A Descriptive Study of Quality of Life Following Neoadjuvant Chemotherapy and Transoral Robotic Surgery for Human Papillomavirus-Associated Oropharyngeal Squamous Cell Carcinoma.

BACKGROUND: Patients with oropharyngeal squamous cell carcinoma (OPSCC) treated with radiation-based therapy suffer from short- and long-term toxicities that affect quality of life (QOL). Transoral robotic surgery (TORS) has an established role in the management of early OPSCC but adjuvant treatment is often indicated postoperatively due to the high incidence of nodal metastasis associated with advanced human papillomavirus (HPV)-related OPSCC. To overcome the need for adjuvant radiation therapy (RT), neoadjuvant chemotherapy followed by TORS and neck dissection (ND) is proposed. This study aimed to assess if QOL in HPV-associated OPSCC receiving neoadjuvant chemotherapy followed by TORS and ND returns to baseline within 12 months of completing treatment. METHODS: A 12 month longitudinal study was carried out at McGill University Health Centre in Montreal, Canada, among a convenience sample of patients with American Joint Committee on Cancer Seventh Edition stage III and IVa HPV-related OPSCC who were treated with neoadjuvant chemotherapy followed by TORS and ND. QOL data were obtained pretreatment and at 1, 3, 6, and 12 months following treatment completion using the European Organisation for Research and Treatment of Cancer Core and Head and Neck extension modules. Paired t tests and mixed models for repeated measures analysis were used to assess changes in QOL from baseline to 12 months postoperatively and over time, respectively. RESULTS: Nineteen of 23 patients (median age 58 years) who received the study treatment fulfilled the eligibility criteria. OPSCC subsites were palatine tonsil (n = 12) and base of tongue (n = 7). All 19 patients were treated per protocol and none required adjuvant RT as per pathology review and protocol requirements at a postoperative multidisciplinary team tumor board discussion. No significant differences were found when comparing 12 month QOL follow-up scores to pretreatment scores in measures that would likely be affected by RT [eg, swallowing (P = .7), social eating (P = .8), xerostomia (P = .9)]. CONCLUSION: In HPV-related OPSCC, neoadjuvant chemotherapy followed by TORS and ND as definitive treatment is associated with excellent QOL outcomes. Postoperative QOL scores returned to baseline by 3 months and were maintained for all measures, indicating a return to normal function.

Comparison of wound surface area measurements obtained using clinically validated artificial intelligence-based technology versus manual methods and the effect of measurement method on debridement code reimbursement cost.

BACKGROUND: Evidence shows that ongoing accurate wound assessments using valid and reliable measurement methods is essential to effective wound monitoring and better wound care management. Relying on subjective interpretation in measuring wound dimensions and assuming a rectilinear shape of all wounds renders an inconsistent and inaccurate wound area measurement. OBJECTIVE: The authors investigated the discrepancy in wound area measurements using a DWMS versus TPR methods and compared debridement codes submitted for reimbursement by assessment method. METHODS: The width and length of 177 wounds in 56 patients were measured at an outpatient clinic in the United States using the TPR method (width × length formula) and a DWMS (traced wound dimensions). The maximal allowable payment for debridement was calculated for both methods using the reported CPT codes based on each 20-cm2 estimated surface area. RESULTS: The average wound surface area was significantly higher with the TPR method than with the DWMS (20.20 and 12.81, respectively; P = .025). For patients with dark skin tones, ill-defined wound edges, irregular wound shapes, unhealthy tissues, and the presence of necrotic tissues, the use of the DWMS resulted in significantly lower mean differences in wound area measurements of 14.4 cm2 (P < .008), 8.2 cm2 (P = .040), 6.8 cm2 (P = .045), 13.1 cm2 (P = .036), and 7.6 cm2 (P = .043), respectively, compared with the TPR method. Use of the DWMS for wound surface area measurement resulted in a 10.6% lower reimbursement amount for debridement, with 82 fewer submitted codes, compared with the TPR method. CONCLUSIONS: Compared with the DWMS, TPR measurements overestimated wound area more than 36.6%. This overestimation was associated with dark skin tones and wounds with irregular edges, irregular shapes, and necrotic tissue.

