The effect of using different needle size on patient comfort and pain during the sonographically guided fine needle biopsy of thyroid nodules

The effect of using different needle size on patient comfort and pain during the sonographically guided fine needle biopsy of thyroid nodules | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The effect of using different needle size on patient comfort and pain during the sonographically guided fine needle biopsy of thyroid nodules Mehmet This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4624735/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Backround Fine needle biopsy has been used for many decades, but afew studies showed the relationship between pain and needle diameter. Object This study aimed to compare patients’ pain and satisfaction levels between 22 and 27-gauge (G) needles used for fine-needle biopsy of thyroid nodules. Materials and methods In our study, one hundred sixty-nine patients with thyroid nodule biopsies (159 nodules) were included. Patients with nodules were separated into two independent groups depending on which needle were used. The questionnaire was applied to all the patients after the thyroid biopsy. The main study method was the pain scale measuring a patient’s pain intensity, based on a self-report regarding Visual Analog Scale. The numeric variables between two groups used the Student t test, more than two independent groups used a one-way ANOVA test, and between two categorical variables used a Chi-square test. Results There was no statistically significant difference between 22 G and 27 G needles in terms of pain sensations. (P > 0.05). And also there was no statistical differences between gender, pattern of nodule and diameter of nodules. But the women is more prone to feel sensation than men. (P<0,05) Conclusion Thyroid fine needle aspiration biopsy is one of the invasive methods that could cause unsatisfactory and pain in patients. The use of different gauges of biopsy can affect the biopsy pain and satisfaction. The results of our study showed that fine needle biopsy with 22-G needles had no difference when we compared it to 27- G needle biopsy Pain. Biopsy. Thyroid nodules. Ultrasonography Introduction The pre-surgical diagnosis of thyroid lesions by using fine needle biopsy (FNB) has become the most important and effective tool in recent decades. Because of the very high occurrence of thyroid gland nodular goiter all over Europe, the use of cytological aspiration seems to be one of the principal examinations in the whole endocrinology. Although thyroid nodule FNB has high efficacy (from 79–95%), sensitivity (85.7%), specificity (up to 100%), positive predictive value (up to 100%), negative predictive value (94.9%), and accuracy (96.1%) ( 1 ), in this study we aimed to focus on the side effects of this procedure such as pain and comfort of the patient. The sensation of pain is one of the side effects that affects each patient who undergoing to thyroid fine needle biopsy and it changes from patient to patient, some of them can be described as a pinch and some of them feel much stronger feelings ( 2 ) There are no sufficient data about the pain degree and its relation to parameters like needle size and nodule diameter and nodule sonographic structure, age, and gender, although those parameters which have efficacy on the procedure is a very popular topic of publications. The procedure and results of treatment can not be separated from each other, if we look for the best conditions of medical examinations, it would be important not to avoid underestimating the patient’s sensations of pain. The study aimed to estimate the correlation between the needle size, nodule size, echostructre of nodule parenchyma, age, and gender to the level of pain sensation. Material and methods The study included 159 patients who met the inclusion criteria for study participants between December 2023 and March 2024. The inclusion criteria first, the thyroid nodules that required a US-FNB were 3 mm or larger in the maximum diameter, - and second, the locations of the thyroid nodules were intraglandular and were relatively central in the thyroid. The exclusion criteria for study participants were as follows: patient’s refusal (patient did not sign consent), participants who had a history of bleeding tendency and who had been taking anticoagulants, substernal or sub clavicular localization of the lesion in the case of large goiter. The study protocol was approved by the local ethics committee. The patients were between 23 and 88 years of age (mean, 53,38 years). There were 117 females and 42 males. The main study method was the existence of a pain and pain scale measuring a patient’s pain intensity based on a self-report by using a questionnaire after biopsy. Just after the biopsy, each of the participants had a questionnaire to complete the scale in which she/he was supposed to estimate the individual degree of the pain sensation during the procedure. Also, the patient was asked to comfort degree during the biopsy. When responding to a question, respondents specified their level of pain severity by indicating a position along a continuous line between two end-points: from 0 (no pain) to 10 (unbearable pain). Our questionnaire was based on a very popular psychometric scale VAS, which was previously confirmed to be very effective in subjective pain estimation among patients with various diagnoses ( 3 – 4 ). Different modifications of VAS were used in the psychological assessment of a wide variety of health-related constructs including pain [5], quality of life ( 5 ), and mood ( 6 ). Fine needle biopsy was performed under the guidance of the US examination using a high-resolution ultrasound device (SAMSUNG, HS50, Seul, SOUTH KOREA) with a 12-15-MHz linear probe. An experienced radiologist performed all biopsies using 21-gauge and 27-gauge needles under US guidance. No local anesthesia was used. For each patient, one needle size was used. The procedure was started with patients placed in the supine position with their necks a little extended and after they confirmed to feel comfortable. First, the sterilization is done with a conventional alcohol solution. The adjusting the US probe, the target nodule was