Implications of updated staging system for p16+ oropharyngeal squamous cell carcinoma: Is valuable prognostic information being omitted?

BACKGROUND: This study characterized whether the updated AJCC 8th edition nodal staging system for p16+ oropharyngeal squamous cell carcinoma (OPSCC) resulted in the loss of prognostic value. METHODS: The NCDB was queried for patients with node-positive p16+ OPSCC. The prognostic impact of nodal size, nodal quantity, nodal laterality, and extracapsular extension (ECE) on overall survival (OS) was assessed. RESULTS: In the clinical cohort, inferior 5-year OS was observed in patients with more than one positive lymph node (p < 0.001; 82% vs. 86%), ECE (p < 0.001; 82% vs. 75%), or nodal size >6 cm (p < 0.001; 66% vs. 82%). In the pathologic cohort, inferior 5-year OS was observed in patients with > four positive lymph nodes (p < 0.001; 76% vs. 90%), ECE (p < 0.001; 83% vs. 92%), or largest nodal size >6 cm (p < 0.001; 81% vs. 89%). CONCLUSIONS: Simplifications in the current p16+ OPSCC staging system led to loss of prognostic information in nodal staging.

Prolonged response to checkpoint inhibitor therapy in two metastatic mucoepidermoid salivary gland carcinoma cases: a research report.

Salivary gland tumors (SGTs) are heterogeneous tumors that range from benign masses to aggressive high-grade carcinomas with distant metastatic potential and limited response to chemotherapy. Mucoepidermoid carcinoma (MEC) accounts for 10% of SGTs and has a poor prognosis. In this research report, we describe two cases of metastatic high-grade MECs with prolonged response to immune checkpoint inhibitor pembrolizumab. Case 1 presented with a left neck mass, and biopsy of the parotid mass revealed MEC. The patient underwent surgical resection and adjuvant chemoradiation therapy for stage IVB disease. Post-treatment, she was found to have brain and spinal metastases and was placed on pembrolizumab. Case 2 presented with a left neck mass, and biopsy of the right parotid gland revealed MEC. Further staging demonstrated metastatic disease in the lungs, and he was placed on pembrolizumab. Both cases of MEC demonstrated prolonged extracranial responses to pembrolizumab. Although both cases reported little to no PD-L1 expression, these results demonstrate immunotherapy efficacy in advanced/metastatic MEC.

Factors predictive of 90-day mortality after surgical resection for oral cavity cancer: Development of a recursive partitioning analysis for risk stratification.

BACKGROUND: Factors that influence postoperative mortality (POM) have been identified, but a predictive model to guide clinicians treating oral cavity cancer (OCC) has not been well established. METHODS: Patients with OCC undergoing upfront surgical resection were included. Primary outcome was 90-day POM (90dPOM). RESULTS: 33 845 were identified using the National Cancer Database. Rate of 90dPOM was 3.2%. Predictors of higher 90dPOM include older age, higher comorbidity scores, nonprivate insurance, lower income, treatment in an academic facility, higher T- and N-classification, radical excision, and presence of positive margins. On RPA, two high-risk (90dPOM > 10%) patient subsets were identified: patients ≥80 years of age with T3-4 disease and patients <80 years, with any comorbidity and T3-4, N2-3 disease. CONCLUSIONS: We identified a subset of patients in this cohort who are at high risk for 90dPOM. These patients may warrant additional perioperative and postoperative monitoring in addition to better preoperative assessment and screening.

Effects of Intermediate-Tinted Lenses on Pistol Marksmanship and Visual Performance.

