Dyadic Yoga for Head and Neck Cancer Patients Undergoing Chemoradiation and their Family Caregivers.

OBJECTIVES: Concurrent chemoradiation to treat head and neck cancer (HNC) may result in debilitating toxicities. Targeted exercise such as yoga therapy may buffer against treatment-related sequelae; thus, this pilot RCT examined the feasibility and preliminary efficacy of a yoga intervention. Because family caregivers report low caregiving efficacy and elevated levels of distress, we included them in this trial as active study participants. METHODS: HNC patients and their caregivers were randomized to a 15-session dyadic yoga program or a waitlist control (WLC) group. Prior to randomization, patients completed standard symptom (MDASI-HN) and patients and caregivers completed quality of life (SF-36) assessments. The 15-session program was delivered parallel to patients' treatment schedules. Participants were re-assessed at patients' last day of chemoradiation and again 30 days later. Patients' emergency department visits, unplanned hospital admissions and gastric feeding tube placements were recorded over the treatment course and up to 30 days later. RESULTS: With a consent rate of 76%, 37 dyads were randomized. Participants in the yoga group completed a mean of 12.5 sessions and rated the program as "beneficial." Patients in the yoga group had clinically significantly less symptom interference and HNC symptom severity and better QOL than those in the WLC group. They were also less likely to have a hospital admission (OR = 3.00), emergency department visit (OR = 2.14), and/or a feeding tube placement (OR = 1.78). CONCLUSION: Yoga therapy appears to be a feasible, acceptable, and possibly efficacious behavioral supportive care strategy for HNC patients undergoing chemoradiation. A larger efficacy trial is warranted.

Utilizing Artificial Intelligence and Chat Generative Pretrained Transformer to Answer Questions About Clinical Scenarios in Neuroanesthesiology.

OBJECTIVE: We tested the ability of chat generative pretrained transformer (ChatGPT), an artificial intelligence chatbot, to answer questions relevant to scenarios covered in 3 clinical guidelines, published by the Society for Neuroscience in Anesthesiology and Critical Care (SNACC), which has published management guidelines: endovascular treatment of stroke, perioperative stroke (Stroke), and care of patients undergoing complex spine surgery (Spine). METHODS: Four neuroanesthesiologists independently assessed whether ChatGPT could apply 52 high-quality recommendations (HQRs) included in the 3 SNACC guidelines. HQRs were deemed present in the ChatGPT responses if noted by at least 3 of the 4 reviewers. Reviewers also identified incorrect references, potentially harmful recommendations, and whether ChatGPT cited the SNACC guidelines. RESULTS: The overall reviewer agreement for the presence of HQRs in the ChatGPT answers ranged from 0% to 100%. Only 4 of 52 (8%) HQRs were deemed present by at least 3 of the 4 reviewers after 5 generic questions, and 23 (44%) HQRs were deemed present after at least 1 additional targeted question. Potentially harmful recommendations were identified for each of the 3 clinical scenarios and ChatGPT failed to cite the SNACC guidelines. CONCLUSIONS: The ChatGPT answers were open to human interpretation regarding whether the responses included the HQRs. Though targeted questions resulted in the inclusion of more HQRs than generic questions, fewer than 50% of HQRs were noted even after targeted questions. This suggests that ChatGPT should not currently be considered a reliable source of information for clinical decision-making. Future iterations of ChatGPT may refine algorithms to improve its reliability as a source of clinical information.

Enhanced Recovery After Surgery for Head and Neck Oncologic Surgery Requiring Microvascular Reconstruction.

It has been demonstrated since the 1990's that surgical outcomes can be improved through protocolized perioperative interventions. Since then, multiple surgical societies have engaged in adopting Enhanced Recovery After Surgery (ERAS) Societal recommendations to improve patient satisfaction, decrease the cost of interventions, and improve outcomes. In 2017, ERAS released consensus recommendations detailing the perioperative optimization of patients undergoing head and neck free flap reconstruction. This population was identified as a high resource demand, oftentimes burdened with challenging comorbidity, and poorly described cohort for which a perioperative management protocol could help to optimize outcomes. The following pages aim to further detail perioperative strategies to streamline patient recovery after head and neck reconstructive surgery.