placed in the center of the image after appropriate positioning. The needle was then vertically inserted into the target nodule in the center of the transverse US image. After properly puncturing the target part of the nodule, the needle was moved up and down for a few seconds only by movement of the operator’s wrist, without aspiration with a syringe. Just after the procedure (within a maximum of 5 minutes), each patient was given to complete a pain survey with a nurse helping and then he/she estimated his/her pain sensation by marking the number. Collected data were tabelarized and SPSS 21 for Windows was used for statistical analysis. Results The mean pain sensation for the whole study group was 4,11 ± 2,652. According to Sex differences, There were no statistical differences between men and women in the subjective estimation of pain intensity during FNAB. (P > 0.05 CI: -0,305-1,794)) Table 1 . It can be supposed that the lack of differences might result from the small number of men involved in the study, as in the general population most thyroid patients are women. When we compare patient comfort between the two genders, nominally women were more pleased than men. But statistically, there was no difference between them. It is because the number of samples of men was inadequate. ( Pearson chi -Square P > 0,05) Graphic 1. Table 2 . Table 1 Pain score and sex. Group Statistics GENDER N Mean Std. Deviation Std. Error Mean Voc scla Woman 117 4,29 2,571 0,257 Man 42 3,55 2,851 0,496 Table 2 Patient comfort and sex cross table. Patient comfort not pleased low pleased pleased very pleased Total Woman Count 5 11 65 36 117 Expected Count 5,2 11,8 59,6 40,5 117,0 % within GENDER 4,3% 9,4% 55,6% 30,8% 100,0% Man Count 2 5 16 419 42 Expected count 1,8 4,2 21,4 14,5 42 % within GENDER 4,8% 11,9% 38,1% 45,2% 100% No correlation was found between the type of needle and the pain sensation. There were sixty seven patients % 42,1 who underwent biopsy with 21 Gauge needles and 92 patients % 57,9 with 27 Gauge needles. Statistically, there was no difference between them. (p > 0.05)The median pain score in biopsy with 21 G is 3,49 and with 27 G is 3,67. The highest degree was 10 within three patients who biopsied with 27 G. Table 3 , Graphic 2. Table 3 Voc scale and group statistic cross table Group Statistics Frequency Percent Mean Std. Dev. Std.Error Mean VOC Scale 21 Gauge 67 42,1 3,49 2,590 0,316 27 Gauge 92 57,9 3,67 2,762 0,288 Total 159 100,0 There was no statistically significant correlation between pain and the pattern of nodules (P > 0.05). 34% of the patients’ pattern of nodules are heterogenous and have 3,51 ± 2,39 average pain score meanwhile 9,4% of patients’ nodule patterns are hyperechoic patterns have 3,87 ± 2,99 Table 4 , Graphic 3. Table 4 Voc scale and nodule pattern. Voc scale Nodule Patern Mean N Std. Deviation Izoechoic 3,51 43 2,394 Hypherechoic 3,87 15 2,997 Hyphoechoic 4,04 47 2,743 Heterogeneous 3,2 54 2,743 Total 3,60 159 2,684 There was a statistical correlation between pain and nodule diameter. (P < 0,05). Pain with a large nodule diameter was estimated less than others. 11 patients have between 41–50 mm nodule diameter with an estimated average pain score of 3,0 ± 2,280. Table 5 , Graphic 4 Table 5 Voc scale means and maximum diameter cross table. Voc sclae maximum diameter Mean N Std. Deviation 0–10 mm 3,97 30 2,58 11–20 mm 4,56 62 2,934 21–30 mm 2,38 45 1,910 31–40 mm 2,8 10 2,700 41–50 mm 3,00 11 2,280 51–60 mm 2,00 1 To search for pain in thyroid biopsy patients and to explore patients who are much more inclined to feel pain, consisted of a model that includes age, gender, nodule pattern, maximum diameter, and biopsy needles by using binary logistic regression analysis. In this model, -2 log-likelihood is 192,165 and too high. The model that was created was not available. Because of being R square was 0,21. The factors we used to explain which factor affects pain have only 21% percent over the pain Table 6 . In this model that is shaped with categorical and numerical data we found that between genders had meaningful results in that women had less pain when we consider men had. Table 6. Logistic regression analysis. Model Summary Step -2 Log likelihood Cox & Snell R Square Nagelkerke R Square 1 192,165a 0,158 0,210 a. Estimation terminated at iteration number 20 because maximum iterations has been reached. Final solution can not be found Discussion Approximately the past 20 years FNABs of thyroid nodules have been routinely used worldwide. However the complications that would happen are not reported. Despite using thinner needles during the biopsy, the patient seems to easily tolerate the pain or discomfort related to procedure. As a result many of patients complain about the pain sensations and tryto avoid the next biopsy. Because of being inexact operator’s puncture, pain and discomfort in some cases might contribute to inadequate cytological results ( 7 ). The consequence of different reasons: patient’s instable position during the procedure, tensioning of neck muscles, emotional reactions affecting the operator’s activity or probably other – awareness of the disease. The patients’ expectations and prevent complications related to pain and having in mind patients’ rights, it is important to find a way of improving their comfort during the procedure. And also it is important to identify pain intensity and reasons of its increased perception. It has also already been reported that using different anesthetics reduces the pain accompanying thyroid FNAB ( 8 , 9 ), however some other reports lead to opposite conclusions ( 10 – 12 ). Thinking about the pain we intended to document its real intensity. Despite prior anxious declarations, most of the patients in the study described the pain as moderate. The average pain level among the patients was 4,1 on a scale of 1 to 10. That is close to other studies ( 13 ) The fact that we did not reveal any correlation between the pain level and sex, type of needle, pattern of nodules, and maximum diameter. The specialist who was the performer of all biopsies was experienced and well-trained, so it excluded lack of expertise and vigorous handling of the needle which might also increase the severity of pain. Comparable