INTRODUCTION: The standard issue clear or sun Military Combat Eye Protection (MCEP) is often inadequate in visually challenging training or combat environment. Intermediate-tinted lenses may offer a viable option for warfighters operating in dynamic visual conditions such as moving rapidly from bright sunny areas to darker building interiors in combat. Because the use of intermediate-tinted lenses has been delayed as a result of a potential negative impact on vision performance such as color perception, this investigation evaluated several commercially available intermediate-tinted lenses for operation performance during a U.S. military field training. Test lenses complied with all the requirements of the current MCEP except for the visible light transmittance (VLT) values that ranged between 32 and 62%. MATERIALS AND METHODS: Study subjects consisted of 22 service members who attended a military Close Combat and Marksmanship training course in May 2019. Visual and pistol marksmanship performance of three intermediate-tinted lenses (Eye Safety Systems [ESS] Copper [32% VLT], Oakley Prizm TR45 [44% VLT], and ESS Bronze [62% VLT]) was compared to that of a standard issue MCEP, ESS Clear (90% VLT). Quick contrast sensitivity function test was used to assess quality vision (AULCSF, area under a log contrast sensitivity function) and visual acuity (CSF Acuity). Color vision was assessed by Cone Contrast Test. Pistol marksmanship (Bill Drill) was used for performance testing. A pre-survey inquired about MCEP use, and a MCEP survey during the pistol marksmanship testing inquired about lens performance and ranking. RESULTS: AULCSF and CSF Acuity were significantly affected by the lenses (general linear model, repeated measures, P < .05). Bonferroni post hoc test showed a significant reduction of binocular AULCSF from ESS Clear to Oakley Prizm TR45 (P = .003) and ESS Copper (P < .001) and a significant reduction in binocular CSF Acuity from ESS Clear to ESS Copper (P = .001). Color vision and pistol marksmanship performance were not significantly affected by wearing different lenses (P > .05). Subjectively, there were no statistically significant differences among study lenses in perceived "clarity of vision," "ability to clearly identify the target," or "overall performance" (Friedman test and Wilcoxon signed-rank post hoc test with Bonferroni adjustment, P > .017). Participants ranked Prizm TR45 (44% VLT) and ESS Bronze (62% VLT) lenses significantly more favorably than EES Clear (P = .001 and P = .009). CONCLUSIONS: Quality of vision and visual acuity decreased with darker lenses; however, the study lenses had insignificant impacts on pistol marksmanship and subjective acceptance. Our surveys indicated that Intermediate-tinted lenses were operationally acceptable and preferred over a standard issue MCEP. While more evaluations for color vision deficient subjects are needed, overall results suggest that commercially available intermediate-tinted lenses may be a viable option to enhance protection and performance in a visually dynamic combat environment.

An Analysis and Comparison of Survival and Functional Outcomes in Oropharyngeal Squamous Cell Carcinoma Patients Treated with Concurrent Chemoradiation Therapy within City of Hope Cancer Center Sites.

Oropharyngeal squamous cell carcinoma (OPSCC) is a subset of head and neck cancers that can arise due to human papillomavirus (HPV) infection. We designed a retrospective analysis to determine differences in outcomes of OPSCC patients treated at City of Hope (COH) Cancer Center's main campus versus selected satellite sites with COH-associated faculty and facilities. Patients diagnosed with OPSCC and treated with concurrent chemoradiation therapy (n = 94) were identified and included in the study. Patients underwent treatment at the COH main campus site (n = 50) or satellite sites (n = 44). The majority of patients were Caucasian, male, and diagnosed with p16 positive stage IV locally advanced OPSCC by AJCC 7th edition. Most patients completed their prescribed cumulative radiation therapy dose and had a complete response to treatment. No significant difference in overall survival and progression-free survival was observed between the main campus and the satellite sites. Our study demonstrates successful treatment completion rates as well as comparable recurrence rates between the main campus and COH-associated satellite sites. A trend toward significant difference in feeding tube dependency at 6-months was observed. Differences in feeding tube placement and dependency rates could be addressed by the establishment of on-site supportive services in satellite sites.

Once-Daily Polymeric Tazarotene 0.045% Lotion for Moderate-to-Severe Acne: Pooled Phase 3 Analysis by Sex.