Enhanced recovery after surgery (ERAS) in head and neck oncologic surgery: Impact on return to intended oncologic therapy (RIOT) and survival.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) pathways in head and neck cancer (HNC) have shown to improve perioperative outcomes and reduce complications. The longer term implications on adjuvant treatment and survival have not been studied. We hereby report the first study on the impact of an ERAS pathway on return to intended oncologic treatment (RIOT) and overall survival (OS) in HNC. METHODS: 200 patients undergoing head and neck oncologic surgery on an ERAS pathway between March 1, 2016 and March 31, 2019 were matched to controls over the same interval. Demographic, tumor and adjuvant therapy-related data were collected, including time to adjuvant therapy(TAT) and treatment package time(TPT). Risk factors for TAT > 42 days and TPT ≥ 85 days were assessed. OS was compared and risk factors for inferior OS determined. RESULTS: Baseline characteristics including co-morbidities and tumor stage were similar. Of 179 patients planned for adjuvant treatment, there was no difference in RIOT rate (89.0% vs 87.5%, p = 0.753), proportion of TAT > 42 days of surgery (55.6% vs 59.7%, p = 0.642), or TPT ≥ 85 days (48.1% vs 57.1, p = 0.258), for the ERAS and control groups, respectively. On multivariate analysis, alcohol use (OR 3.58; 95 %CI 1.11-11.52) and recurrent disease status (OR 2.88; 95 %CI 1.40-5.93) were independently associated with prolonged TAT. Three-year OS was similar between the ERAS and control groups (73% vs 76%, p = 0.521). CONCLUSION: ERAS has not shown to improve RIOT or OS in the current study. However, its benefit for perioperative outcomes is undeniable and further studies are required on longer term quality and survival outcomes.

Impact of Body Mass Index on Surgical Outcomes in Oncologic Microvascular Head and Neck Reconstruction.

BACKGROUND: Despite increasing recognition, obesity continues to represent a major health issue for millions of people in the USA and worldwide. There is a paucity in the literature regarding the effect of body mass index (BMI) on microsurgical head and neck reconstruction. The present study hypothesized that high BMI is predictive of postoperative recipient- and donor-site complications with longer operative times. PATIENTS AND METHODS: Retrospective review of patients who underwent free flap surgery for head and neck reconstruction was performed between January 2005 and December 2018. Patients were categorized into four groups based on BMI: < 20 kg/m2, 20-30 kg/m2, 30-40 kg/m2, and ≥ 40 kg/m2. Patient characteristics and surgical outcomes were compared between the four groups. RESULTS: Overall, 4000 free flap surgeries were included in the present study, performed on 3753 patients, of whom 9.9% had a BMI < 20 kg/m2, 64.9% had a BMI between 20 and 30 kg/m2, 21.6% had a BMI between 30 and 40 kg/m2, and 3.6% had a BMI ≥ 40 kg/m2. After adjusting for potential confounders, multivariate analysis showed no association between BMI and any complication, major recipient complications, or total flap loss. However, multivariate linear regression model showed BMI 30-40 kg/m2 and BMI ≥ 40 kg/m2 to be independently associated with longer operative times compared with BMI < 20 kg/m2. CONCLUSION: Obesity and high BMI increase operative times; however, with meticulous surgical technique and diligent postoperative care, microvascular head and neck reconstructions can be performed safely and reliably in the majority of patients regardless of BMI with similar overall, recipient-site, and donor-site complications.

What does community resilience mean in the context of trauma-informed communities? A scoping review.