Management of bone metastasis with zoledronic acid: A systematic review and Bayesian network meta-analysis.

Background: While considered the mainstay of treatment for specific bone metastases, ZA is used predominantly to treat osteolytic lesions. The purpose of this network meta-analysis is to compare ZA to other treatment options in its ability to improve specific clinical outcomes in patients with bone metastases secondary to any primary tumor. Methods: PubMed, Embase and Web of Science were systematically searched from inception to May 5th, 2022. Keywords used were solid tumor, lung neoplasm, kidney neoplasm, breast neoplasm, prostate neoplasm, ZA and bone metastasis. Every randomized controlled trial and non-randomized quasi-experimental study of systemic ZA administration for patients with bone metastases and any comparator were included. A Bayesian network meta-analysis was done on the primary outcomes including number of SREs, time to developing a first on-study SRE, overall survival, and disease progression-free survival. Secondary outcome was pain at 3, 6 and 12 months after treatment. Results: Our search yielded 3861 titles with 27 meeting inclusion criteria. For the number of SRE, ZA in combination with chemotherapy or hormone therapy was statistically superior to placebo (OR 0.079; 95 % CrI: 0.022-0.27). For the time to the first on study SRE, the relative effectiveness of ZA 4 mg was statistically superior to placebo (HR 0.58; 95 % CrI:0.48-0.77). At 3 and 6 months, ZA 4 mg was significantly superior to placebo for reducing pain with a SMD of -0.85 (95 % CrI:-1.6, -0.0025) and -2.6 (95 % CrI:-4.7, -0.52) respectively. Conclusions: This systematic review shows the benefits of ZA in decreasing the incidence of SREs, increasing the time to the first on-study SRE, and reducing the pain level at 3 and 6 months.

Long-Term Quality of Life After Esophagectomy for Esophageal Cancer.

BACKGROUND: Surgery, as part of a multimodal approach, offers the greatest chance of cure for esophageal cancer. However, esophagectomy is often perceived as having a lasting impact on quality of life (QOL), biasing some physicians and patients toward nonoperative management. A comprehensive understanding of the dynamic changes in patient-centered outcomes is therefore important for decision making. Our objective was to determine the long-term QOL after esophagectomy. METHODS: Data were obtained from a prospectively collected (2006-2015) esophagectomy database at a high-volume center, and patients surviving 3 or more years were identified. Health-related QOL was evaluated using the Functional Assessment of Cancer Therapy-Esophageal Module (FACT-E) at diagnosis and every 3 to 6 months, and was stratified according to operative approach, stage, and complications. In addition, QOL scores were compared with normative population values. RESULTS: Of 480 patients, 47% (n = 226) survived 3 or more years and 70% (158 of 226) completed the health-related QOL assessments. Time of follow-up was 5.1 ± 2.8 years. After a reduction at 1 to 3 months, FACT-E increased from a baseline of 126 (95% CI, 121-131) to 133 (95% CI, 127-139) at 12 months, and to 147 (95% CI, 142-153) by 5 years. There was no difference in long-term FACT-E with respect to the surgical approach, clinical and pathologic stage, or postoperative complications. At long-term follow-up (more than 3 years), QOL did not differ significantly from the normative population reference values. CONCLUSIONS: The long-term QOL of esophagectomy patients surviving at least 3 years is improved when compared with the time of diagnosis and does not differ from the general population.

The association between household food insecurity and obesity in Mexico: a cross-sectional study of ENSANUT MC 2016.

