Liver transplantation in New Orleans: parity in a world of disparity?

BACKGROUND: Racial disparity in access to liver transplantation among African Americans (AA) compared to Caucasians (CA) has been well described. The aim of this investigation was to examine the presentation of AA liver transplant recipients in a socioeconomically challenged region. METHODS: 680 adult liver transplant candidates and 233 resultant recipients between 2007 and 2015 were analyzed using univariate and multivariate analyses to evaluate factors significant for transplantation. RESULTS: Percentages of wait list patients transplanted were similar between CA and AA (34.9% vs. 32.2%, p = 0.5205). AA were younger (50.4 ± 1.8 vs. 56.3 ± 0.7 yrs, p = 0.0003) with higher average MELD scores (22.9 ± 1.6 vs. 19.4 ± 0.7, p = 0.0230). Overall patient mortality was similar (AA 22.7% vs. CA 26.3%, p = 0.5931). A multiple linear regression showed that male gender was strongly associated with transplantation. CONCLUSIONS: Equal access to liver transplantation remains challenging for racial minorities. At our institution, AA were accepted and transplanted at an equivalent rate as CA despite a higher AA population, HCV rate and diagnosed HCC. AA were younger and sicker at the time of transplant, but overall had similar outcomes compared to CA. Our study highlights the need for studies to delineate the underpinnings of disparity in transplantation access.

Metadherin Expression is Associated with Extrathyroidal Extension in Papillary Thyroid Cancer Patients.

BACKGROUND: Metadherin (MTDH) is widely recognized as a promising molecular marker for tumor recurrence and poor survival in many cancers. By multiple pathways, MTDH promotes oncogenesis, metastasis, and chemoresistance. This study investigated the role of MTDH in papillary thyroid carcinoma (PTC) to determine its potential association with aggressive clinical and pathologic features, including its relation in tumors harboring a BRAF (V600E) mutation. METHODS: Expression of MTDH was assessed by immunohistochemistry in 96 cases of PTC, including primary thyroid malignancies and lymph node metastases. The status of BRAF (V600E) mutation was determined by real-time polymerase chain reaction. RESULTS: Overexpression of MTDH was observed in 26 % (23/88) of primary PTC cases. High-intensity staining was observed in 75 % (6/8) of lymph nodes with metastatic PTC and moderate staining in 25 % (2/8) of cases. Normal adjacent thyroid tissue and benign thyroid controls were found to have significantly lower MTDH expression than cancer tissue (p < 0.05). Apical staining of MTDH was observed in 19 % of thyroid tumors and not observed in normal thyroid tissue. Interestingly, MTDH expression was associated with extrathyroidal extension (p < 0.05) and not associated with age, gender, overall tumor stage, or BRAF (V600E) mutation status. CONCLUSION: In a subset of PTC patients, MTDH was overexpressed and associated with extrathyroidal extension. Further studies are warranted to explore the utility of MTDH to improve risk stratification of current molecular panels for PTC.

Human Adipose Tissue-Derived Stromal/Stem Cells Promote Migration and Early Metastasis of Head and Neck Cancer Xenografts.

BACKGROUND: Fat grafting has become popular for repair of postsurgical/postradiation defects after head/neck cancers resection. Fat graft supplementation with adipose tissue-derived stromal/stem cells (ASCs) is proposed to improve graft viability/efficacy, although the impact of ASCs on head/neck cancer cells is unknown. OBJECTIVES: To determine whether ASCs affect growth, migration, and metastasis of human head/neck cancer. METHODS: Human Cal-27 and SCC-4 head/neck cancer cells were co-cultured human ASCs, or treated with ASC conditioned medium (CM), and cancer cell growth/migration was assessed by MTT, cell count, and scratch/wound healing assays in vitro. Co-injection of 3 × 10(6) Cal-27/green fluorescent protein (GFP) cells and ASCs into the flank of NUDE mice assessed ASC effect on tumor growth/morphology. Quantitation of human chromosome 17 DNA in mouse organs assessed ASC effects on micrometastasis. Primary tumors were evaluated for markers of epithelial-to-mesenchymal transition, matrix metalloproteinases, and angiogenesis by immunohistochemistry. RESULTS: Co-culture of Cal-27 or SCC-4 cells with ASCs from 2 different donors or ASC CM had no effect on cell growth in vitro. However, ASC CM stimulated Cal-27 and SCC-4 migration. Co-injection of ASCs from 2 different donors with Cal-27 cells did not affect tumor volume at 6 weeks, but increased Cal-27 micrometastasis to the brain. Evaluation of tumors sections from 1 ASC donor co-injection revealed that ASCs were viable and well integrated with Cal-27/GFP cells. These tumors exhibited increased MMP2, MMP9, IL-8, and microvessel density. CONCLUSIONS: Human ASCs did not alter growth of human head/neck cancer cells or tumor xenografts, but stimulated migration and early micrometastasis to mouse brain.