Several communities are implementing trauma-informed, community-level approaches focused on addressing/preventing adverse childhood experiences (ACEs), yet most community resilience definitions from published articles are based on acute traumas. This scoping review aims to determine how community resilience is defined and operationalized within the context of chronic/complex traumas. METHODS: We performed a rigorous, comprehensive literature search using multiple databases. RESULTS: The 38 included articles addressed multiple types of chronic traumas, including historical trauma, poverty, minority stress, mass incarceration, and ACEs. A variety of definitions of community resilience were cited, several of which stressed the ability to thrive despite risk factors and the safety and wellbeing of residents. Few articles operationalized community resilience within the context of ACEs, suggesting significant gaps in the literature. CONCLUSION: This review can serve as an important building block to develop expanded definitions of community resilience for chronic traumas and assist communities in promoting community-wide responses to ACEs.

The joint effect of multiple health behaviors on odds of diabetes, depression.

This study examines the relationship between health determinant behaviors themselves, and their subsequent combined relationship with chronic illness (diabetes/impaired glucose regulation, depression). While numerous studies have proven the benefits of engaging in more healthy behaviors, the question has not been answered whether the effect of multiple healthy behaviors together is greater than the sum of the effects alone. The study design is cross-sectional, using data on the adult population from the 2017 California Health Interview Survey (CHIS). A total of 21,116 participants were included in final analyses. We used multivariable adjusted logistic regression to calculate odds ratios for diabetes and for depression at each subsequent level of a healthy lifestyle index (HLI). We also calculated the adjusted odds ratios between adjacent levels of the index. The odds of having depression and, separately, of having diabetes each decreased with each additional healthy lifestyle behavior, with three of five depression ratios significant at p < 0.05, and four of five significant for diabetes. The magnitude of the association between the HLI level and odds for disease declines exponentially with each additional healthy lifestyle factor, contrary to the hypothesis, for depression, but fits the hypothesis for diabetes. Our results are important for health promotion, suggesting that even one healthy behavior may dramatically decrease the odds for having depression, regardless of the type of healthy behavior chosen. Our results also show an association between lower prevalence of depression and health behaviors historically only considered preventive for physical illness.

Dose Matters in Evaluation of a School-Based Adolescent Sexual Health Education Program.

BACKGROUND: Research on the effects of intervention dose on outcomes within adolescent sexual health education programming is lacking. Existing research on dose typically utilizes the number of sessions as a variable. In a school setting, there are scheduling limitations, student absences, and other logistical barriers that have the potential to affect the number of sessions for an intervention and, in turn, impact the efficacy of programming. METHODS: This article evaluates the effectiveness of a school-based, peer-led adolescent comprehensive sexual health education program, with a focus on dose. A repeated measures MANOVA was used to evaluate the effects of individual difference variables and intervention variables on changes in participants' knowledge and attitudes across 2 time points. Additionally, paired t-tests were used to evaluate changes in specific behaviors. RESULTS: Results indicated that knowledge improved following the intervention, and specifically larger doses, measured in minutes, of the intervention were associated with larger improvements in knowledge. There were no significant effects related to attitudes or behavioral outcomes. CONCLUSIONS: This study adds to the knowledge base by including analysis of how the dose of intervention may impact youth outcomes. Implications for school health practices and research are discussed.

Outcomes after definitive surgery for mandibular osteoradionecrosis.

OBJECTIVES: To analyze charges, complications, survival, and functional outcomes for definitive surgery of mandibular osteoradionecrosis (ORN). MATERIALS AND METHODS: Retrospective analysis of 76 patients who underwent segmental mandibulectomy with reconstruction from 2000 to 2009. RESULTS: Complications occurred in 49 (65%) patients and were associated with preoperative drainage (odds ratio [OR] 4.40, 95% confidence interval [CI] 1.01-19.27). The adjusted median charge was $343 000, and higher charges were associated with double flap reconstruction (OR 8.15, 95% CI 2.19-30.29) and smoking (OR 5.91, 95% CI 1.69-20.72). Improved swallow was associated with age <67 years (OR 3.76, 95% CI 1.16-12.17) and preoperative swallow (OR 3.42, 95% CI 1.23-9.51). Five-year ORN-recurrence-free survival was 93% while overall survival was 63% and associated with pulmonary disease (HR [hazard ratio] 3.57, 95% CI 1.43-8.94). CONCLUSIONS: Although recurrence of ORN is rare, surgical complications are common and charges are high. Poorer outcomes and higher charges are associated with preoperative factors.