impressions of pain among examined men and women confirmed the results of other studies ( 13 ) but might result from a small number of males in the group. Despite not having any studies on using different needles that could affect pain sensation and comfort we couldn't compare our results. Independence from the pain scale, we wanted to explain which factors could affect on existence of pain. It was much more related to gender only itself. But other factors such as age, nodule diameter, needle type, and sonographic pattern did not. Many studies reported that anxious, non-cooperative, pain-phobic or needle-phobic patients might represent a small group with higher pain sensations ( 13 – 14 ). It was clear that there was a positive relationship between anxiety and pain. We could face our daily clinical routine in clinical settings ( 15 – 16 ) During medical invasive procedures accurate preparatory information alleviated pain by disengaging the hippocampus. It supports the proposal that during anxiety, the hippocampal formation amplifies aversive events to prime behavioral responses that are adaptive to the worst possible outcome. ( 17 ) It is also important that the patient’s mental status and attitude. thus patients need a proper psychological approach before every single procedure could help in fighting anxiety, tension, and overreaction related to thyroid puncture. In this way, the number of ineffective biopsies may be decreased, and repeated examinations could also encouraged. This type of psychological support may be also helpful for the patient to agree to the biopsy. The patient is informed about biopsy side effects including accompanying pain and its meaning which can involve fear and anxiety could be effective for such agreement ( 13 ). The patient should be also informed about possible types of anesthesia in cases of painful methods of treatment. The disadvantages and advantages of the specified method must be included in this information. The procedure may be applied after obtaining the patient’s consent, but the key role is the rules of proper communication. A proper psychological approach, involving effective patient-physician communication before this invasive procedure seems to be one of many factors improving the quality of thyroid biopsy. The using alternative FNAB methods such as core needle biopsy could be considered. But it has a comparable needle diameter that is larger than our needles’ diameter and probably is painfull method than our methods. There are still no studies investigating this problem. Also, some studies suggested that core needle biopsy could be more beneficial than classical FNAB due to its lower non-diagnostic rate ( 18 ), but others suggest lower accuracy ( 19 ). Conclusions In the study group, we found that a moderate level of pain accompanying thyroid biopsy appeared to be dominant. There were no statistically significant correlations between the intensity of pain, gender, pattern, and diameter of the nodules of the patient. However, the model which was constructed with age, gender, pattern, and diameter of nodule to explain which one of them is more prone to have existing pain sensation demonstrated that women are more prone to feel pain than men. References Kim DW, Lee EJ, Kim SH, et al. Ultrasound-guided fine-needle aspiration biopsy of thyroid nodules: comparison in efficacy according to nodule size. Thyroid 2009; 19: 27-31. Newkirk KA, Ringel MD, Jelinek J, et al. Ultrasound-guided fine-needle aspiration and thyroid disease. Otolaryngol Head Neck Surg 2000; 123: 700-5 Jensen MP, Chen C, Brugger AM. Interpretation of visual analog scale ratings and change scores: a reanalysis of two clinical trials of postoperative pain. J Pain 2003; 4: 407-14. Williams VS, Morlock RJ, Feltner D. Psychometric evaluation of a visual analog scale for the assessment of anxiety. Health Qual Life Outcomes 2010; 8: 57.. De Boer AG, van Lanschot JJ, Stalmeier PF, et al. Is a single-item visual analogue scale as valid, reliable and responsive as multi-item scales in measuring quality of life? Qual Life Res 2004; 13: 311-20. Lingjaerde O, Føreland AR. Direct assessment of improvement in winter depression with a visual analogue scale: high reliability and validity. Psychiatry Res 1998; 81: 387-92. Leung AM, Farwell AP. Unsatisfactory consequences from fine-needle aspiration biopsy of thyroid nodules. Thyroid 2008; 18: 491-2. Gursoy A, Ertugrul DT, Sahin M, et al. Needle-free delivery of lidocaine for reducing the pain associated with the fine-needle aspiration biopsy of thyroid nodules: time-saving and efficacious procedure. Thyroid 2007; 17: 317-21 Gursoy A, Ertugrul DT, Sahin M, et al. The analgesic efficacy of lidocaine/ prilocaine (EMLA) cream during fine-needle aspiration biopsy of thyroid nodules. Clin Endocrinol 2007; 66: 691-4. Rausch P, Nowels K, Jeffrey RB Jr. Ultrasonographically guided thyroid biopsy: a review with emphasis on technique. J Ultrasound Med 2001; 20: 79-85. O’Malley ME, Weir MM, Hahn PF, et al. US-guided fine-needle aspiration biopsy of thyroid nodules: adequacy of cytologic material and procedure time with and without immediate cytologic analysis. Radiology 2002; 222: 383-7 Demirci H, Erdamar H, Karakoc A, Arslan M. Thyroid fine needle aspiration biopsy: is topical local anaesthesia beneficial? Int J Clin Pract 2010; 64: 25-8. Adam S , Marek R, Izabela W, et al. Pain associated with fine-needle aspiration biopsy of thyroid nodules.Przegląd Menopauzalny 2012; 3: 233–238. Degirmenci B, Haktanir A, Albayrak R, et al. Sonographically guided fine needle biopsy of thyroid nodules: the effects of nodule characteristics, sampling technique, and needle size on the adequacy of cytological material. Clin Radiol 2007; 62: 798-803. Melzack R. The puzzle of pain. Basic Books, New York 1979 Grachev ID, Fredickson BE, Apkarian AV. Dissociating anxiety from pain: mapping the neuronal marker N-acetyl aspartate to perception distinguishes closely interrelated characteristics of chronic pain. Mol Psychiatry 2001; 6: 256-8. Ploghaus A, Narain C, Beckmann CF, et al. Exacerbation of pain by anxiety is associated with activity in a hippocampal network. J Neurosc 2001; 21: 9896-903. Harvey JN, Parker D, De P, et al. Sonographically guided core biopsy in