OBJECTIVE: To examine the association between household food insecurity and overweight, obesity and abdominal obesity in Mexican adults. DESIGN: Cross-sectional study. SETTING: We analysed data from the Mexican Halfway National Health and Nutrition Survey 2016, a nationally representative survey that accounted for rural and urban areas in four regions of Mexico: North, Centre, Mexico City and South. PARTICIPANTS: Adults from 20 to 59 years old (n 5456, which represents 45 804 210 individuals at the national level). RESULTS: 70·8 % of the Mexican adults had some degree of household food insecurity. This situation showed larger proportions (P < 0·05) among indigenous people, those living in a rural area, in the Southern region or the lowest socio-economic quintiles. The prevalence of obesity and abdominal obesity was higher in female adults (P < 0·001), with the highest proportions occurring among those experiencing severe household food insecurity. Among women, mean BMI and waist circumference were higher as household food insecurity levels increased (P < 0·001). According to multivariate logistic regression models, severe household food insecurity showed to be positively associated with obesity (OR: 2·36; P = 0·001) in Mexican adult females. CONCLUSIONS: Our findings confirm the association between household food insecurity and obesity among Mexican women. Given the socio-demographic characteristics of the food-insecure population, it is alarming that prevailing socio-economic inequalities in the country might also be contributing to the likelihood of obesity. Therefore, it is crucial to maintain and bolster surveillance systems to track both problems and implement adequate policies and interventions.

Local Delivery of Therapeutic Boron for Bone Healing Enhancement.

OBJECTIVES: To evaluate if local delivery of boron can accelerate bone healing and examine if the bioactive salt impacts the osteogenic response of bone-derived osteoclasts and osteoblasts by the regulation of the Wnt/ß-catenin pathway. METHODS: Bilateral femoral cortical defects were created in 32 skeletally mature C57 mice. On the experimental side, boric acid (8 mg/kg concentration) was injected locally, whereas on the control side, saline was used. Mice were euthanized at 7, 14, and 28 days. MicroCT was used to quantify bone regeneration at the defect. Histological staining for alkaline phosphatase and tartrate-resistant acid phosphatase was used to quantify osteoblast and osteoclast activity, respectively. Immunohistochemical antibodies, ß-catenin, and CD34 were used to quantify active ß-catenin levels and angiogenesis, respectively. RESULTS: The boron group exhibited higher bone volume and trabecular thickness at 28 days on microCT. Both alkaline phosphatase activity and ß-catenin activity was significantly higher in the boron group at 7 days. In addition, CD34 staining revealed increased angiogenesis at 14 days in boron-treated groups. We found boron to have no association with osteoclast activity. CONCLUSIONS: This study shows that local delivery of boron is associated with an increase in osteoblast activity at early phases of healing. The corresponding increase in ß-catenin likely supports that boron increases osteoblast activity by the Wnt/ß-catenin pathway. Increased angiogenesis at 14 days could be a separate mechanism of increasing bone formation that is independent of Wnt/ß-catenin activation.

ERAS 2.0: Continued Refinement of an Established Enhanced Recovery Protocol for Esophagectomy.

BACKGROUND: We have previously demonstrated that implementing an enhanced recovery protocol (ERP) improved outcomes after esophagectomy. We sought to examine if, after a decade of an established ERP, further improvements in postoperative outcomes could be made after continually optimizing and revising the pathway. METHODS: Patients undergoing esophagectomy for cancer from January 2019 to January 2020 were compared with our early-experience group within the initial ERP (June 2010-May 2011) and pre-ERP traditional care (June 2009-May 2010). The original ERP was initiated on June 2010 and underwent several revisions from 2014 to 2018, incorporating the following, amongst other elements: shorten the planned length of stay from 7 to 6 days, elimination of nasogastric tubes, use of soft closed-suction chest drains, and increased application of minimally invasive esophagectomy (MIE). Thirty-day outcomes (complications, length of stay, readmission) were compared for patients undergoing esophagectomy during the initial and most recent ERPs. RESULTS: Overall, 175 patients were identified; 47 underwent esophagectomy before ERP implementation (traditional care), 59 patients underwent esophagectomy after implementation of the original ERP, and 69 patients underwent esophagectomy after the most recent ERP (ERP 2.0). The groups were similar with respect to age, sex, and diagnosis. There were three times more MIEs in the ERP 2.0 group with a shorter median length of stay (7 [6-9] vs. 8 [7-17] vs. 10 [9-17]; p < 0.001) without impacting postoperative morbidity or readmission rate. CONCLUSION: Continued evaluation of institutional outcomes after esophagectomy should be performed to identify target areas for optimization and revision of established enhanced recovery protocols. ERPs are dynamic processes that can be further refined to yield greater improvements in outcomes.