COVID-19 infection and its consequences among surgical oncology patients: A systematic analysis, meta-analysis and meta-regression.

We conducted this meta-analysis to address the outcomes in cancer patients after oncologic surgery during COVID-19 pandemic. The primary endpoint was the COVID-19-related mortality rate. Higher body mass index was significantly and negatively associated with higher all-cause mortality and in-hospital COVID-19 infection rates. Male sex, preoperative respiratory disease, and smoking history were positively and significantly associated with increased all-cause mortality rates. Furthermore, male sex was positively and significantly associated with the COVID-19 infection rate.

Multifocal regression and pathologic response predicts recurrence after neoadjuvant chemotherapy in head and neck squamous cell carcinoma.

OBJECTIVES: Complete pathological response after neoadjuvant chemotherapy (NAC) in head and neck squamous cell carcinomas (HNSCC) is a good prognostic factor. Multifocal regression post-NAC in breast cancer has proven to impact locoregional control (LRC) but has not been evaluated in HNSCC. We evaluate the impact of multifocal regression and major pathologic response (MPR) on survival indices in HNSCC. MATERIALS AND METHODS: Retrospective review of HNSCC patients receiving NAC followed by surgery with curative intent between March 2016 to March 2019 at MD Anderson Cancer Center. Tumor focality (uni- or multifocal), pathologic response and other pathologic data were collected. MPR was defined as ≤ 10% residual tumor. Overall survival (OS) and LRC were analyzed and multivariate Cox regression analysis was performed. RESULTS: 101 patients were analyzed, with 18.8% pathologic complete response, 18.8% with 1-10% viable tumor and 60.4% with > 10% viable tumor. 61 (60.4%) had unifocal disease while 19 (18.8%) had multifocal disease. Tumor focality was significantly associated with LRC but not OS, where the 3-year LRC was 82%, 69% and 52% (p = 0.015) for no viable tumor, unifocal disease and multifocal disease respectively. On multivariate analysis, multifocal disease (HR 10.43; 95 %CI 1.24-87.5) and extranodal extension (HR 4.4; 95 %CI 1.60-12.07) continued to be significant independent predictors of LRC. MPR group displayed significantly better 3-year OS (75% vs 51%, p = 0.041) and 3-year LRC (80% vs 62%, p = 0.011) than those with > 10% viable tumor. CONCLUSION: Multifocal regression and less than MPR after NAC in HNSCC predicts for locoregional recurrence and should be routinely reported.

Comparison of Resident and Faculty Screening for Social Determinants of Health in an Academic Pediatric Primary Care Practice.

BACKGROUND: Social determinants of health (SDH) have an important role in children's health and development and should be investigated in pediatric well child care. METHODS: A retrospective chart review of children aged 5-17 at well visits at an urban academic pediatric primary care practice was performed. Chi-square tests of independence and z-test for proportions were used to assess differences between residents and faculty SDH screening.  Results: Faculty screened for SDH more frequently than residents (P<0.05). Residents screened less frequently for food insecurity (P<0.05) and financial insecurity (P<0.05). Financial insecurity was endorsed less frequently by resident families (P<0.05), while school absence was endorsed more frequently by resident families (P<0.05). Referrals to the clinic's community resource desk did not differ between residents and faculty. CONCLUSIONS: Differences exist in screening and need between clinician groups. Despite these differences, there was no difference in community resource desk referrals.

Pilot Phase II Trial of Neoadjuvant Immunotherapy in Locoregionally Advanced, Resectable Cutaneous Squamous Cell Carcinoma of the Head and Neck.