Background: Two identical phase 3 randomized, double-blind, vehicle-controlled, 12-week studies (NCT03168321 and NCT03168334) demonstrated the efficacy and safety of tazarotene 0.045% lotion in participants with moderate-to-severe acne. Data from these studies were pooled and analyzed post hoc to evaluate outcomes by sex. Methods: Patients aged ≥9 years with moderate-to-severe acne (score 3 or 4 on the Evaluator's Global Severity Score [EGSS]) were randomized (1:1) to once-daily tazarotene 0.045% lotion or vehicle lotion for 12 weeks. Outcomes comprised inflammatory/noninflammatory lesion counts, treatment success (proportion of participants achieving ≥2-grade reduction from baseline in EGSS and score of 0 ["clear"] or 1 ["almost clear"]), and treatment-emergent adverse events (TEAEs). Results: A total of 1,064 females and 550 males were included in this analysis. For both sexes, least-squares mean percent changes from baseline to week 12 in lesion counts were significantly greater with tazarotene 0.045% lotion versus vehicle (inflammatory: females, -60.1% vs -52.1%; males, -53.6% vs -39.8%; noninflammatory: females, -57.6% vs -44.9%; males, -52.9% vs -36.5%; P<0.001, all). The percentage of participants achieving treatment success at week 12 was also significantly higher with tazarotene 0.045% lotion versus vehicle in females and males (P<0.001, both). Compared with tazarotene-treated males, tazarotene-treated females had significantly greater changes from baseline in inflammatory and noninflammatory lesions and a greater proportion achieved treatment success at week 12 (P<0.05, all). TEAE rates were similar between tazarotene- and vehicle-treated males; rates were higher for tazarotene-treated females than vehicle-treated females. Conclusions: Tazarotene 0.045% lotion was efficacious and well tolerated in the treatment of moderate-to-severe acne in female and male participants. J Drugs Dermatol. 2020;19(8): doi:10.36849/JDD.2020.5249

Halobetasol Propionate Lotion 0.01% for Moderate-to-Severe Plaque Psoriasis: Pooled Analysis in Male and Female Participants.

Introduction: Psoriasis is a chronic, immune-mediated skin disease that is associated with sex-related differences. Two double-blind, vehicle-controlled, phase 3 studies evaluated halobetasol propionate (HP) 0.01% lotion for the treatment of moderate-to-severe localized plaque psoriasis; pooled post hoc analyses investigated efficacy and safety in male and female subgroups. Methods: Participants were randomized (2:1) to once-daily HP or vehicle lotion for 8-weeks of double-blind treatment, with a 4-week posttreatment follow-up. Post hoc efficacy assessments in male (n=253) and female (n=177) subgroups included treatment success (≥2­grade improvement in Investigator's Global Assessment [IGA] score and score of 'clear' or 'almost clear'), treatment success in psoriasis signs (erythema, plaque elevation, and scaling) at the target lesion, and change in affected body surface area (BSA). Treatment-emergent adverse events (TEAEs) were evaluated. Results: At week 8, rates of IGA-rated treatment success were significantly greater for HP versus vehicle in males (34.0% vs 6.4%) and females (42.7% vs 14.6%; P<0.001 both). Treatment success in each psoriasis sign approached or exceeded 50% for HP-treated males and females, with all differences versus vehicle statistically significant (P<0.001). Percent reduction in affected BSA was significantly greater for HP versus vehicle in males (34.9% vs 6.7%) and females (35.6% vs 4.6%; P<0.001 both). Five HP treatment-related TEAEs (all application site-related) were reported through week 8. Conclusions: HP lotion was associated with significant reductions in disease severity in male and female participants with moderate-to-severe psoriasis, with good tolerability and safety over 8 weeks of once-daily use. In the overall pooled population, results were similar. J Drugs Dermatol. 2020;19(8): doi:10.36849/JDD.2020.5250.

Factors predicting for patient refusal of head and neck cancer therapy.

BACKGROUND: The purpose of this study was to evaluate the national rate of treatment refusal in head and neck cancer (HNC). METHODS: The National Cancer Database was queried for nonmetastatic squamous cell carcinoma of the head and neck. Oncologic therapy referred to receipt of surgery, radiotherapy, or chemotherapy. RESULTS: Compared to the 230 424 patients who received treatment, 2965 (1.3%) were reported to have refused definitive therapy. Predictors included older age, female sex, African-American/other race, nonprivate insurance, greater comorbidities, more advanced disease, and residence closer to the treating facility (P < .05). Patients with a prior history of cancer, Hispanic race, those treated at academic centers, and those from higher income counties were less likely to refuse therapy (P < .05). Patients who refused definitive therapy experienced poorer survival (median 79.1 vs 8.7 months, P < .001). CONCLUSIONS: Refusing oncologic therapy is relatively rare in HNC and appears to be multifocal in nature.