the assessment of thyroid nodules. J Clin Ultrasound 2005; 33: 57-62. Liu Q, Castelli M, Gattuso P, Prinz RA. Simultaneous fine-needle aspiration and core-needle biopsy of thyroid nodules. Am Surg 1995; 61: 628-32. Graphic Graphic 1-4 are available in the Supplementary Files section. Additional Declarations The authors declare no competing interests. Supplementary Files grafic1.jpg Graphic 1.Patient comfort and sex graphic2.jpg Graphic 2. Box plot voc scale and the needles type graphic3.jpg Graphic 3. Box plot graphic nodule pattern and Voc scale. graphic4.jpg Graphic 4. Voc scale and Nodule Diameter Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4624735","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":317852474,"identity":"ac754739-103d-4893-9758-5ad8f6f6ada9","order_by":0,"name":"Mehmet","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7UlEQVRIiWNgGAWjYBCDBCBmfAAkePiIUM3YANHCzGwA0sJGihY2CRCXoBaD48evP+bNscnTbe8/Vvk1x06GjYH54aMb+LScySls5t2WVmx25jDbbdltyUCHsRkb5+DTciAnEajlcOK2G8lstyW3MQO18LBJ49Vy/g1Iy//EbfcfsxVLbqsnQsuN9INALQeAtjCzMX7cdpiwFskbbxhnzt2WnLjtTLKxNOO24zxszAT8wnc+/cGHt9vsErcdP/jw489t1fb87M0PH+PTonCAxwDOYeYBk3iUg4B8A/sDOIfxBwHVo2AUjIJRMDIBADgsTs7Q9DkkAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0009-0005-4272-7544","institution":"Yağtu","correspondingAuthor":true,"prefix":"","firstName":"","middleName":"","lastName":"Mehmet","suffix":""}],"badges":[],"createdAt":"2024-06-23 09:53:42","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":true,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-4624735/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4624735/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":58986680,"identity":"e5c9c462-1286-4b25-8591-d0df8b9273dd","added_by":"auto","created_at":"2024-06-25 03:54:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":332448,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4624735/v1/d12d5d89-1719-4eb6-bf6d-f75763dea07a.pdf"},{"id":58984941,"identity":"f0536233-215a-4ccb-9ccd-95742ace76bc","added_by":"auto","created_at":"2024-06-25 03:30:48","extension":"jpg","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":29163,"visible":true,"origin":"","legend":"\u003cp\u003eGraphic 1.Patient comfort and sex\u003c/p\u003e","description":"","filename":"grafic1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4624735/v1/ad1b21df9cabbd2ecf2e312b.jpg"},{"id":58985834,"identity":"43b589c8-3602-40b3-b861-8525ce9109b5","added_by":"auto","created_at":"2024-06-25 03:46:48","extension":"jpg","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":36323,"visible":true,"origin":"","legend":"\u003cp\u003eGraphic 2. Box plot voc scale and the needles type\u003c/p\u003e","description":"","filename":"graphic2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4624735/v1/d4039bb9973b744ccb3cba7d.jpg"},{"id":58985185,"identity":"ce6a3e3e-ba61-4b50-abc9-8ef2954b4b63","added_by":"auto","created_at":"2024-06-25 03:38:48","extension":"jpg","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":43207,"visible":true,"origin":"","legend":"\u003cp\u003eGraphic 3. Box plot graphic nodule pattern and Voc scale.\u003c/p\u003e","description":"","filename":"graphic3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4624735/v1/eb843981f9cf31556fc6f6ef.jpg"},{"id":58984944,"identity":"86767c8e-fbf3-4054-9b35-d1f2c3b1c911","added_by":"auto","created_at":"2024-06-25 03:30:48","extension":"jpg","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":45256,"visible":true,"origin":"","legend":"\u003cp\u003eGraphic 4. Voc scale and Nodule Diameter\u003c/p\u003e","description":"","filename":"graphic4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4624735/v1/7684a504d81e821ac3b1a614.jpg"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eThe effect of using different needle size on patient comfort and pain during the sonographically guided fine needle biopsy of thyroid nodules\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe pre-surgical diagnosis of thyroid lesions by using fine needle biopsy (FNB) has become the most important and effective tool in recent decades. Because of the very high occurrence of thyroid gland nodular goiter all over Europe, the use of cytological aspiration seems to be one of the principal examinations in the whole endocrinology. Although thyroid nodule FNB has high efficacy (from 79\u0026ndash;95%), sensitivity (85.7%), specificity (up to 100%), positive predictive value (up to 100%), negative predictive value (94.9%), and accuracy (96.1%) (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), in this study we aimed to focus on the side effects of this procedure such as pain and comfort of the patient. The sensation of pain is one of the side effects that affects each patient who undergoing to thyroid fine needle biopsy and it changes from patient to patient, some of them can be described as a pinch and some of them feel much stronger feelings (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) There are no sufficient data about the pain degree and its relation to parameters like needle size and nodule diameter and nodule sonographic structure, age, and gender, although those parameters which have efficacy on the procedure is a very popular topic of publications.\u003c/p\u003e \u003cp\u003eThe procedure and results of treatment can not be separated from each other, if we look for the best conditions of medical examinations, it would be important not to avoid underestimating the patient\u0026rsquo;s sensations of pain. The study aimed to estimate the correlation between the needle size, nodule size, echostructre of nodule parenchyma, age, and gender to the level of pain sensation.\u003c/p\u003e"},{"header":"Material and methods","content":"\u003cp\u003eThe study included 159 patients who met the inclusion criteria for study participants between December 2023 and March 2024. The inclusion criteria first, the thyroid nodules that required a US-FNB were 3 mm or larger in the maximum diameter, - and second, the locations of the thyroid nodules were intraglandular and were relatively central in the thyroid. The exclusion criteria for study participants were as follows: patient\u0026rsquo;s refusal (patient did not sign consent), participants who had a history of bleeding tendency and who had been taking anticoagulants, substernal or sub clavicular localization of the lesion in the case of large goiter. The study protocol was approved by the local ethics committee. The patients were between 23 and 88 years of age (mean, 53,38 years). There were 117 females and 42 males.