PURPOSE: In locoregionally advanced, resectable cutaneous squamous cell carcinoma of the head and neck (CSCC-HN), surgery followed by radiotherapy is standard but can be cosmetically and functionally devastating, and many patients will have recurrence. PATIENTS AND METHODS: Newly diagnosed or recurrent stage III-IVA CSCC-HN patients amenable to curative-intent surgery received two cycles of neoadjuvant PD-1 inhibition. The primary endpoint was ORR per RECIST 1.1. Secondary endpoints included pathologic response [pathologic complete response (pCR) or major pathologic response (MPR; ≤10% viable tumor)], safety, DSS, DFS, and OS. Exploratory endpoints included immune biomarkers of response. RESULTS: Of 20 patients enrolled, 7 had recurrent disease. While only 6 patients [30%; 95% confidence interval (CI), 11.9-54.3] had partial responses by RECIST, 14 patients (70%; 95% CI, 45.7-88.1) had a pCR (n = 11) or MPR (n = 3). No SAEs ocurred during or after the neoadjuvant treatment. At a median follow-up of 22.6 months (95% CI, 21.7-26.1), one patient progressed and died, one died without disease, and two developed recurrence. The 12-month DSS, DFS, and OS rates were 95% (95% CI, 85.9-100), 89.5% (95% CI, 76.7-100), and 95% (95% CI, 85.9-100), respectively. Gene expression studies revealed an inflamed tumor microenvironment in patients with pCR or MPR, and CyTOF analyses demonstrated a memory CD8+ T-cell cluster enriched in patients with pCR. CONCLUSIONS: Neoadjuvant immunotherapy in locoregionally advanced, resectable CSCC-HN is safe and induces a high pathologic response rate. Pathologic responses were associated with an inflamed tumor microenvironment.

Consensus of free flap complications: Using a nomenclature paradigm in microvascular head and neck reconstruction.

BACKGROUND: We aim to define a set of terms for common free flap complications with evidence-based descriptions. METHODS: Clinical consensus surveys were conducted among a panel of head and neck/reconstructive surgeons (N = 11). A content validity index for relevancy and clarity for each item was computed and adjusted for chance agreement (modified kappa, K). Items with K < 0.74 for relevancy (i.e., ratings of "good" or "fair") were eliminated. RESULTS: Five out of nineteen terms scored K < 0.74. Eliminated terms included "vascular compromise"; "cellulitis"; "surgical site abscess"; "malocclusion"; and "non- or mal-union." Terms that achieved consensus were "total/partial free flap failure"; "free flap takeback"; "arterial thrombosis"; "venous thrombosis"; "revision of microvascular anastomosis"; "fistula"; "wound dehiscence"; "hematoma"; "seroma"; "partial skin graft failure"; "total skin graft failure"; "exposed hardware or bone"; and "hardware failure." CONCLUSION: Standardized reporting would encourage multi-institutional research collaboration, larger scale quality improvement initiatives, the ability to set risk-adjusted benchmarks, and enhance education and communication.

Implementation of a teacher-led mindfulness program in a low-income pre- and early-elementary school as part of a trauma-responsive, resilience-building community initiative.

Children living in disadvantaged communities experience higher rates of adverse childhood experiences (ACEs) which can lead to poor health outcomes. Mindfulness has been shown to help individuals who are exposed to cumulative stress build resilience and psychological well-being. This pilot study aimed to determine teachers' perceptions of a 6-week school-based, teacher-led mindfulness program in a Gainesville, Florida pre- and early elementary low-income school. The program was conducted as part of a trauma-responsive, resilient community initiative. Teachers were trained on a set of mindfulness skills and were asked to lead practices for 10-15 min per day, 3 or more times per week for 6 weeks. Teachers completed qualitative interviews to determine their perceptions of the program. A total of eight teachers participated, with 124 students receiving the program. Teachers reported high impressions of the program and that students were calmer and more relaxed as a result of the program. Training teachers to deliver mindfulness practices as part of their normal classroom activities is realistic, easily adaptable, and can lead to adoption of a community-wide mindfulness framework. Diffusing mindfulness programs more broadly as part of a preventive, trauma-responsive community has the potential to lessen the effects of ACEs.