The Predictive Value of Inflammatory Biomarkers in Esophageal Anastomotic Leaks.

BACKGROUND: This study investigated the role of the neutrophil-to-lymphocyte ratio (NLR) in predicting anastomotic leak (AL) after esophagectomy for esophageal adenocarcinoma. METHODS: This is a retrospective analysis of a prospectively collected database from the McGill University Health Center. Included were all patients with esophageal adenocarcinoma who underwent esophagectomy between 2005 and 2016. Patients with chronic infections, concurrent active malignancies, and autoimmune conditions were excluded. NLR values were obtained on postoperative days (POD) 0, 1, 2, and 3. Receiver operating characteristic curve study and multivariable logistic analysis were conducted to evaluate the diagnostic value of NLR. RESULTS: The study included 330 patients, and AL developed in 16%. Mean NLR values on POD1, 2, and 3 were higher in patients with leaks (20 vs 14 on POD1, P < .001; 20 vs 12 on POD2, P < .001; and 19 vs 10 on POD3, P < .001). The NLR value on POD3 was associated with an area under the curve of 70% and a negative predictive value of 92.4%. Multivariable analyses identified higher American Society of Anesthesiologists Physical Status Classification, increasing NLR trend (between POD1 and POD3), POD1 NLR, POD2 NLR, and POD3 NLR as independent factors associated with AL. CONCLUSIONS: Patients who developed AL demonstrate higher mean NLR values in the early postoperative period with rising trends. Conversely a low NLR is associated with a high negative predictive value for AL. This simple metric allows risk stratification that may guide treatment decisions in esophagectomy patients.

Ranitidine Impairs Bone Healing and Implant Osseointegration in Rats' Tibiae.

PURPOSE: Ranitidine has been found to have an impact on bone metabolism by suppressing osteoclastogenesis. We hypothesized that the use of ranitidine would impair bone healing and implant osseointegration. This study investigated the effect of postoperative administration of ranitidine on bone healing and osseointegration in rats. MATERIALS AND METHODS: Twenty-two Sprague-Dawley rats underwent surgery to create a unicortical bone defect in each tibia. A titanium implant was placed on the right tibial defect, whereas the contralateral defect was left unfilled. After surgery, the rats were randomly divided into 2 groups receiving a daily dose of ranitidine or saline solution for 14 days and then euthanized for assessment of bone healing and osseointegration using micro-computed tomography (CT) and histomorphometry. RESULTS: Micro-CT analysis of the bone defect showed a larger bone defect volume in the ranitidine group (0.82 ± 0.13 µL vs 0.66 ± 0.16 µL, P = .034), thinner cortical thickness (0.54 ± 0.07 mm vs 0.63 ± 0.11 mm, P = .026), and less bone regeneration at the defect site (40% ± 12% vs 57% ± 11%, P = .003). Implant-site micro-CT analysis showed less osseointegration in the ranitidine group (34.1% ± 2.7% vs 43.5% ± 2.1%, P = .014), and implant-site histologic analysis showed less medullary (P = .021), cortical (P = .001), and total (P = .003) bone-implant contact and less peri-implant bone volume-tissue volume (P = .002) in the ranitidine group. Histologic analysis for osteoclastic activity showed a lower number of osteoclasts in the ranitidine group (4.8 ± 2.4 mm-2 vs 9.1 ± 2.1 mm-2, P = .026). CONCLUSIONS: The postoperative use of ranitidine impaired bone healing and osseointegration.

Defective bone repair in diclofenac treated C57Bl6 mice with and without lipopolysaccharide induced systemic inflammation.