The utility of molecular markers in pre-operative assessment of thyroid nodules.

The pre-operative diagnosis of thyroid tumors is determined by gold standard fine needle aspiration (FNA) biopsy. This has been widely accepted and offers the most cost-effective approach for evaluation of thyroid nodules. However, its diagnostic accuracy can pose a challenging scenario to surgeons. These diagnostic difficulties may subject patients to unnecessary thyroidectomies for benign thyroid nodules. Thus, additional molecular tests are needed to improve the sensitivity and specificity of FNA. The role of molecular markers is being proposed to predict the type and risk of malignancy to abate the need for diagnostic thyroidectomies. This review discusses their utility and validity in pre-operative diagnosis of thyroid nodules and how these markers can enhance the accuracy of FNA cytology.

Tracheostoma reconstruction with the supraclavicular artery island flap.

Tracheostoma wounds are complex defects that commonly occur in patients with vessel-depleted necks after cervical lymphadenectomy, who have multiple medical comorbidities, and a history of radiation therapy. The authors report reconstruction of 5 tracheostoma wounds using a pedicled, supraclavicular artery island flap as a reconstructive alternative. There were no flap losses, fistulas or leaks, revisions, or other complications. The supraclavicular artery island flap is a versatile, reliable, and effective option for tracheostoma reconstruction.

Thyroid cancer in black thyroid glands: the effect of age and race.

BACKGROUND: Black thyroid pigmentation is a rare entity. The risk of malignancy is higher in black thyroid compared to non-black thyroid glands. We aimed to examine the effect of age and race on the risk of malignancy in black thyroid glands. METHODS: We identified a series of consecutive patients who underwent thyroidectomy at an academic institution between January 1998 and May 2013. Patient demographics, clinical characteristics, and histopathology data were reviewed. RESULTS: Among 925 patients who underwent thyroidectomy, 112 (12.1%) patients with black thyroid glands were identified. The incidence of thyroid cancer was 55.4% in black thyroid glands compared to 32.8% in non-black thyroid glands (p < 0.0001). The incidence of papillary thyroid cancer among the black and non-black thyroid glands was 34.8 and 20%, respectively (p < 0.001). The mean age (± SD) for patients with black thyroid glands and those with non-black thyroid was 54.3 ± 12.8 and 51.2 ± 15.7 years, respectively (p = 0.05). Black thyroid glands were also associated with a higher incidence of microcarcinomas (76 vs. 59%, p = 0.02). Among patients with black thyroid glands, Caucasians had a higher malignancy rate (63.4%) than African-Americans (37%; p = 0.03). CONCLUSION: The incidence of malignancy is higher in black thyroid compared to non-black thyroid glands, specifically in Caucasians.

The impact of surgical volume on racial disparity in thyroid and parathyroid surgery.