Comparison of Internal Patient Satisfaction Scores at a Cancer Center With Star Ratings on Online Physician-Rating Websites.

PURPOSE: Patients have been increasingly using physician-rating websites (PRWs); however, few studies have analyzed the validity of star ratings on PRWs. We aimed to compare PRW patient satisfaction scores with internally generated patient satisfaction scores (internal scores) of physicians at a large quaternary cancer center. METHODS: We collected internal scores and PRW scores for physicians at MD Anderson Cancer Center. Internal scores were based on patient responses to the Clinician and Group Consumer Assessment of Healthcare Providers and Systems patient experience (CG-CAHPS) survey. Only physicians with an internal score on the basis of ≥ 30 patient reviews were included. The median numbers of reviews and median scores were compared between internal data and four PRWs (Google, HealthGrades, Vitals, and WebMD). Both internally and on PRWs, possible scores ranged from 1 (least satisfied) to 5 (most satisfied). RESULTS: Of 640 physicians with an internal score, 510 (79.7%) met the inclusion criteria. For these 510 physicians, the median (IQR) number of internal reviews was 49.5 (30-93) and the median (IQR) internal score was 4.89 (4.81-4.93); the median number of reviews on PRWs ranged from 2 to 7, and the median score on PRWs ranged from 4.40 to 5.00. No physician had an internal score < 4, but the proportions with score < 4 on PRWs ranged from 16% to 30%. CONCLUSION: Internal patient satisfaction scores were higher and calculated from more reviews than PRW patient satisfaction scores and correlated weakly with PRW scores. Given that patients rely on PRWs when evaluating potential physicians, we recommend publishing internal scores online to give patients more complete information regarding physician performance.

Delay to surgery after neoadjuvant chemotherapy in head and neck squamous cell carcinoma affects oncologic outcomes.

BACKGROUND: Neoadjuvant chemotherapy (NAC) is used in head and neck squamous cell carcinoma (HNSCC) for downstaging advanced disease and decreasing distant metastasis (DM). To the authors' knowledge, no study has specifically examined the impact of a delayed time to surgery (TTS) after NAC on oncologic outcomes. They thus aimed to identify a cutoff for TTS after NAC and its effect on survival indices. METHODS: This was a retrospective review of all patients with HNSCC receiving NAC followed by surgery with curative intent between March 2016 and March 2019 at the MD Anderson Cancer Center. Receiver operating characteristic analysis was used to identify a cutoff for TTS, and this cutoff was used to analyze the overall survival (OS), locoregional recurrence rate, DM-free rate, and disease-free survival (DFS). A multivariate Cox regression analysis was performed. RESULTS: One hundred one patients were analyzed with a median follow-up of 24.7 months. The 3-year OS and locoregional recurrence rates did not differ with a TTS ≥ 34 days. However, the 3-year DM-free rate was significantly worse (56% vs 90%; P = .001) in the group with a TTS ≥ 34 days, and the 3-year DFS was significantly lower (26% vs 64%; P = .006). In a multivariate analysis, a TTS ≥ 34 days (hazard ratio [HR], 4.92; 95% confidence interval [CI], 1.84-13.13) and extracapsular extension (HR, 3.01; 95% CI, 1.13-8.00) were significant independent predictors of a poorer DM-free rate. Weight loss > 10% (HR, 5.53; 95% CI, 1.02-30.24) was the only independent predictor for a TTS ≥ 34 days. CONCLUSIONS: Emphasis should be placed on early definitive locoregional treatment after NAC, particularly in patients who do not respond to NAC. There is a need to validate these findings and establish new benchmarks for the interval between NAC and surgery.