The Effect of Time to Postoperative Radiation Therapy on Survival in Resected Merkel Cell Carcinoma.

OBJECTIVES: Delays from surgery to adjuvant radiation therapy (aRT) are associated with poorer prognosis in multiple neoplasms. Presently, no data exist for Merkel cell carcinoma (MCC). The authors sought to assess the time interval from surgery to aRT and effect on outcomes in MCC. MATERIALS AND METHODS: The National Cancer Database was queried for histologically confirmed nonmetastatic MCC status post resection and aRT diagnosed between 2004 and 2015 who received aRT within 24 weeks of surgery. Kaplan-Meier analysis assessed univariate overall survival (OS); multivariable Cox proportional hazards modeling assessed multivariate OS; χ and logistic regression assessed differences in baseline characteristics and predictors of delayed aRT. RESULTS: Of 5952 patients meeting criteria, 13% commenced aRT within 4 weeks, 48% between 4 and 7 weeks, 23% between 8 and 11 weeks, 11% between 12 and 15 weeks, and 6% between 16 and 24 weeks. There were no differences in OS on the basis of the surgery-aRT interval (P=0.99). Predictors of worse OS on the multivariate analysis included advanced age, greater comorbidities, male sex, lower regional income, earlier year of diagnosis, more advanced tumor and nodal staging, positive margins, head and neck location, and treatment at community facilities (P<0.05 for all). Factors predictive of delayed aRT were identified. Subset analyses on these factors, such as receipt of chemotherapy or positive lymph nodes, did not demonstrate that the timing of aRT affected survival (P≥0.37). CONCLUSION: This study of a contemporary national database revealed that delays from resection to aRT were not associated with survival in MCC, somewhat discordant from other malignancies such as squamous cell carcinoma.

Postoperative radiation performed at the same surgical facility associated with improved overall survival in oral cavity squamous cell carcinoma.

BACKGROUND: The purpose of this analysis is to evaluate whether postoperative radiotherapy (PORT) at the same facility as surgery portends to better survival outcomes compared to PORT given at a different facility. METHODS: Patients underwent upfront surgery at the National Cancer Database reporting facility followed by PORT. PORT was coded as performed at either the same facility or at a different facility as surgery. RESULTS: A total of 10 832 patients were selected. Five-year overall survival (OS) was higher in patients undergoing PORT at the same facility: 52.5% vs 48.4% (P < 0.001). PORT performed at the same facility was associated with improved OS under multivariate (HR, 0.92; P = 0.01) and propensity score matched (hazard ratio, 0.90; P = 0.004) analyses. CONCLUSIONS: OS was better among patients with head and neck cancer who received PORT at the same facility as surgery.

Rapid Onset of Action in Patients With Moderate-to-Severe Plaque Psoriasis With Halobetasol 0.01%/Tazarotene 0.045% Fixed Combination.

