Effect of Cleft Palate Repair Timing on Inpatient Complication Rate: Review of a National Database.

OBJECTIVES: Timing of cleft palate repair is controversial. We aim to assess whether timing of cleft palate repair affects rates of inpatient complications, length of stay (LOS), and cost of stay. METHODS: The Healthcare Cost and Utilization Project Kids' Inpatient Database 2009 was queried for all admissions with a primary diagnosis of cleft palate during which cleft palate repair was performed as a primary procedure. Age 6 months or less was termed "early" repair, while age >6 months was termed "standard" repair. Patients age >3 years old, inpatient stays >30 days, and those stays in which a cleft lip repair was performed were excluded. Logistic regressions were used to model the probability of complications. Generalized linear models and a natural log link function were used for LOS and hospital charges, using SAS 9.4. RESULTS: We included 223 early and 1482 standard repair patients. Early repairs were exclusively performed in urban hospitals (P < 0.001). Eighty-nine patients experienced a total of 100 complications, including respiratory failure (N = 53), airway obstruction (N = 18), and oropharyngeal hemorrhage (N = 13). We found no significant difference in complication rate or total hospital charges in the 2 groups. The earlier repair group had a slightly longer LOS (P = 0.048). CONCLUSION: Over 85% of United States cleft palate repairs are performed after 6 months of age. All early repairs were performed at urban hospitals, and had slightly longer LOS. There was a 5.1% overall complication rate. Available data revealed no significant difference in complication rates between early repair and standard repair groups. LEVEL OF EVIDENCE: 3b.

Immunological modulation by 1α,25-dihydroxyvitamin D3 in patients with squamous cell carcinoma of the head and neck.

Prior studies showing that treatment of head and neck squamous cell carcinoma (HNSCC) patients with 1α,25-dihydroxyvitamin D(3) [1,25(OH)(2)D(3)] stimulated intratumoral immune infiltration were extended to analysis of cytokine profiles in the periphery and in oral tissues. Most prominent was the disparity between cytokine levels in plasma and in either pathologically normal oral tissue or HNSCC tissue from patients that were untreated or treated with 1,25(OH)(2)D(3). Levels of IL-6 and IL-10, but not IL-2, IFN-γ or TNF-α, tended to be increased in the plasma of HNSCC patients and 1,25(OH)(2)D(3) further increased plasma levels of all of these cytokines. While these cytokines tended to be increased in HNSCC tissue, 1,25(OH)(2)D(3) resulted in variable cytokine responses that showed a general tendency toward further increased levels. Levels of IL-8 and VEGF were increased in plasma and tissue of untreated HNSCC patients, and were further increased in plasma, but not in tissues, of patients treated with 1,25(OH)(2)D(3). Levels of IL-1α and IL-1ß were similar in plasma of controls and HNSCC patients, but were increased in HNSCC tissues. In contrast to that seen in plasma where 1,25(OH)(2)D(3) increased levels of IL-1α and IL-1ß, this was not seen in tissue following 1,25(OH)(2)D(3) treatment. These results show a discordant relationship between systemic and intratumoral cytokine profiles and suggest a tendency of 1,25(OH)(2)D(3)to increase a multitude of cytokines within tumor tissue.

Nasal cavity dimensions in congenital pyriform aperture stenosis.

OBJECTIVE: To determine the dimensions of the nasal cavity in infants with congenital pyriform aperture stenosis (CPAS). STUDY DESIGN: The nasal cavities of seven children with CPAS were identified and were compared to the nasal cavities of 13 neonates (<30 days old) who had received CT scans for other indications. METHODS: The width of the nasal cavities was measured at the pyriform aperture, choana, and at two standardized points along the lateral nasal wall (LW-1 and LW-2) between the pyriform aperture and choana. RESULTS: Comparison between neonates with and without CPAS demonstrates significant narrowing of the nasal cavity (not just the pyriform aperture) in infants with CPAS. Significantly smaller nasal width was noted at pyriform aperture, LW-1, and LW-2 (p<0.01, p<0.01, p=0.02). No significant narrowing was seen at the choana. CONCLUSION: These findings suggest that CPAS is associated with narrowing of the anterior 75% of the nasal cavity. This has implications for surgical management because simple pyriform aperture ostectomy may not be sufficient to relieve symptoms of obstruction.

Predicting HPV status in head and neck cancer: the predictive value of sociodemographic and disease characteristics.

OBJECTIVE: To determine whether the human papillomavirus (HPV) status of head and neck squamous cell carcinomas (HNSCCs) can be reliably predicted based on sociodemographic and disease characteristics alone. DESIGN A retrospective medical chart review of clinical and pathologic features. SETTING: Tertiary academic medical center. PATIENTS: We studied patients treated for HNSCC who were tested for markers of HPV or had tissue available for testing between 2006 and 2010. MAIN OUTCOME MEASURES: Four otolaryngology-head and neck surgery trainees were given the database of patient clinical and pathologic features and asked to predict the HPV status for each patient. The trainees' responses were scored for accuracy, positive and negative predictive value, and interrater agreement. Multiple linear regression analyses were performed to determine predictors of HPV positivity. RESULTS: A total of 174 patients meeting inclusion criteria were identified, 95 of whom were determined to have HPV-positive tumor tissue. Residents were able to accurately predict HPV status in 110 to 125 patients (63%-72%), with positive predictive values of 76% to 84% and negative predictive values of 61% to 69%. The only variables significantly related to HPV status were male sex (P = .01) and oropharyngeal subsite (P = .02). Only 4 patients had a "typical" HPV-positive profile. CONCLUSIONS: Knowledge of cancer stage, primary site, basaloid features, tumor differentiation, and presence of cystic neck disease and patient age, race, and smoking status did not allow accurate predictions of HPV status in many patients. Clinical testing of tumor tissue remains essential for a diagnosis of HPV-positive disease.

