Radiologic findings of occult nodal metastasis during clinically-N0 salvage total laryngectomy.

INTRODUCTION: Occult nodal disease (OND) during clinically-N0 salvage total laryngectomy (TL) can be detected with the Neck-Imaging-Reporting-and-Data-Systems (NI-RADS). However, some patients will still have OND revealed on final pathology. METHODS: A retrospective study on all patients who had OND during salvage TL with elective neck dissection (END) between 2009 and 2021 was performed. Repeat CT and PET scan interpretation was performed to evaluate their preoperative imaging for suspicious features. RESULTS: Among 81 salvage TL patients undergoing END, 12 (16%) had OND and a total of 26 occult nodes were identified. On pathology, the average node length [SD] was 0.6 cm [0.3]. On CT, 31% (8 of 26) had rounded morphology. On PET, most had SUVmax below blood pool. One patient scored NI-RADS 2; the rest scored 1. CONCLUSIONS: On re-review of preoperative imaging, occult nodes were subtle and challenging to identify. Despite no clear impact on survival, performing an END may provide prognostic information.

The Repeatability of Pharyngeal Opening Pressure Under Drug-Induced Sleep Endoscopy.

OBJECTIVE: Pharyngeal opening pressure (PhOP) is a measure of upper airway collapsibility that can be obtained during drug-induced sleep endoscopy (DISE) using a continuous positive airway pressure (CPAP) titration. However, the stability of PhOP over the course of sedation during DISE remains unclear. This study aims to compare repeat measures of PhOP over the course of DISE. STUDY DESIGN: Single arm prospective study. SETTING: Single tertiary care institution. METHODS: Patients had 2 CPAP titrations while undergoing DISE. Collected data included patient demographics, PhOP, patient sedation index (PSI), and duration of and between CPAP titrations. t Tests, test-retest coefficient analysis, and repeated measures correlation were performed. RESULTS: Twenty-five patients completed the study between 2022 and 2023 with 22 patients having sedation depth (PSI) recording. Most were male (76%), obese (average body mass index: 30.24 kg/m2), with severe obstructive sleep apnea (average apnea-hypopnea index: 39.8 events/hr). Test-retest analysis showed good-excellent correlation between PhOP values (intraclass correlation coefficient = 0.892, P < .0001, n = 25). Average time between CPAP titrations was 15 minutes to 6 seconds. Over that time, PhOP increased by an average of 0.72 cmH2O (P = .06, n = 25) and PSI decreased by 9.5 units (P = .01, n = 22). Repeated measures correlation showed a weak negative correlation between PhOP and PSI (r = -.45, P = .03, n = 22). CONCLUSION: The results showed repeatability of PhOP values over the course of DISE. When adjusted for sedation depth (PSI), deeper sedation was weakly associated with greater PHOP. However, the magnitude of this change was small and we conclude that PhOP remains relatively stable over the course of DISE (Effects of Lung Volume on Upper Airway Patency During DISE [DISE-Pulm], NCT05350332, clinicaltrials.gov).

Stacked fibula flap for unilateral total maxillectomy reconstruction with orbital preservation.

Unilateral total maxillectomy is indicated for locally advanced maxillary tumors that require complete removal of the midface bony structure and inferior orbital rim. Reconstruction of this defect is challenging due to aesthetic and functional concerns. A retrospective review of patients at two tertiary-care institutions undergoing unilateral total maxillectomy reconstruction with a stacked fibula flap from 2018 to 2022 was performed. Each patient's clinical course was reviewed, and attention was focused on the demonstration of surgical steps with photos. Twenty patients underwent stacked fibula flap reconstruction for unilateral total maxillectomy orbital preservation defects. Surgical extirpation was performed for malignancy (80%, 16/20) and for osteoradionecrosis or benign tumor in 20% (4/20). The complication rate was 30% (6/20). Most flaps survived (95%, 19/20). We present a modified, reproducible method of fibula flap reconstruction for unilateral total maxillectomy with orbital preservation that only requires two segments and maintains positive aesthetic and functional results.

Penetrating Head and Neck Trauma: A Narrative Review of Evidence-Based Evaluation and Treatment Protocols.

Penetrating injury to the head and neck accounts for a minority of trauma but significant morbidity in the US civilian population. The 3-zone anatomical framework has historically guided evaluation and management; however, the most current evidence-based protocols favor a no-zone, systems-based approach. In stable patients, a thorough physical examination and noninvasive imaging should be prioritized, with surgical exploration of the head and neck reserved for certain circumstances. Diagnostic and management decisions should be tailored to the mechanism of injury, history, physical examination, experience of personnel, availability of equipment, and clinical judgment.

Oncologic Outcomes After Clinically Node-Negative Salvage Laryngectomy.