PURPOSE: The aim of this study was to evaluate the association between surgeon volume and patient outcomes among different race ethnicities undergoing thyroid or parathyroid surgery. METHODS: The nationwide inpatient sample was used to identify all thyroidectomy and parathyroidectomy admissions from 2003 to 2009, using International Classification of Diseases, 9th Clinical Modification (ICD-9-CM) procedure codes. Race, demographic, and clinical characteristics of patients were collected, along with surgeon volume, to predict the length of stay (LOS), complication rates, mortality, and total charges by racial group, using univariate and multivariate analyses. RESULTS: A total of 106,314 thyroid and parathyroid surgeries were included in the current analysis. Of these patients, 54 % were Caucasian, 11 % African American, 7 % Hispanic, and 3 % Asian. Mean LOS was longer for African American patients (4 ± 8.7 days) than for Caucasians (2.3 ± 5.5 days) [p < 0.001]. African Americans had higher overall complications (16.8 %) compared with Caucasians (11 %), Hispanics (13.5 %), and Asians (12 %) [p < 0.001]. In-hospital mortality was higher for African Americans (0.8 %) compared with that from other race groups (0.3 %) [p < 0.001]. Mean total charges were significantly higher for African Americans ($33,292 ± $67,387) compared with those for Caucasians ($22,855 ± $40,167) (p < 0.001). African Americans had less access to intermediate- (10-99 cases) and high- (>100 cases) volume surgeons compared with Caucasians-45 versus 49 %, and 16 versus 19 %, respectively (p < 0.001). Higher surgeon volume was associated with improved outcomes (p < 0.001). Racial disparity in all investigated outcomes was still significantly evident even after stratification by surgeon volume. CONCLUSION: Higher surgeon volume is associated with improved patient outcomes. However, our data suggests that the observed racial disparities in thyroid and parathyroid surgery go beyond access to quality healthcare providers.

Adipose stem cell therapy in cancer reconstruction: a critical review.

Found in most mesenchymally derived organs, mesenchymal stem cells are undifferentiated cells capable of developing into many cell types. Adipose stem cells are a type of mesenchymal stem cell easily extracted from lipoaspirate, often readily available, and are conformable to the tissue defect. Their ability for self-renewal, unlimited proliferation and proangiogenic, and immunomodulatory properties have made them attractive adjuncts in plastic surgery. Since the discovery of pluripotent cells in adipose tissue, plastic surgeons have applied the technology toward improving wound healing, soft tissue augmentation, and tissue engineering. More recently, some surgeons have used adipose stem cells in cancer reconstruction. By mixing lipoaspirate with concentrated fractions of adipose stem cells through a technique termed cell-assisted lipotransfer, plastic surgeons have claimed improved aesthetic results. Promising early results have been tempered by in vitro and animal studies demonstrating increased tumor proliferation and metastasis rates with the use of adipose and other mesenchymal stem cells. This review provides a succinct yet comprehensive overview of the current literature evaluating the oncologic risks associated with adipose stem cell use in cancer.

Cervical Necrotizing Fasciitis, Diagnosis and Treatment of a Rare Life-Threatening Infection.

IMPORTANCE: Necrotizing fasciitis is a relatively uncommon and potentially life-threatening soft tissue infection, with morbidity and mortality approaching 25% to 35%, even with optimal treatment. The challenge of diagnosis for necrotizing soft tissue infections (NSTIs) is their rarity, with the incidence of approximately 1000 cases annually in the United States. Given the rapid progression of disease and its similar presentation to more benign processes, early and definitive diagnosis is imperative. FINDINGS: Signs and symptoms of NSTIs in the early stages are virtually indistinguishable from those seen with abscesses and cellulitis, making definitive diagnosis difficult. The clinical presentation will depend on the pathogen and its virulence factors which ultimately determine the area and depth of invasion into tissue. There are multiple laboratory value scoring systems that have been developed to support the diagnosis of an NSTI. The scoring system with the highest positive (92%) and negative (96%) predictive value is the laboratory risk indicator for necrotizing fasciitis (LRINEC). The score is determined by 6 serologic markers: C-reactive protein (CRP), total white blood cell (WBC) count, hemoglobin, sodium, creatinine, and glucose. A score ≥ 6 is a relatively specific indicator of necrotizing fasciitis (specificity 83.8%), but a score <6 is not sensitive (59.2%) enough to rule out necrotizing fasciitis. In terms of imaging, computed tomography (CT) imaging, while more sensitive (80%) than plain radiography in detecting abnormalities, is just as nonspecific. Computed tomography imaging of NSTIs demonstrates fascial thickening (with potential fat stranding), edema, subcutaneous gas, and abscess formation. Magnetic resonance imaging (MRI) has demonstrated sensitivity of 100% and specificity of 86%, though MRI may not show early cases of fascial involvement of necrotizing fasciitis. CONCLUSIONS AND RELEVANCE: Necrotizing soft tissue infections are rapidly progressive and potentially fatal infections that require a high index of clinical suspicion to promptly diagnose and aggressive surgical debridement of affected tissue in order to ensure optimal outcomes.Prompt surgical and infectious disease consultation is necessary for the treatment and management of these patients. While imaging is useful for further characterization, it should not delay surgical consultation. Necrotizing soft tissue infection remains a clinical diagnosis, although plain radiography, CT imaging, and ultrasound can provide useful clues. In general, the management of these patients should include rapid diagnosis, using a combination of clinical suspicion, laboratory data (LRINEC score), and imaging (MRI being the recommended imaging modality), prompt infectious disease and surgical consultation, surgical debridement, and delayed reconstruction. Laboratory findings that can more strongly suggest a diagnosis of NSTI include elevated CRP, elevated WBC, low hemoglobin, decreased sodium, and increased creatinine. Imaging findings include fascial thickening (with potential fat stranding), edema, subcutaneous gas, and abscess formation. Broad-spectrum antibiotics should be started in all cases of suspected NSTI. Surgical debridement, however, remains the lynchpin for treatment of cervical necrotizing fasciitis.

