randomly assigned to the invasive strategy had greater improvement in angina-related health status than those assigned to the conservative strategy. The modest mean differences favoring the invasive strategy in the overall group reflected minimal differences among asymptomatic patients and larger differences among patients who had had angina at baseline