BACKGROUND: Psoriasis is a chronic condition often managed with topical therapy. Patients have high expectations about the speed at which improvement is achieved, which then can have a marked impact on the patient's adherence to treatment. Recently, clinical data on a new fixed combination of halobetasol and tazarotene (HP/TAZ) have been presented. HP/TAZ lotion was statistically more effective than individual active ingredients or its vehicle, with a predictable safety profile. OBJECTIVES: Here we review the efficacy and tolerability data with a specific focus on the first two weeks of therapy. METHODS: Multicenter, randomized, double-blind, vehicle-controlled Phase 2 study in moderate or severe psoriasis (N=212). Subjects randomized (2:2:2:1 ratio) to receive halobetasol 0.01%/tazarotene 0.045% (HP/TAZ), individual active ingredients (HP or TAZ), or vehicle, once-daily for 8 weeks. Efficacy assessments included treatment success (defined as at least a 2-grade improvement from baseline in the IGA score and a score of 'clear' or 'almost clear'), and impact on individual signs of psoriasis (erythema, plaque elevation, and scaling) at the target lesion. RESULTS: As early as 2 weeks, HP/TAZ lotion demonstrated statistically significant superiority for treatment success over vehicle (P equals 0.047) and TAZ (P equals 0.029). By week 2, 47.5% of patients were 'mild', 'almost clear' or 'clear' compared with 33.3%, 16.9%, and 12.9% of patients treated with HP, TAZ, or vehicle, respectively; plaque elevation and scaling were significantly improved compared with HP, TAZ, or vehicle, and erythema was significantly improved compared with TAZ. Improvements in baseline itching (45.6%), dryness (42.2%), burning/stinging (55.9%) with HP/TAZ lotion at 2 weeks were similar to those seen with HP, and greater than that achieved with TAZ (30.8% [P equals 0.099], 35.4%, and 13.3%, respectively). CONCLUSION: The HP/TAZ fixed combination lotion provides rapid relief of psoriasis symptoms, with apparent benefits over both HP and TAZ by week 2. J Drugs Dermatol. 2018;17(8):863-868.

Projection Stereolithographic Fabrication of BMP-2 Gene-activated Matrix for Bone Tissue Engineering.

Currently, sustained in vivo delivery of active bone morphogenetic protein-2 (BMP-2) protein to responsive target cells, such as bone marrow-derived mesenchymal stem cells (BMSCs), remains challenging. Ex vivo gene transfer method, while efficient, requires additional operation for cell culture and therefore, is not compatible with point-of-care treatment. In this study, two lentiviral gene constructs - (1) Lv-BMP/GFP, containing human BMP-2 and green fluorescent protein (GFP) gene (BMP group); or (2) Lv-GFP, containing GFP gene (GFP group) - were incorporated with human BMSCs into a solution of photocrosslinkable gelatin, which was then subjected to visible light-based projection stereolithographic printing to form a scaffold with desired architectures. Upon in vitro culture, compared to the GFP group, cells from BMP group showed >1,000-fold higher BMP-2 release, and the majority of them stained intensely for alkaline phosphatase activity. Real-time RT-PCR also showed dramatically increased expression of osteogenesis marker genes only in the BMP group. 3.5 months post-implantation into SCID mice, the micro-computed tomography imaging showed detectable mineralized areas only in the BMP group, which was restricted within the scaffolds. Alizarin red staining and immunohistochemistry of GFP and osteocalcin further indicated that the grafted hBMSCs, not host cells, contributed primarily to the newly formed bone.

The New Face of Head and Neck Cancer: The HPV Epidemic.

There has been a significant increase in the incidence of human papillomavirus (HPV)-mediated oropharyngeal cancer in the United States. This entity is most commonly diagnosed in nonsmoking middle-aged white males. The majority of the patients present with asymptomatic, persistent neck masses despite antibiotic therapy. An awareness of this condition and a high degree of suspicion is necessary for timely diagnosis. HPV-mediated oropharyngeal squamous cell carcinomas (HPV-OPSCCs) are unique biologically and clinically, and affected patients enjoy better outcomes with existing standard therapies than do patients with OPSCC mediated by tobacco exposure. The p16 protein is usually overexpressed in HPV-OPSCC, and its detection on immunohistochemistry is a reliable surrogate marker for this disease. In this review, we discuss current paradigms in the diagnosis and management of HPV-OPSCC, and we emphasize pertinent research questions to investigate going forward, including whether to deintensify treatment in these patients.

The efficacy and safety of efinaconazole 10% solution for treatment of mild to moderate onychomycosis: a pooled analysis of two phase 3 randomized trials.