Importance: Controversy exists regarding management of the clinically node-negative neck in patients with recurrent larynx or hypopharynx cancers who received total laryngectomy after definitive radiation with or without chemotherapy. Objective: To explore clinical and oncologic outcomes after elective neck dissection vs observation in patients who received clinically node-negative salvage total laryngectomy. Design, Setting, and Participants: This cohort study was performed from January 2009 to June 2021 at a single, high-volume tertiary care center. Follow-up was conducted through June 2021 for all patients. Survival outcomes were based on at least 2 years of follow-up. Patients aged 18 years or older with recurrent, clinically node-negative larynx or hypopharynx tumors after definitive nonsurgical treatment who were treated with a salvage total laryngectomy were included. Data were analyzed from October 2021 through September 2022. Exposures: Elective neck dissection. Main Outcomes and Measures: Presence and location of occult nodal metastasis in electively dissected necks, along with differences in fistula rates and overall and disease-free survival between patients receiving elective neck dissection vs observation. Results: Among 107 patients receiving clinically node-negative salvage total laryngectomy (median [IQR] age, 65.0 [57.8-71.3] years; 91 [85.0%] men), 81 patients underwent elective neck dissection (75.7%) and 26 patients underwent observation (24.3%). Among patients with elective neck dissection, 13 patients had occult nodal positivity (16.0%). Recurrent supraglottic (4 of 20 patients [20.0%]) or advanced T classification (ie, T3-T4; 12 of 61 patients [19.7%]) had an occult nodal positivity rate of 20% or more, and positive nodes were most likely to occur in levels II and III (II: 6 of 67 patients [9.0%]; III: 6 of 65 patients [9.2%]; VI: 3 of 44 patients [6.8%]; IV: 3 of 62 patients [4.8%]; V: 0 of 4 patients; I: 0 of 18 patients). There was a large difference in fistula rate between elective neck dissection (12 patients [14.8%]) and observed (8 patients [30.8%]) groups (difference, 16.0 percentage points; 95% CI, -3.4 to 35.3 percentage points), while the difference in fistula rate was negligible between 50 patients undergoing regional or free flap reconstruction (10 patients [20.0%]) vs 57 patients undergoing primary closure (10 patients [17.5%]) (difference, 2.5 percentage points; 95% CI, -12.4 to 17.3 percentage points). Undergoing elective neck dissection was not associated with a clinically meaningful improvement in overall or disease-free survival compared with observation. Recurrent hypopharynx subsite was associated with an increased risk of death (hazard ratio, 4.28; 95% CI, 1.81 to 10.09) and distant recurrence (hazard ratio, 7.94; 95% CI, 2.07 to 30.48) compared with glottic subsite. Conclusions and Relevance: In this cohort study, patients with recurrent supraglottic or advanced T classification tumors had an increased occult nodal positivity rate, elective neck dissection was not associated with survival, and patients with recurrent hypopharynx subsite were more likely to have a distant recurrence and die of their disease. These findings suggest that underlying disease pathology rather than surgical management may be associated with survival outcomes in this population.

Preservation of Musical Memory Throughout the Progression of Alzheimer's Disease? Toward a Reconciliation of Theoretical, Clinical, and Neuroimaging Evidence.

Through this review of 25 clinical and experimental works on long-term musical memories in Alzheimer's disease (AD) patients, we attempt to clarify the conceptual understanding of musical memories, identify their evolution across the stages of the pathology, and propose possible explanations concerning the neural and cognitive mechanisms that underpin the preservation and impairment of certain musical memories. After clarifying the different kind of musical memories, we investigated their alterations throughout AD's progression from mild to severe stages. Both procedural and retrograde semantic memory seem relatively spared in AD, while episodic memory appears to be impaired early. Moreover, partial preservation of music encoding in AD can be revealed through paradigms that are especially designed for AD patients (relying on behavioral cues, using adapted settings, etc.). Although seldomly used, they would definitely help understanding the preserved capacities in every stage of AD. However, more research is needed to better understand this phenomenon and assess its specificity to music or other types of supports. These findings could lead to multiple applications in care settings and research designs, bringing more nuanced understanding of how long-term musical memory degrades throughout the course of AD, and should encourage us to prioritize patients' preserved cognitive abilities in current AD recreational and care programs.

Parathyroidectomy versus Cinacalcet in the Management of Tertiary Hyperparathyroidism: Surgery Improves Renal Transplant Allograft Survival.