Bone repair after trauma or surgical intervention involves a tightly regulated cascade of events that starts with hemostasis and an inflammatory response, which are critical for successful healing. Nonsteroidal anti-inflammatory drugs (NSAID) are routinely prescribed for pain relief despite their potential inhibitory effect on bone repair. The goal of this study was to determine the impact of administration of the non-selective NSAID diclofenac in the inflammatory phase of bone repair in mice with or without lipopolysaccharide-induced systemic inflammation. Repair of femoral window defects was characterized using micro computed tomography imaging and histological analyses at 2 weeks postoperative. The data indicate (a) impaired bone regeneration associated with reduced osteoblast, osteoclast, and macrophage activity; (b) changes in the number, activity, and distribution of mast cells in regenerating bone; and (c) impaired angiogenesis due to a direct toxic effect of diclofenac on vascular endothelial cells. The results of this study provide strong evidence to support the conjecture that administration of NSAIDs in the first 2 weeks after orthopaedic surgery disrupts the healing cascade and exacerbates the negative effects of systemic inflammation on the repair process.

Correlation and agreement between depressive symptoms in children and their parent's perception / Correlación y concordancia entre síntomas depresivos en niños y su percepción por los padres

ABSTRACT: Introduction: Childhood depression is a disease that is becoming more frequent. Few reports address parental perception of children depressive symptoms, and these studies have not been carried out in community samples. Objective: To evaluate the correlation and agreement of depressive symptoms in school-age children, and their parent's perception about emotional and conduct abnormalities. Method: A transversal study was performed in 284 children who filled a Children Depression Inventory. One of their parents filled a Strengths and Difficulty Questionnaire, and correlation between scores and subcomponent scores were assessed. Agreement between presence of depressive symptoms in children and their parent's perception of abnormal emotional and/or conduct reports was also obtained. Results: 47 children were identified with depressive symptoms. We found moderate correlation between scores. We did not find agreement between the presence of depressive symptoms in the children and the report of emotional and conduct abnormalities by parents. Discussion and conclusion: There is a modest correlation between depressive symptom severity and parental perception of abnormal emotions and/or behaviors. We found no evidence of agreement between these domains in our study, which suggests that parents fail to perceive negative emotions or conducts as depressive symptoms in their children. Parental reports should be addressed by healthcare workers, and their emotional significance should be interpreted. An intentional search of depressive symptomatology in children should be a priority.

RESUMEN: Introducción: La prevalencia de la depresión infantil está al alza. Pocos estudios han evaluado la percepción parental de los síntomas depresivos en niños, y los que se han realizado no han sido replicados en la comunidad. Objetivo: Evaluar la correlación y la concordancia entre los síntomas depresivos en niños de edad escolar con la percepción de sus padres sobre problemas emocionales y conductas anormales. Método: Se realizó un estudio transversal en 284 niños que contestaron el Inventario de Depresión Infantil y se compararon los puntajes con el Cuestionario de Fortalezas y Dificultades que llenó uno de los padres. Se evaluó la correlación entre los puntajes totales y por sub-escalas, así como la concordancia entre la presencia de puntajes sugestivos de depresión infantil y la percepción parental de emociones y conductas anormales. Resultados: 47 niños fueron identificados con puntajes indicativos de sintomatología depresiva. Encontramos correlación moderada entre los puntajes de las escalas. No encontramos concordancia entre la presencia de síntomas depresivos y el reporte parental de emociones o conductas anormales. Discusión y conclusión: Existe correlación entre la severidad de los síntomas depresivos y la percepción parental de emociones y conductas anormales. No encontramos concordancia entre ambas mediciones, lo cual sugiere que los padres fallan al identificar las conductas y emociones anormales de sus hijos como los síntomas depresivos. Los reportes de los padres deben ser tomados en cuenta y ser interpretados por el personal de salud. La búsqueda intencionada de síntomas depresivos en niños debe ser parte fundamental del proceso de cuidado de esta población.