Reirradiation after osteocutaneous free flap reconstruction for locally recurrent head and neck cancer.

PURPOSE: Recurrent head and neck cancer poses difficult management. Even after salvage surgery, many patients are considered high-risk for further recurrence and benefit from reirradiation, despite the sequelae such as chronic wounds, tissue necrosis, osteoradionecrosis and vascular damage associated with re-irradiation. Free flaps not only enable the reconstruction following salvage surgery, but there has been limited studies suggesting that free flap reconstruction may reduce the amount of reirradiation complications. However, there are no studies to date specifically examining the effects of osteocutaneous free flap reconstruction upon reirradiation outcomes. MATERIALS AND METHODS: In this retrospective study, patients with recurrent head and neck cancer that had a history of prior head and neck radiation who underwent salvage surgery with osteocutaneous free flaps followed by reirradiation were identified. Descriptive statistics were performed to assess outcomes. RESULTS: Five patients met criteria. Complications included chronic wound infection in one patient, fistula in one patient, plate exposure in two patients and plate removal in one patient. No patients had osteoradionecrosis or carotid rupture after reirradiation. There was an association between complications and further local disease recurrence. All patients were tube feed dependent at their most recent follow-up and two patients were tracheostomy dependent 12 months post-irradiation. Two patients had disease recurrence. Median overall survival was 16 months after reirradiation. CONCLUSIONS: Osteocutaneous free flap surgery with reirradiation may result in high rates of complications and low functional status with an equivocal improvement in survival. Larger studies are needed to substantiate these findings and assess the risk-benefit analysis.

An Overlooked Medication-Induced Celiac Flare Complicating Treatment of Osteoporosis.

Background/Objective: Celiac disease, an immune reaction to gluten causing nutrient malabsorption, and long-term glucocorticoid therapy adversely affect bone metabolism and increase fracture risk. Case Report: A patient with long-standing celiac disease on a strict gluten-free diet and long-term glucocorticoid therapy status post kidney transplant for Sjögren syndrome-induced interstitial nephritis presented for management of osteoporosis. Initial evaluation was notable for secondary hyperparathyroidism, which resolved after switching to a gluten-free calcium citrate supplement. Given normal serum total alkaline phosphatase (ALP) and parathyroid hormone (PTH), she began treatment of osteoporosis with abaloparatide. Two months later, she reported abrupt onset of diarrhea with significant weight loss. Biochemical investigation revealed a threefold increase in serum ALP level. As a precaution, abaloparatide was suspended, yet symptoms persisted with elevated ALP and PTH levels. Endoscopy revealed a celiac flare. The clinic-based pharmacist found that her pharmacy had inadvertently dispensed prednisone tablets containing wheat starch. A switch to a gluten-free formulation led to rapid resolution of the diarrhea with weight regain. Serum ALP and PTH levels normalized, and abaloparatide was resumed without biochemical abnormalities. Discussion: An unintended switch to a gluten-containing prednisone formulation resulted in uncontrolled celiac disease causing calcium malabsorption, secondary hyperparathyroidism, elevated ALP levels, and an interruption in osteoporosis therapy. Common supplements and drugs can be a hidden source of gluten. Collaboration with a clinic-based pharmacist enhances the detection and prevention of medication-induced adverse reactions. Conclusion: This case highlights the importance of a careful review of gluten-containing medications and supplements in patients with celiac disease.

The effect of standardization of insertion and removal of percutaneous left ventricular assist device.

BACKGROUND: The effect of standardizing an insertion and removal protocol for pVAD devices has not been previously described. OBJECTIVES: We sought to evaluate clinical outcomes in patients who underwent pVAD insertion pre- and post-protocol standardization. METHODS: All patients who underwent pVAD insertion that remained in place at index procedure completion between January 2017 and September 2023 at a single academic center for both high-risk PCI and cardiogenic shock indications were included in the study. The primary outcome was the incidence of limb ischemia and major bleeding before and after the protocol initiation. Secondary outcomes included in-hospital and 30-day MACCE rate (death, myocardial infarction, stroke, emergent CABG), and how often the operators followed the protocol. RESULTS: A total of 89 patients had pVAD left in place (29 pre-protocol initiation and 60 post-protocol initiation). There was a significant decrease in incidence of limb ischemia post-protocol initiation compared to pre (17.2 % vs 1.7 %, p = 0.01) but no difference in bleeding incidence (13.8 % vs 20.0 %, p = 0.47). Adherence increased in all components of the protocol except for right heart catheterization. CONCLUSION: Standardization of an insertion and removal protocol for pVAD devices led to a statistically significant decrease in limb ischemia in a high-risk patient population.

Draft Genome Sequence of Klebsiella pneumoniae UMB8492, Isolated from the Female Urinary Tract.

Here, we present the draft genome sequence for Klebsiella pneumoniae strain UMB8492, isolated from a urine sample from a female patient with overactive bladder (OAB) symptoms. The assembled genome has a length of 5,660,575 bp, a G+C content of 57.19%, and an N 50 value of 136,315 bp.