Current knowledge and management of vascular anomalies: I. Hemangiomas.

OBJECTIVE: To present current information on the diagnosis, pathogenesis, natural history, and treatment of infantile hemangiomas. METHODS: Literature review. RESULTS: Infantile hemangiomas are the most common vascular tumors of childhood. They are thought to be derived from embolized placental progenitor cells that lodge in privileged sites of the developing embryo. They exhibit a characteristic postnatal course with defined periods of growth and regression. CONCLUSIONS: Multimodality intervention involving observation, medical therapy, laser photocoagulation, and surgery is the accepted modern approach. Timing of the intervention to obtain the best possible results in concert with developmental milestones is the goal. "Leave it alone-it will go away" is no longer universally acceptable advice for infantile hemangiomas.

Current knowledge and management of vascular anomalies, II: malformations.

OBJECTIVE: To present current information on the diagnosis, pathogenesis, natural history, and treatment of vascular malformations. METHOD: Literature review. RESULTS: Vascular malformations are a heterogeneous group of congenital lesions resulting from aberrations of vascular embryogenesis. They are distinct from the vascular tumors with which they are commonly confused in presentation, natural history, and management. CONCLUSIONS: Multimodality intervention involving medical therapy, laser photocoagulation, and surgery is available for the various types of vascular malformations. Multidisciplinary care is crucial for the evaluation and management of these complicated lesions. Clarification of underlying pathogenesis and molecular biologic mechanisms will provide opportunities for expansion of available treatments.

Cetuximab therapy for head and neck squamous cell carcinoma: a systematic review of the data.

OBJECTIVE: To review the current state of the data on the use of cetuximab in head and neck squamous cell carcinoma (HNSCC). DATA SOURCES: The National Center for Biotechnology Information's PubMed and the Cochrane collection. REVIEW METHODS: Search terms included cetuximab and head and neck cancer. These results were reviewed, and a second search was performed using limits: meta-analysis, randomized controlled trial, and clinical trial. RESULTS: The literature search yielded 412 articles. Fifteen were identified for analysis. For patients with recurrent/metastatic disease who received combination chemotherapy in phase I/II trials, the overall response (OR) was 18.7% (95% confidence interval [CI], 10.4%-27.0%). Phase III trial data for combination chemotherapy in recurrent/metastatic disease showed OR to be 17.0% (95% CI, 12.6%-21.4%) for platinum-based regimens and 34.2% (28.6%-39.7%) for platinum-based regimens with cetuximab. For this same group, the estimated aggregate hazard ratio comparing platinum-based therapy plus cetuximab to platinum therapy alone was 1.10 (95% CI, 0.78- 1.54), indicating no significant improvement in overall survival in the aggregate analysis. Combination chemoradiation with cetuximab in both phase I/II trials and the single phase III trial shows enhanced responsiveness, but the data are difficult to interpret because it is not used with standard-of-care regimens for advanced-stage disease. CONCLUSION: Early evidence has shown cetuximab to be effective in the treatment of HNSCC, and it should be used to enhance, but not replace, current treatment paradigms until further phase III data are available.

A cost-effectiveness analysis of alternative HIV retesting strategies in sub-saharan Africa.

BACKGROUND: Guidelines in sub-Saharan Africa on when HIV-seronegative persons should retest range from never to annually for lower-risk populations and from annually to every 3 months for high-risk populations. METHODS: We designed a mathematical model to compare the cost-effectiveness of alternative HIV retesting frequencies. Cost of HIV counseling and testing, linkage to care, treatment costs, disease progression, and mortality, and HIV transmission are modeled for three hypothetical cohorts with posited annual HIV incidence of 0.8%, 1.3%, and 4.0%, respectively. The model compared costs, quality-adjusted life-years gained, and secondary infections averted from testing intervals ranging from 3 months to 30 years. Input parameters from sub-Saharan Africa were used and explored in sensitivity analyses. RESULTS: Accounting for secondary infections averted, the most cost-effective testing frequency was every 7.5 years for 0.8% incidence, every 5 years for 1.3% incidence, and every 2 years for 4.0% incidence. Optimal testing strategies and their relative cost-effectiveness were most sensitive to assumptions about HIV counseling and testing and treatment costs, rates of CD4 decline, rates of HIV transmission, and whether tertiary infections averted were taken into account. CONCLUSIONS: While higher risk populations merit more frequent HIV testing than low risk populations, regular retesting is beneficial even in low-risk populations. Our data demonstrate benefits of tailoring testing intervals to resource constraints and local HIV incidence rates.