\u003c/p\u003e \u003cp\u003eThe main study method was the existence of a pain and pain scale measuring a patient\u0026rsquo;s pain intensity based on a self-report by using a questionnaire after biopsy. Just after the biopsy, each of the participants had a questionnaire to complete the scale in which she/he was supposed to estimate the individual degree of the pain sensation during the procedure. Also, the patient was asked to comfort degree during the biopsy. When responding to a question, respondents specified their level of pain severity by indicating a position along a continuous line between two end-points: from 0 (no pain) to 10 (unbearable pain). Our questionnaire was based on a very popular psychometric scale VAS, which was previously confirmed to be very effective in subjective pain estimation among patients with various diagnoses (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Different modifications of VAS were used in the psychological assessment of a wide variety of health-related constructs including pain [5], quality of life (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), and mood (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Fine needle biopsy was performed under the guidance of the US examination using a high-resolution ultrasound device (SAMSUNG, HS50, Seul, SOUTH KOREA) with a 12-15-MHz linear probe. An experienced radiologist performed all biopsies using 21-gauge and 27-gauge needles under US guidance. No local anesthesia was used. For each patient, one needle size was used. The procedure was started with patients placed in the supine position with their necks a little extended and after they confirmed to feel comfortable. First, the sterilization is done with a conventional alcohol solution. The adjusting the US probe, the target nodule was placed in the center of the image after appropriate positioning. The needle was then vertically inserted into the target nodule in the center of the transverse US image. After properly puncturing the target part of the nodule, the needle was moved up and down for a few seconds only by movement of the operator\u0026rsquo;s wrist, without aspiration with a syringe. Just after the procedure (within a maximum of 5 minutes), each patient was given to complete a pain survey with a nurse helping and then he/she estimated his/her pain sensation by marking the number. Collected data were tabelarized and SPSS 21 for Windows was used for statistical analysis.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe mean pain sensation for the whole study group was 4,11\u0026thinsp;\u0026plusmn;\u0026thinsp;2,652. According to Sex differences, There were no statistical differences between men and women in the subjective estimation of pain intensity during FNAB. (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05 CI: -0,305-1,794)) Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. It can be supposed that the lack of differences might result from the small number of men involved in the study, as in the general population most thyroid patients are women. When we compare patient comfort between the two genders, nominally women were more pleased than men. But statistically, there was no difference between them. It is because the number of samples of men was inadequate. ( Pearson chi -Square P\u0026thinsp;\u0026gt;\u0026thinsp;0,05) Graphic 1. Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003ePain score and sex.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"6\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"6\"\u003e\n \u003cp\u003eGroup Statistics\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eGENDER\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStd. Deviation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStd. Error Mean\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eVoc scla\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWoman\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e117\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,571\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0,257\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,851\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0,496\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003ePatient comfort and sex cross table.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"8\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"8\"\u003e\n \u003cp\u003ePatient comfort\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003enot pleased\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003elow pleased\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003epleased\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003every pleased\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"6\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eWoman\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCount\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e117\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eExpected Count\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e117,0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e% within GENDER\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9,4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55,6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30,8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100,0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eMan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCount\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e419\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eExpected count\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21,4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e% within GENDER\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11,9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38,1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45,2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eNo correlation was found between the type of needle and the pain sensation. There were sixty seven patients % 42,1 who underwent biopsy with 21 Gauge needles and 92 patients % 57,9 with 27 Gauge needles. Statistically, there was no difference between them. (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05)The median pain score in biopsy with 21 G is 3,49 and with 27 G is 3,67. The highest degree was 10 within three patients who biopsied with 27 G. Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e, Graphic 2.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eVoc scale and group statistic cross table\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"7\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"7\"\u003e\n \u003cp\u003eGroup Statistics\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePercent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStd. Dev.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStd.Error Mean\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eVOC Scale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21 Gauge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,590\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0,316\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 Gauge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,762\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0,288\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e159\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThere was no statistically significant correlation between pain and the pattern of nodules (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). 34% of the patients\u0026rsquo; pattern of nodules are heterogenous and have 3,51\u0026thinsp;\u0026plusmn;\u0026thinsp;2,39 average pain score meanwhile 9,4% of patients\u0026rsquo; nodule patterns are hyperechoic patterns have 3,87\u0026thinsp;\u0026plusmn;\u0026thinsp;2,99 Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e, Graphic 3.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eVoc scale and nodule pattern.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eVoc scale\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNodule Patern\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStd. Deviation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIzoechoic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,394\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHypherechoic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,997\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHyphoechoic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,743\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHeterogeneous\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,743\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e159\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,684\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThere was a statistical correlation between pain and nodule diameter. (P\u0026thinsp;\u0026lt;\u0026thinsp;0,05). Pain with a large nodule diameter was estimated less than others. 11 patients have between 41\u0026ndash;50 mm nodule diameter with an estimated average pain score of 3,0\u0026thinsp;\u0026plusmn;\u0026thinsp;2,280. Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e, Graphic 4\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab5\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eVoc scale means and maximum diameter cross table.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eVoc sclae\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003emaximum diameter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStd. Deviation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u0026ndash;10 mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,58\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u0026ndash;20 mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,934\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21\u0026ndash;30 mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,910\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31\u0026ndash;40 mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,700\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41\u0026ndash;50 mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,280\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51\u0026ndash;60 mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eTo search for pain in thyroid biopsy patients and to explore patients who are much more inclined to feel pain, consisted of a model that includes age, gender, nodule pattern, maximum diameter, and biopsy needles by using binary logistic regression analysis. In this model, -2 log-likelihood is 192,165 and too high. The model that was created was not available. Because of being R square was 0,21. The factors we used to explain which factor affects pain have only 21% percent over the pain Table \u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e. In this model that is shaped with categorical and numerical data we found that between genders had meaningful results in that women had less pain when we consider men had.\u003c/p\u003e\n\u003cp\u003eTable 6. Logistic regression analysis.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"602\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eModel Summary\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-2 Log likelihood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCox \u0026amp; Snell R Square\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNagelkerke R Square\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e192,165a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0,158\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0,210\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003ea. Estimation terminated at iteration number 20 because maximum iterations has been reached. Final solution can not be found\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eApproximately the past 20 years FNABs of thyroid nodules have been routinely used worldwide. However the complications that would happen are not reported. Despite using thinner needles during the biopsy, the patient seems to easily tolerate the pain or discomfort related to procedure. As a result many of patients complain about the pain sensations and tryto avoid the next biopsy.