Cigarette smoking cessation, duration of smoking abstinence, and head and neck squamous cell carcinoma prognosis.

BACKGROUND: Tobacco use is a major risk factor for developing head and neck squamous cell carcinoma (HNSCC). However, the prognostic associations with smoking cessation are limited. The authors assessed whether smoking cessation and increased duration of abstinence were associated with improved overall (OS) and HNSCC-specific survival. METHODS: Clinicodemographic and smoking data from patients with HNSCC at Princess Margaret Cancer Center (2006-2019) were prospectively collected. Multivariable Cox and Fine and Gray competing-risk models were used to assess the impact of smoking cessation and duration of abstinence on overall mortality and HNSCC-specific/noncancer mortality, respectively. RESULTS: Among 2482 patients who had HNSCC, former smokers (adjusted hazard ratio [aHR], 0.71; 95% CI, 0.58-0.87; p = .001; N = 841) had a reduced risk of overall mortality compared with current smokers (N = 931). Compared with current smokers, former smokers who quit >10 years before diagnosis (long-term abstinence; n = 615) had the most improved OS (aHR, 0.72; 95% CI, 0.56-0.93; p = .001). The 5-year actuarial rates of HNSCC-specific and noncancer deaths were 16.8% and 9.4%, respectively. Former smokers (aHR, 0.71; 95% CI, 0.54-0.95; p = .019) had reduced HNSCC-specific mortality compared with current smokers, but there was no difference in noncancer mortality. Abstinence for >10 years was associated with decreased HNSCC-specific death compared with current smoking (aHR, 0.64; 95% CI, 0.46-0.91; p = .012). Smoking cessation with a longer duration of quitting was significantly associated with reduced overall and HNSCC-specific mortality in patients who received primary radiation. CONCLUSIONS: Smoking cessation before the time of diagnosis reduced overall mortality and cancer-specific mortality among patients with HNSCC, but no difference was observed in noncancer mortality. Long-term abstinence (>10 pack-years) had a significant OS and HNSCC-specific survival benefit.

Hypothalamic-pituitary-adrenal axis suppression and intranasal corticosteroid use: A systematic review and meta-analysis.

BACKGROUND: Intranasal corticosteroids (INCS) are used in the management of sinonasal conditions. Use of exogenous steroids can be associated with hypothalamic-pituitary-adrenal axis dysfunction and adrenal insufficiency (AI). We aimed to estimate the rate of AI after INCS use in a meta-analysis, stratified by steroid type and treatment duration. METHODS: Ovid Medline, Embase Classic, PubMed, Web of Science, and CINAHL databases were searched following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify studies investigating INCS use and AI. AI was defined as morning serum cortisol <550 nmol/L and <80 nmol/L with and without adrenocorticotropic hormone stimulation. INCS were classified as first (beclomethasone dipropionate, triamcinolone acetonide, beclomethasone, budesonide, dexamethasone) and second (ciclesonide, mometasone furoate, and fluticasone propionate) generation. Duration of treatment was classified as short (<1 month), medium (1-12 months), and long-term (>12 months) time periods. RESULTS: This search identified 3668 articles. A total of 39 studies (1678 patients) were included in the final analysis. The pooled percentage of AI for routinely utilized first- and second-generation INCS was 0.70% (95% confidence interval [CI], 0.29-1.12%). Stratified by type, AI was observed in 0.78% (95% CI, 0.25-1.30%) of first-generation and 0.58% (95% CI, -0.1% to 1.26%) of second-generation steroids. AI was seen in 0.48% (95% CI, -0.01% to 0.96%) of short-term, 1.13% (95% CI, 0.2-2.1%) of medium-term, and 1.67% (95% CI, 0.37-2.9%) of long-term use of INCS. CONCLUSION: Overall, the use of INCS carries a low risk for AI. Although modest, this risk may differ depending on the length of duration and type of INCS used. Informing patients of these risks is of importance for the treatment of chronic sinonasal conditions.

Contralateral nodal failures in oropharyngeal cancers after TORS and unilateral neck management: a retrospective study.