BACKGROUND: Onychomycosis is a fungal infection of the nail apparatus that can be challenging to treat due to the modest efficacy of existing antifungal therapies and a high rate of relapse and recurrence. OBJECTIVES: To investigate the efficacy and safety of efinaconazole 10% solution in pooled Phase III clinical trial participants with mild to moderate onychomycosis. METHODS: Phase III clinical trials data from NCT01008033 and NCT01007708 were pooled. Efficacy analysis for the primary and secondary outcome variables was conducted using the mITT population and analysed using Cochran-Mantel-Haenszel tests. Subgroup analysis was conducted for prognostic factors that may affect drug efficacy. Safety analysis was conducted on all recipients of a single drug dose. RESULTS: Efinaconazole 10% nail solution was superior to vehicle for all primary and secondary outcome measures assessed. Complete cure was 18.5% vs 4.7% P< 0.001 [mITT] and mycological cure was 56.3% vs 16.6%, P< 0.001 [mITT]. Complete or almost complete cure and treatment success were achieved in 27.7% and 47.2% compared to 7.9% and 18.2% with vehicle, respectively (P< 0.001 [mITT]). In all subgroups, efinaconazole 10% solution had statistically higher cures rates compared to vehicle. Higher complete cure rates were observed in women and individuals with mild disease (≤33% involvement), but not in any other subgroup assessed. Treatment associated adverse events in the efinaconazole 10% solution group were similar to vehicle and limited to local site reactions (2%). CONCLUSIONS: The findings from this pooled analysis suggest that efinaconazole 10% solution may become the preferred topical agent for mild to moderate onychomycosis.

The suborbicularis oculi fat (SOOF) and the fascial planes: has everything already been explained?

IMPORTANCE: During anatomic and surgical dissections, a connection was seen between the superficial layer of the deep temporal fascia and the prezygomatic area. These findings were in contrast to previous evaluations. This study defines this connection, which is important to understand from both surgical and anatomic standpoints. OBJECTIVE: To define the connection between the superficial layer of the deep temporal fascia and the prezygomatic area and demonstrate the presence of a deep fascial layer in the midface. DESIGN AND SETTING: Anatomical study performed at the Laboratoire d'Anatomie de la Faculté de Médecine de Nice, Sophia Antipolis, France; at the Centre du Don des Corps de l'Université Paris Descartes, Paris, France; and at the Department of Experimental Medicine, Histology, and Embryology Unit of the University of Pavia, Pavia, Italy. Twenty-four hemifaces of 14 white cadavers were dissected to define the relationship between deep temporal fascia and the midface. Four biopsy samples were harvested for histologic analysis. MAIN OUTCOMES AND MEASURES: Dissection of 24 hemifaces from the fresh cadavers revealed the following findings. There is a connection of the deep fascia of the temple (superficial layer of deep temporal fascia) to the midface that divides the fat deep to the orbicularis muscle into 2 layers. One layer of fat is the so-called suborbicularis oculi fat (SOOF), which is superficial to the deep fascia, and the other layer of fat (preperiosteal) is deep to the deep fascia and adherent to malar bone. These findings are in contrast to previous anatomical findings. RESULTS In 12 hemifaces, the superficial layer of the deep temporal fascia directly reached the prezygomatic area as a continuous fascial layer. In 16 hemifaces, the superficial sheet of the deep temporal fascia inserted at the level of the zygomatic and lateral orbital rim and continued as a deep fascial layer over the prezygomatic area. In all specimens, a deep fascial layer was present in the prezygomatic-infraorbital area. This deep fascial layer is adherent to the muscles of the infraorbital area, and it divided the fat located deep to the orbicularis oculi muscle into 2 layers: the SOOF and a deeper layer. Histologic examination of the biopsy samples confirmed these findings. CONCLUSIONS AND RELEVANCE: This study demonstrates the existence of a deep fascial layer in the midface. This fascia is connected to the superficial layer of the deep temporal fascia, and it divides the fat deep to the orbicularis oculi muscle into 2 layers. This new finding carries interesting implications related to the classic concept of the superficial musculoaponeurotic system. LEVEL OF EVIDENCE: NA.

Middle cranial fossa facial nerve decompression before two years of age.