\u003c/p\u003e \u003cp\u003eBecause of being inexact operator\u0026rsquo;s puncture, pain and discomfort in some cases might contribute to inadequate cytological results (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). The consequence of different reasons: patient\u0026rsquo;s instable position during the procedure, tensioning of neck muscles, emotional reactions affecting the operator\u0026rsquo;s activity or probably other \u0026ndash; awareness of the disease. The patients\u0026rsquo; expectations and prevent complications related to pain and having in mind patients\u0026rsquo; rights, it is important to find a way of improving their comfort during the procedure. And also it is important to identify pain intensity and reasons of its increased perception. It has also already been reported that using different anesthetics reduces the pain accompanying thyroid FNAB (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), however some other reports lead to opposite conclusions (\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThinking about the pain we intended to document its real intensity. Despite prior anxious declarations, most of the patients in the study described the pain as moderate. The average pain level among the patients was 4,1 on a scale of 1 to 10. That is close to other studies (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) The fact that we did not reveal any correlation between the pain level and sex, type of needle, pattern of nodules, and maximum diameter. The specialist who was the performer of all biopsies was experienced and well-trained, so it excluded lack of expertise and vigorous handling of the needle which might also increase the severity of pain. Comparable impressions of pain among examined men and women confirmed the results of other studies (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) but might result from a small number of males in the group. Despite not having any studies on using different needles that could affect pain sensation and comfort we couldn't compare our results.\u003c/p\u003e \u003cp\u003eIndependence from the pain scale, we wanted to explain which factors could affect on existence of pain. It was much more related to gender only itself. But other factors such as age, nodule diameter, needle type, and sonographic pattern did not.\u003c/p\u003e \u003cp\u003eMany studies reported that anxious, non-cooperative, pain-phobic or needle-phobic patients might represent a small group with higher pain sensations (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). It was clear that there was a positive relationship between anxiety and pain. We could face our daily clinical routine in clinical settings (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) During medical invasive procedures accurate preparatory information alleviated pain by disengaging the hippocampus. It supports the proposal that during anxiety, the hippocampal formation amplifies aversive events to prime behavioral responses that are adaptive to the worst possible outcome. (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) It is also important that the patient\u0026rsquo;s mental status and attitude. thus patients need a proper psychological approach before every single procedure could help in fighting anxiety, tension, and overreaction related to thyroid puncture. In this way, the number of ineffective biopsies may be decreased, and repeated examinations could also encouraged. This type of psychological support may be also helpful for the patient to agree to the biopsy. The patient is informed about biopsy side effects including accompanying pain and its meaning which can involve fear and anxiety could be effective for such agreement (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The patient should be also informed about possible types of anesthesia in cases of painful methods of treatment. The disadvantages and advantages of the specified method must be included in this information. The procedure may be applied after obtaining the patient\u0026rsquo;s consent, but the key role is the rules of proper communication. A proper psychological approach, involving effective patient-physician communication before this invasive procedure seems to be one of many factors improving the quality of thyroid biopsy.\u003c/p\u003e \u003cp\u003eThe using alternative FNAB methods such as core needle biopsy could be considered. But it has a comparable needle diameter that is larger than our needles\u0026rsquo; diameter and probably is painfull method than our methods. There are still no studies investigating this problem. Also, some studies suggested that core needle biopsy could be more beneficial than classical FNAB due to its lower non-diagnostic rate (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), but others suggest lower accuracy (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn the study group, we found that a moderate level of pain accompanying thyroid biopsy appeared to be dominant. There were no statistically significant correlations between the intensity of pain, gender, pattern, and diameter of the nodules of the patient. However, the model which was constructed with age, gender, pattern, and diameter of nodule to explain which one of them is more prone to have existing pain sensation demonstrated that women are more prone to feel pain than men.\u003c/p\u003e"},{"header":"References","content":"\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eKim DW, Lee EJ, Kim SH, et al. Ultrasound-guided fine-needle aspiration biopsy of thyroid nodules: comparison in efficacy according to nodule size. Thyroid 2009; 19: 27-31.\u003c/li\u003e\n \u003cli\u003eNewkirk KA, Ringel MD, Jelinek J, et al. Ultrasound-guided fine-needle aspiration and thyroid disease. Otolaryngol Head Neck Surg 2000; 123: 700-5\u003c/li\u003e\n \u003cli\u003eJensen MP, Chen C, Brugger AM. Interpretation of visual analog scale ratings and change scores: a reanalysis of two clinical trials of postoperative pain. J Pain 2003; 4: 407-14.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eWilliams VS, Morlock RJ, Feltner D. Psychometric evaluation of a visual analog scale for the assessment of anxiety. Health Qual Life Outcomes 2010; 8: 57..