Supraclavicular Artery Island Flap for Head and Neck Oncologic Reconstruction: 15-year Experience, Past, Present, Future.

Head and neck reconstruction poses unique challenges due to the complex structure of the region. Primary goals include soft-tissue coverage, adequate color and texture match, and minimal donor-site morbidity. Local and musculocutaneous regional flaps have largely been replaced with fasciocutaneous free flaps (FFF) over recent years. The supraclavicular artery island flap (SCAIF), a locoregional, fasciocutaneous, axially-based flap, has been shown to produce similar outcomes to FFF. We present our 15-year experience using the SCAIF for head and neck reconstruction, discuss its evolution, and provide case examples for its range of indications. Methods: Retrospective chart review identified 128 patients who underwent reconstruction of the head and neck with the SCAIF between the years 2006-2021 at Tulane University Medical Center. Patient demographics, lengths of stay, operative times, surgical indications, and complications were recorded. Results: The cohort mean age was 66.9 years. Mean lengths of stay and follow-up times were 6.9 days and 9.1 months, respectively. The most common indications for SCAIF reconstruction were recurrent radiated neck disease (n=27, 21.1%), pharyngeal wall defects (n=23, 18.0%), and parotidectomy defects (n=21, 16.4%). Overall complication rate was 17.2%. Partial thickness flap loss (5.5%), contained pharyngeal leak (3.2%), and distal tip necrosis (2.4%) were the most common complications. No functional donor site morbidity was encountered. Conclusions: The SCAIF is a versatile, fasciocutaneous, axially-based flap able to produce similar outcomes to FFF in the reconstruction of the head and neck region while reducing costs, lengths of stay, operative times, and donor site morbidity.

The use of multislice CT angiography preoperative study for supraclavicular artery island flap harvesting.

BACKGROUND: The vascular anatomy of the supraclavicular artery island (SAI) flap has been investigated using both cadaveric anatomic dissections and angiographic studies. Accurate preoperative evaluation and localization of its vascular pedicle confirms its location, course, anatomic variation, and improves flap success. The objective of this report is to demonstrate the utility of multislice computed tomography (CT) angiography for confirming the presence of the vascular pedicle of the SAI flap when planning head and neck reconstruction. METHODS: Patients were studied using 64-multislice CT angiography (CTA) to localize the supraclavicular artery, including its origin and destination. Axial images, multiplanar reconstructions, and 3D volume-rendered images were analyzed on a Philips workstation. Radiologic image findings and clinical experience will be described. RESULTS: SAI CT angiography was successfully performed in 15 patients (30 shoulders) ranging from ages 22 to 81 years. Accurate identification of the main vascular pedicle was achieved in 14/15 patients. Location, course, pedicle length, and anatomic variations were reported for 23 of 30 arteries. Mean vessel diameter was found to be 1.49 mm (range, 0.8-2.0 mm) on the right and 1.51 mm (range, 1.0-2.1 mm) on the left. The mean length of the artery was 38.3 mm on the right (range, 26.6-59.6 mm) and 38.4 mm on the left (range, 24.3-67.0 mm). In all patients, the supraclavicular artery originated off the transverse cervical artery-a branch of the thyrocervical trunk. Positioning of the patient's upper extremities at the side was helpful in the identification of the supraclavicular artery and its distribution. Contrast injection site should be contralateral to the side needed for the flap if sidedness is of importance, secondary to contrast bolus artifact. CONCLUSIONS: Preoperative evaluation of the SAI flap with multislice computed tomography angiography is feasible in patients. A radiologic study protocol has been developed which improves the ability to detect this vessel. This technique provides a noninvasive approach to the identification of the vascular anatomy and is easily standardized/reproducible. The identification of the vascular pedicle and its anatomy can be a benefit to the surgical team during preoperative design of the SAI flap; however, clinical experience confirming these radiologic findings will be needed to optimize surgical outcome.