We present a case report of a 17-month old patient who underwent serial bilateral total facial nerve decompression procedures for complete bilateral facial paralysis in the setting of craniometaphyseal dysplasia via combined middle cranial fossa and transmastoid approaches. The surgical decision-making process and procedures were reviewed. The patient recovered without complications from the staged surgical procedures, and developed partial return of function of both facial nerves postoperatively, with symmetric House-Brackmann grades of II-III. Despite its technical difficulty in the setting of this particular disorder, facial nerve decompression may be appropriate in the setting of acute facial palsy in craniometaphyseal dysplasia, with the potential for return of function. Given the extremely rare nature of the disease process, variable surgical experience and the clinical condition of the patient remain our best guides for management.

Psychoacoustic abilities associated with music perception in cochlear implant users.

OBJECTIVES: This study was designed to determine what acoustic elements are associated with musical perception ability in cochlear implant (CI) users and to understand how acoustic elements, which are important to good speech perception, contribute to music perception in CI users. It was hypothesized that the variability in the performance of music and speech perception may be related to differences in the sensitivity to specific acoustic features such as spectral changes or temporal modulations, or both. DESIGN: A battery of hearing tasks was administered to 42 CI listeners. The Clinical Assessment of Music Perception was used, which evaluates complex-tone pitch-direction discrimination, melody recognition, and timbre recognition. To investigate spectral and temporal processing, spectral-ripple discrimination and Schroeder-phase discrimination abilities were evaluated. Speech perception ability in quiet and noise was also evaluated. Relationships between Clinical Assessment of Music Perception subtest scores, spectral-ripple discrimination thresholds, Schroeder-phase discrimination scores, and speech recognition scores were assessed. RESULTS: Spectral-ripple discrimination was shown to correlate with all three aspects of music perception studied. Schroeder-phase discrimination was generally not predictive of music perception outcomes. Music perception ability was significantly correlated with speech perception ability. Nearly half of the variance in melody and timbre recognition was predicted jointly by spectral-ripple and pitch-direction discrimination thresholds. Similar results were observed on speech recognition as well. CONCLUSIONS: This study suggests that spectral-ripple discrimination is significantly associated with music perception in CI users. A previous report showed that spectral-ripple discrimination is significantly correlated with speech recognition in quiet and in noise. This study also showed that speech recognition and music perception are also related to one another. Spectral-ripple discrimination ability seems to reflect a wide range of hearing abilities in CI users. The results suggest that materially improving spectral resolution could provide significant benefits in music and speech perception outcomes in CI users.

Development and validation of the University of Washington Clinical Assessment of Music Perception test.

OBJECTIVES: Assessment of cochlear implant outcomes centers around speech discrimination. Despite dramatic improvements in speech perception, music perception remains a challenge for most cochlear implant users. No standardized test exists to quantify music perception in a clinically practical manner. This study presents the University of Washington Clinical Assessment of Music Perception (CAMP) test as a reliable and valid music perception test for English-speaking, adult cochlear implant users. DESIGN: Forty-two cochlear implant subjects were recruited from the University of Washington Medical Center cochlear implant program and referred by two implant manufacturers. Ten normal-hearing volunteers were drawn from the University of Washington Medical Center and associated campuses. A computer-driven, self-administered test was developed to examine three specific aspects of music perception: pitch direction discrimination, melody recognition, and timbre recognition. The pitch subtest used an adaptive procedure to determine just-noticeable differences for complex tone pitch direction discrimination within the range of 1 to 12 semitones. The melody and timbre subtests assessed recognition of 12 commonly known melodies played with complex tones in an isochronous manner and eight musical instruments playing an identical five-note sequence, respectively. Testing was repeated for cochlear implant subjects to evaluate test-retest reliability. Normal-hearing volunteers were also tested to demonstrate differences in performance in the two populations. RESULTS: For cochlear implant subjects, pitch direction discrimination just-noticeable differences ranged from 1 to 8.0 semitones (Mean = 3.0, SD = 2.3). Melody and timbre recognition ranged from 0 to 94.4% correct (mean = 25.1, SD = 22.2) and 20.8 to 87.5% (mean = 45.3, SD = 16.2), respectively. Each subtest significantly correlated at least moderately with both Consonant-Nucleus-Consonant (CNC) word recognition scores and spondee recognition thresholds in steady state noise and two-talker babble. Intraclass coefficients demonstrating test-retest correlations for pitch, melody, and timbre were 0.85, 0.92, and 0.69, respectively. Normal-hearing volunteers had a mean pitch direction discrimination threshold of 1.0 semitone, the smallest interval tested, and mean melody and timbre recognition scores of 87.5 and 94.2%, respectively. CONCLUSIONS: The CAMP test discriminates a wide range of music perceptual ability in cochlear implant users. Moderate correlations were seen between music test results and both Consonant-Nucleus-Consonant word recognition scores and spondee recognition thresholds in background noise. Test-retest reliability was moderate to strong. The CAMP test provides a reliable and valid metric for a clinically practical, standardized evaluation of music perception in adult cochlear implant users.