\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eDe Boer AG, van Lanschot JJ, Stalmeier PF, et al. Is a single-item visual analogue scale as valid, reliable and responsive as multi-item scales in measuring quality of life? Qual Life Res 2004; 13: 311-20.\u003c/li\u003e\n \u003cli\u003eLingjaerde O, F\u0026oslash;reland AR. Direct assessment of improvement in winter depression with a visual analogue scale: high reliability and validity. Psychiatry Res 1998; 81: 387-92.\u003c/li\u003e\n \u003cli\u003eLeung AM, Farwell AP. Unsatisfactory consequences from fine-needle aspiration biopsy of thyroid nodules. Thyroid 2008; 18: 491-2.\u003c/li\u003e\n \u003cli\u003eGursoy A, Ertugrul DT, Sahin M, et al. Needle-free delivery of lidocaine for reducing the pain associated with the fine-needle aspiration biopsy of thyroid nodules: time-saving and efficacious procedure. Thyroid 2007; 17: 317-21\u003c/li\u003e\n \u003cli\u003eGursoy A, Ertugrul DT, Sahin M, et al. The analgesic efficacy of lidocaine/ prilocaine (EMLA) cream during fine-needle aspiration biopsy of thyroid nodules. Clin Endocrinol 2007; 66: 691-4.\u003c/li\u003e\n \u003cli\u003eRausch P, Nowels K, Jeffrey RB Jr. Ultrasonographically guided thyroid biopsy: a review with emphasis on technique. J Ultrasound Med 2001; 20: 79-85.\u003c/li\u003e\n \u003cli\u003eO\u0026rsquo;Malley ME, Weir MM, Hahn PF, et al. US-guided fine-needle aspiration biopsy of thyroid nodules: adequacy of cytologic material and procedure time with and without immediate cytologic analysis. Radiology 2002; 222: 383-7\u003c/li\u003e\n \u003cli\u003eDemirci H, Erdamar H, Karakoc A, Arslan M. Thyroid fine needle aspiration biopsy: is topical local anaesthesia beneficial? Int J Clin Pract 2010; 64: 25-8.\u003c/li\u003e\n \u003cli\u003eAdam S , Marek R, Izabela W, et al. Pain associated with fine-needle aspiration biopsy of thyroid nodules.Przegląd Menopauzalny 2012; 3: 233\u0026ndash;238.\u003c/li\u003e\n \u003cli\u003eDegirmenci B, Haktanir A, Albayrak R, et al. Sonographically guided fine needle biopsy of thyroid nodules: the effects of nodule characteristics, sampling technique, and needle size on the adequacy of cytological material. Clin Radiol 2007; 62: 798-803.\u003c/li\u003e\n \u003cli\u003eMelzack R. The puzzle of pain. Basic Books, New York 1979\u003c/li\u003e\n \u003cli\u003eGrachev ID, Fredickson BE, Apkarian AV. Dissociating anxiety from pain: mapping the neuronal marker N-acetyl aspartate to perception distinguishes closely interrelated characteristics of chronic pain. Mol Psychiatry 2001; 6: 256-8.\u003c/li\u003e\n \u003cli\u003ePloghaus A, Narain C, Beckmann CF, et al. Exacerbation of pain by anxiety is associated with activity in a hippocampal network. J Neurosc 2001; 21: 9896-903.\u003c/li\u003e\n \u003cli\u003eHarvey JN, Parker D, De P, et al. Sonographically guided core biopsy in the assessment of thyroid nodules. J Clin Ultrasound 2005; 33: 57-62.\u003c/li\u003e\n \u003cli\u003eLiu Q, Castelli M, Gattuso P, Prinz RA. Simultaneous fine-needle aspiration and core-needle biopsy of thyroid nodules. Am Surg 1995; 61: 628-32.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Graphic","content":"\u003cp\u003eGraphic 1-4 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Izmir Atatürk Eğitim ve Araştırma Hastanesi","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Pain. Biopsy. Thyroid nodules. Ultrasonography","lastPublishedDoi":"10.21203/rs.3.rs-4624735/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4624735/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackround\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFine needle biopsy has been used for many decades, but afew studies showed the relationship between pain and needle diameter.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObject\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study aimed to compare patients’ pain and satisfaction levels between 22 and 27-gauge (G) needles used for fine-needle biopsy of thyroid nodules.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn our study, one hundred sixty-nine patients with thyroid nodule biopsies (159 nodules) were included. Patients with nodules were separated into two independent groups depending on which needle were used. \u0026nbsp;The questionnaire was applied to all the patients after the thyroid biopsy. The main study method was the pain scale measuring a patient’s pain intensity, based on a self-report regarding Visual Analog Scale. The numeric variables between two groups used the Student t test, \u0026nbsp;more than two independent groups used a one-way ANOVA test, and between two categorical variables used a Chi-square test.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere was no statistically significant difference between 22 G and 27 G needles in terms of pain sensations. (P \u0026gt; 0.05). And also there was no statistical differences between gender, pattern of nodule and diameter of nodules. But the women is more prone to feel sensation than men. (P\u0026lt;0,05)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThyroid fine needle aspiration biopsy is one of the invasive methods that could cause unsatisfactory and pain in patients. The use of different gauges of biopsy can affect the biopsy pain and satisfaction. The results of our study showed that fine needle biopsy with 22-G needles had no difference when we compared it to 27- G needle biopsy\u003c/p\u003e","manuscriptTitle":"The effect of using different needle size on patient comfort and pain during the sonographically guided fine needle biopsy of thyroid nodules","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-25 03:30:43","doi":"10.21203/rs.3.rs-4624735/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e4ecd340-0bb1-40f0-881f-52f23c307ad7","owner":[],"postedDate":"June 25th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-05-02T09:53:12+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-25 03:30:43","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4624735","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4624735","identity":"rs-4624735","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}