Transaxillary gasless robotic thyroid surgery with nerve monitoring: initial two experince in a North American center.

Minimally invasive thyroid surgery using various techniques is well described. The present study reviews our initial experience with the technique with added intraoperative monitoring to assess its safety and feasibility. The study group consisted of ten consecutive patients with suspicious thyroid nodules who were candidates for thyroid lobectomy from September to December 2009. All patients underwent intraoperative nerve integrity monitoring and postoperative direct laryngoscopy. The patients' demographic information, operative times, learning curve, complications, and postoperative hospital stay were evaluated. All procedures were successfully completed with intraoperative nerve monitoring. No cases were converted to an open procedure. The median age was 38.5 years (σ = 13.5) and nine of the ten patients were females. The mean operating time was 131 minutes (range 101-203 minutes) and the mean operating time with the da Vinci system was 55 minutes. All patients were discharged home after an overnight stay. One patient developed transient radial nerve neuropathy that resolved spontaneously. There were no other postoperative complications. None of the patients complained of postoperative neck pain. Postoperative laryngoscopy showed intact and mobile vocal cords in all patients. Robotic endoscopic thyroid surgery with gasless transaxillary approach is feasible and safe in the treatment of suspicious thyroid nodules. Monitoring of the RLN during this approach is feasible.

Impact of extensive neck dissection on survival from papillary thyroid cancer.

BACKGROUND: Cervical lymph node metastasis commonly occurs in papillary thyroid cancer. Emerging evidence from large population-based studies demonstrates decreased survival with regional lymph node metastasis. There is considerable debate in the literature regarding the optimal initial treatment for papillary thyroid cancer. We hypothesized that overall survival is influenced by the extent of neck involvement and neck dissection. METHODS: The Surveillance, Epidemiology and End Results database was used to identify all patients with papillary thyroid cancer who underwent thyroidectomy. Patients with distant metastasis, invalid, or missing staging, and neck dissection information were excluded. A Kaplan-Meier survival estimate and a multivariate adjusted Cox regression model were used to estimate survival rates of patients undergoing selective, modified, and radical neck dissection as compared to those who did not have a neck dissection. RESULTS: 3,439 eligible patients were included in this analysis. The mean age was 45 years; 76% were females and 86% were white. 2,414 (70.1%) of the patients underwent thyroidectomy without any neck dissection, whereas selective (limited), modified and radical neck dissections were performed on 19.3, 7.9 and 2.7% of the patients, respectively. Five-year patient survival rates were 96.6, 96.4, 89.5 and 80.9% among patients who had no neck dissection, selective, modified, and radical neck dissections, respectively. After adjusting for age, gender and race, the hazard ratios and 95% confidence intervals of survival for modified and radical neck dissection were 2.35 (95% CI: 1.46-3.78) and 4.48 (95% CI: 2.57-7.84), respectively, as compared to no neck dissection (p < 0.001). Similar associations were also noted after stratifying by localized or regional tumor. CONCLUSIONS: Extensive neck dissection among patients with papillary thyroid cancer did not result in an improved survival benefit. Further study is warranted to better understand the extent and requirement of neck dissection among this group of patients.