Clinical assessment of music perception in cochlear implant listeners.

OBJECTIVE: Cochlear implants (CI) have provided tremendous benefit for speech recognition in quiet for patients with severe and profound hearing impairment, but implant users still have great difficulty perceiving music. The purpose of this study was to develop a test to quantify music perception by CI listeners in a clinically practical manner that could be standardized for administration at any implant center. STUDY DESIGN: Prospective convenience sample. SETTING: Hearing research center at an academic hospital. PATIENTS: Eight CI listeners, including 5 men and 3 women with implant experience ranging from 0.5 to 6 years, participated in this study. They represented a variety of implant devices and strategies. INTERVENTION: Administration of the Clinical Assessment of Music Perception test in a standardized sound field. MAIN OUTCOME MEASURES: Music perception was assessed using a computerized test comprising pitch direction discrimination, melody identification, and timbre identification. The pitch subtest used a 2-alternative forced-choice adaptive procedure to determine a threshold interval for discrimination of complex pitch direction change. The melody and timbre subtests assessed recognition of 12 isochronous melodies and 8 musical instruments, respectively. RESULTS: Testing demonstrated a broad range of perceptual accuracy on all 3 subtests. Test duration averaged less than 45 minutes. CONCLUSION: Clinical Assessment of Music Perception is an efficient computerized test that may be used to measure 3 different aspects of music perception in CI users in a standardized and clinically practical manner.

Optimizing independent finger flexion with zone V flexor repairs using the Massachusetts General Hospital flexor tenorrhaphy and early protected active motion.

PURPOSE: Independent FDS action has been cited to be problematic with repair of multiple tendons in zone V owing to adhesion formation between the flexor digitorum superficialis (FDS) and the flexor digitorum profundus (FDP) tendons. Of the several described flexor repair techniques the ideal tendon repair should be strong enough to allow for early active motion to minimize adhesion formation and maximize tendon healing. Biomechanical studies have proven the Massachusetts General Hospital (MGH) repair to be strong enough to allow for early active motion. The purpose of this study was to examine the use of the MGH technique for zone V flexor tendon injuries to allow for early protected active motion to achieve independent finger flexion through better differential gliding of the tendons. METHODS: We performed a retrospective review 168 zone V finger flexor tendon repairs for 29 patients performed consecutively over 4 years when early active motion was not contraindicated. The same early protected active motion protocol was used for all of these patients. We reviewed total active motion, independent flexion, rupture, and need for tenolysis. These injuries involved 103 FDS and 65 FDP tendons to 103 fingers. The median follow-up period was 24 weeks. Of these 29 patients 19 were men and 10 were women. The average patient age was 28 years. RESULTS: The total active motion for these zone V repairs was 236 degrees +/- 5 degrees Overall 97 of 103 digits attained good to excellent function and 88 of 103 developed some differential glide. One of these patients required a tenolysis. Three repairs ruptured in 1 patient owing to suture breakage that was associated with noncompliance with the dorsal extension block splint. CONCLUSIONS: Our retrospective review of 168 consecutive flexor tendon repairs showed that the MGH technique allowed for early protected active motion, which provided good to excellent functional outcomes with 88 of 103 developing independent finger flexion at an acceptably low complication risk.