BACKGROUND: Renal transplant allograft function in patients with tertiary hyperparathyroidism who are treated with cinacalcet versus parathyroidectomy remains unclear. METHODS: This is a retrospective, single-center review of patients with tertiary hyperparathyroidism between 2000 and 2017. We compared clinical parameters and outcomes, including renal allograft failure in patients who had undergone parathyroidectomy versus treatment with cinacalcet therapy. RESULTS: A total of 133 patients were included (33 who received parathyroidectomy and 100 who received cinacalcet); median renal allograft survival was 5.9 years (interquartile range 4.0-9.0). There were no differences in age, sex, body mass index, comorbidities, duration of pretransplant dialysis, cadaveric donor utilization, or rates of delayed allograft function between cohorts. In the parathyroidectomy cohort, normalization of parathyroid hormone occurred more frequently (67% vs 15%, P < .001) and renal allograft failure rates were less (9% vs 33%, P = .007), with similar median posttransplant follow-up (7.0 years [interquartile range 4.5-10.0]). On multivariable analysis, parathyroidectomy was inversely associated with allograft failure (odds ratio 0.20, 95%-confidence interval 0.06-0.71, P = .013); there were no other associated factors. A greater median parathyroid hormone (pg/mL) 1 year posttransplant (348 [interquartile range 204-493] vs 195 [interquartile range 147-297], P = .025) was associated with allograft failure in the cinacalcet cohort. CONCLUSION: Parathyroidectomy for tertiary hyperparathyroidism is associated with lesser rates of renal allograft failure compared with cinacalcet management. Patients with inadequate parathyroid hormone control on cinacalcet at 1 year posttransplant should be considered for parathyroidectomy to prevent potential allograft failure.

JAK2 inhibition sensitizes resistant EGFR-mutant lung adenocarcinoma to tyrosine kinase inhibitors.

Lung adenocarcinomas with mutant epidermal growth factor receptor (EGFR) respond to EGFR-targeted tyrosine kinase inhibitors (TKIs), but resistance invariably occurs. We found that the Janus kinase (JAK)/signal transduction and activator of transcription 3 (STAT3) signaling pathway was aberrantly increased in TKI-resistant EGFR-mutant non-small cell lung cancer (NSCLC) cells. JAK2 inhibition restored sensitivity to the EGFR inhibitor erlotinib in TKI-resistant cell lines and xenograft models of EGFR-mutant TKI-resistant lung cancer. JAK2 inhibition uncoupled EGFR from its negative regulator, suppressor of cytokine signaling 5 (SOCS5), consequently increasing EGFR abundance and restoring the tumor cells' dependence on EGFR signaling. Furthermore, JAK2 inhibition led to heterodimerization of mutant and wild-type EGFR subunits, the activity of which was then blocked by TKIs. Our results reveal a mechanism whereby JAK2 inhibition overcomes acquired resistance to EGFR inhibitors and support the use of combination therapy with JAK and EGFR inhibitors for the treatment of EGFR-dependent NSCLC.

Nutrition impacts the prevalence of peripheral arterial disease in the United States.

OBJECTIVE: Traditional recommendations for peripheral arterial disease (PAD) risk factor reduction include smoking cessation, low-fat/low-salt diet, exercise, and optimal medical management of chronic disease. Little attention has been paid to the role of dietary supplementation of specific nutrients in the prevention of PAD. METHODS: This cross-sectional study used the National Health and Nutrition Examination Survey (NHANES) to determine specific nutrients that are associated with prevalent PAD in the United States (US) population. NHANES data include nationwide sampling of the US population, using physical examination, questionnaire, and laboratory testing. PAD status was defined by an ankle-brachial index (ABI) of <0.9. Nutritional information was collected by 24-hour dietary recall using the US Department of Agriculture dietary collection instrument. Data were linked to a database of foods and their nutrient composition. Univariate and multivariate logistic regression analyses were performed to evaluate associations between specific nutrient intake and the presence of PAD. Multivariate models adjusted for the effects of age, gender, hypertension, coronary vascular disease, diabetes, and smoking. RESULTS: NHANES data for 1999 to 2004 included 7203 lower extremity examinations, of which 422 individuals had prevalent PAD (5.9%). Examinees with PAD had significantly higher rates of hypertension, coronary artery disease, diabetes, and smoking than those without PAD. Univariate analysis revealed that consumption of all nutrients considered were associated with lower odds of PAD, including antioxidants (vitamins A, C, and E), folate, other B vitamins (B(6), B(12)), fiber, and polyunsaturated and saturated fatty acids. After adjustment for traditional risk factors, nutrients associated with reduced prevalence of PAD were vitamin A (odds ratio [OR], 0.79; P = .036), vitamin C (OR, 0.84; P < .001), vitamin E (OR, 0.78; P = .011), vitamin B(6) (OR, 0.71; P = .023), fiber (OR, 0.65; P < .001), folate (OR, 0.67; P = .006), and omega-3 (alpha-linolenic) fatty acid (OR, 0.79; P = .028). CONCLUSIONS: Improved nutrition is associated with a reduced prevalence of PAD in the US population. Higher consumption of specific nutrients, including antioxidants (vitamin A, C, and E), vitamin B(6), fiber, folate, and omega-3 fatty acids have a significant protective effect, irrespective of traditional cardiovascular risk factors. These findings suggest specific dietary supplementation may afford additional protection, above traditional risk factor modification, for the prevention of PAD.