Comparison of ultrasound-guided biopsy technique for thyroid nodules with respect to adequacy of cytological material.

BACKGROUND: Ultrasound-guided fine-needle aspiration cytology (FNAC) sampling of the thyroid represents a standard diagnostic procedure in the evaluation of thyroid nodules. The specimen can be acquired using either of two different techniques. In the first, the short axis is used with observation only of the tip of the needle whilst in the nodule. In the second technique, the long axis is used with the observation of the entire length of the needle. The decision to sample utilizing either technique was done randomly. This study is a retrospective review performed to compare these two techniques with regard to specimen adequacy. METHODS: Ultrasound-guided FNACs were performed in 80 thyroid nodules between May 2008 and February 2009. One physician acquired the cytology specimens using one of these two methods after localization. Data on the type of technique and its diagnostic accuracy were collected. RESULTS: Forty-nine of 80 thyroid nodules were sampled using the long-axis technique. The overall and deep-lesion diagnostic adequacies of specimens were significantly higher using this technique (93.9 and 95.1%, respectively, p < 0.01) than the short-axis technique. When comparing the long and short axes for superficial lesions, there was no significant difference in adequacy of the samples (p = 0.92). CONCLUSIONS: This is the first study to compare long- and short-axis techniques with regard to specimen adequacy for thyroid nodules. The long-axis technique decreased the rate of inadequate material and provided more accurate cytological evaluation for deeper lesions.

Posterolateral skull base reconstruction using the supraclavicular artery island flap.

The supraclavicular artery island (SAI) flap is a viable fasciocutaneous option for the reconstruction of head and neck defects. Although authors have reported success using SAI flaps for various reconstructive indications, concerns of a tenuous blood supply and distal ischemia have previously limited its use in the posterolateral skull base. This case series reports the outcomes of 5 consecutive patients receiving SAI flaps for posterolateral skull base reconstruction. All flaps were harvested in less than 1 hour with primary closure of all donor sites. A single patient developed superficial necrosis of the distal flap, which was repaired with a full-thickness skin graft. There were no other complications, and no donor site morbidity was observed. The SAI flap is an excellent option for the reconstruction of posterolateral skull base defects. The close color match, easy harvest within 1 hour, lack of microsurgical anastomosis, and absence of donor site morbidity support its continued utilization.

The effect of race, socioeconomic status, and comorbidity on patients afflicted with COVID 19: A Local Perspective.

PURPOSE: The aim of this study is to further examine the associations of race, socioeconomic factors, and comorbidity with COVID-19 health outcomes. METHODS: This is a retrospective cohort study of 309 PCR confirmed COVID-19 positive adults who presented to Tulane Medical Center in New Orleans, LA, from March 9 to May 29, 2020. The primary outcomes investigated were need for invasive mechanical ventilation (IMV) and in-hospital mortality. A multivariate analysis was performed to determine socioeconomic and medical risk factors for IMV and in-hospital mortality. RESULTS: Compared to white patients, Black patients were more likely to present younger, female, obese, unemployed, and underinsured. However, when controlled for common risk factors, Black and white patients had similar risk for IMV and mortality. Increased age (≥65 years), obesity, and increased comorbidity were associated with increased risk for IMV and mortality. CONCLUSIONS: Race and socioeconomic factors may increase risk for COVID-19 infection but did not affect health outcomes within the hospital setting. Therefore, the higher rates of COVID-19 infection and mortality in vulnerable populations may be better explained by lower socioeconomic status, with subsequent higher comorbidity, in these populations. Community health initiatives should be prioritized in response to the COVID-19 pandemic.

A simple and safe minimally invasive technique for laparoscopic gastrostomy.

INTRODUCTION: Percutaneous endoscopic gastrostomy (PEG) is the procedure of choice in the nutritional management of patients requiring gastrostomies. However, PEG tubes are not always feasible. The aim of the present study was to determine the feasibility, complications, and adequacy of feeding support of a novel laparoscopic gastrostomy technique in adults where PEG tubes were neither feasible nor safe. METHODS: A retrospective chart review of patients who underwent a laparoscopic gastrostomy from August 2007 to July 2008 was performed. Demographic and outcome data were abstracted. RESULTS: Fourteen patients underwent laparoscopic gastrostomy. Nine had obstructing head/neck cancer, 2 had severe head trauma, and one was morbidly obese. Nine patients had previous abdominal surgery. The mean operative time was 29.8 minutes (+/-7.2). There were no conversions to open gastrostomy. Two ports (5mm and 10mm) were used in the majority of patients (78.5%). No major complications were observed. The mean follow-up was 3.1 months (range, 2 to 8). CONCLUSION: This innovative 2-port laparoscopic technique for gastrostomy tube placement is safe and effective. It allows for the quick, accurate, and safe insertion of the feeding tube under direct visualization and avoids open techniques in patients where PEG tubes are not feasible.

Knowledge Gaps among Patients and Providers in HPV-Related Oropharyngeal Cancer: A Systematic Review.

OBJECTIVE: To describe the level of knowledge of human papillomavirus (HPV) and HPV-associated oropharyngeal squamous cell carcinoma (OPSCC) among the general population and health care providers. DATA SOURCES: Systematic search was performed on December 20, 2018, using MEDLINE (1966 to December 2018), EMBASE (1975 to December 2018), Web of Science (1900 to December 2018), and CENTRAL (1996 to December 2018) databases. English-language literature involving human subjects was used, and studies were limited to case series, case-control, cohort, and randomized controlled trial designs. REVIEW METHODS: Studies were included if they assessed knowledge of HPV and HPV-associated OPSCC. The primary outcome measure was the knowledge of HPV-associated OPSCC among the general population and with health care providers. Meta-analysis of proportions was attempted using random-effects model. The PRISMA guidelines were used for accuracy of reporting. RESULTS: Thirty-two studies were included with 17,288 participants. There was a high degree of heterogeneity preventing completion of a meta-analysis. Knowledge of HPV and HPV-associated OPSCC varied between the general population and health care providers. The proportion of the general population and health care providers with knowledge of HPV ranged from 16% to 75% and 21% to 84%, respectively. Knowledge of HPV-associated OPSCC was greater in health care providers and ranged from 22% to 100% compared with the general population, which ranged from 7% to 57%. CONCLUSION: There is a knowledge gap of HPV-associated OPSCC for both the general population and health care providers. Additional education may not only increase awareness but may also result in prevention and earlier detection.

Risk of SARS-CoV-2 Transmission During Flexible Laryngoscopy: A Systematic Review.

IMPORTANCE: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reportedly infected otolaryngologists disproportionately in the early parts of the coronavirus disease 2019 pandemic. Recommendations from national and international health organizations suggest minimizing the use of flexible laryngoscopy as a result. OBJECTIVE: To review evidence on the risks of aerosolization and transmission of SARS-CoV-2 from patients to health care personnel during endoscopy of the upper aerodigestive tract. EVIDENCE REVIEW: A comprehensive review of literature was performed on April 19, 2020, using the PubMed/MEDLINE (1966-April 2020), Embase (1975-April 2020), and Web of Science (1900-April 2020) databases. All English-language primary research studies were included if they assessed the transmission of SARS-CoV-2 or SARS-CoV-1 during procedures in the upper aerodigestive tract. The primary outcome measure was disease transmission among health care workers. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used for accuracy of reporting. FINDINGS: The queries for SARS-CoV-2 and SARS-CoV-1 identified 6 articles for systematic review. No studies included in this review provided data for SARS-CoV-2 transmission during flexible laryngoscopy. A total of 204 of 1264 health care workers (16.1%) had procedure-specific infections of SARS-CoV-1 or SARS-CoV-2. Among those, 53 of 221 (24.0%) were exposed during intubation, 1 of 15 (6.7%) during bronchoscopy, and 1 of 1 (100%) during endoscopy-assisted intubation. CONCLUSIONS AND RELEVANCE: A substantial lack of research precludes formal conclusions about the safety of flexible laryngoscopy and transmission of SARS-CoV-2 from patients to health care workers. The use of appropriate precautionary measures and personal protective equipment appears to reduce the risk of transmission. Given the uncertainty in transmission and the known benefits of safety precautions, upper airway endoscopy may be reasonable to perform if precautionary steps are taken.