BACKGROUND: Report the incidence of contralateral nodal failure rates in well-lateralized oropharyngeal carcinoma treated with upfront surgery and unilateral neck management. METHODS: Lateralized oropharyngeal carcinomas treated with upfront surgery using transoral robotic surgery (TORS) and unilateral neck management (unilateral neck dissection ± unilateral radiation treatment) were identified. Primary endpoint was contralateral regional control (CRC). Secondary endpoints were local control (LC), and overall survival (OS). RESULTS: Thirty-two patients were included. Pathologic T categories included 66% pT1, 31% pT2 and 3% pT3. Nodal diseases comprised 41% N0 and 47% N1 (AJCC 8th). Twenty-three (72%) patients had HPV related tumors. 3-years CRC, LC and OS were 100%, 96% (89-100) and 96% (CI 89-100). One patient developed a second primary with contralateral nodal disease. Only one patient died from another primary cancer. CONCLUSION: In selected patients with lateralized oropharyngeal cancer, treatment with TORS and ipsilateral management of the neck may be oncologically safe without significant risk of contralateral failure. LEVEL OF EVIDENCE: Level 2.

Glasgow Benefit Inventory in Cochlear Implantation: A Reliable Though Ancillary Quality of Life Metric.

OBJECTIVE: The Glasgow Benefit Inventory (GBI) is a health-related quality of life instrument used to detect changes in health status following otolaryngologic interventions. Despite its use in cochlear implant literature, assessment of utility, reliability, and validity of GBI in an adult cochlear implants (CI) patient population has yet to be performed. STUDY DESIGN: Retrospective case series. SETTING: Academic, tertiary referral center. PATIENTS: Postlingually deafened, adult CI patients with at least 1 year of device use. INTERVENTIONS: Five hundred fifty-two patients were administered GBI questionnaires at least 1 year following CI activation during follow-up visits. MAIN OUTCOME MEASURES: GBI total and subscale scoring were compared to either the Hearing Handicap Inventory for Adults or Hearing Handicap Inventory for the Elderly. Moreover, a factor analysis and Cronbach's alpha were performed to determine GBI validity and internal reliability, respectively. RESULTS: The average overall GBI score was 38.6 ±â€Š21.7. This was weakly correlated to the reduction in Hearing Handicap Inventory for Adults/Hearing Handicap Inventory for the Elderly (τb = 0.282, p < 0.05). High factor loading with minimal cross-loading was noted on a three-factor solution, which emulated the original GBI development. Internal reliability was acceptable for the general benefit (α = 0.913) and social support subclasses (α = 0.706), whereas physical health's was low (α = 0.643). CONCLUSIONS: Although GBI possesses adequate convergent and discriminant validity with acceptable reliability, its routine use to capture CI-specific health-related changes should not supersede validated CI-specific QoL instruments.

Clinical Prediction Models for Suspected Pediatric Foreign Body Aspiration: A Systematic Review and Meta-analysis.

Importance: Although various clinical prediction models (CPMs) have been described for diagnosing pediatric foreign body aspiration (FBA), to our knowledge, there is still no consensus regarding indications for bronchoscopy, the criterion standard for identifying airway foreign bodies. Objective: To evaluate currently available CPMs for diagnosing FBA in children. Data Sources: Performed in Ovid MEDLINE, Ovid Embase, PubMed, Web of Science, and CINAHL database with citation searching of retrieved studies. Study Selection: Prediction model derivation and validation studies for diagnosing FBA in children were included. Exclusion criteria included adult studies; studies that included variables that were not available in routine clinical practice and outcomes for FBA were not separate or extractable. Data Extraction and Synthesis: We followed the Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modeling Studies and the Prediction Model Risk of Bias Assessment Tool framework. Data were pooled using a random-effects model. Main Outcomes and Measures: The primary outcome was the diagnosis of FBA as confirmed by bronchoscopy. Characteristics of CPMs and individual predictors were evaluated. The final model presentation with available measures of performance was provided by narrative synthesis. A meta-analysis of individual predictor variables and prediction models was performed. Results: After screening 4233 articles, 7 studies (0.2%; 1577 patients) were included in the final analysis. There were 6 model derivation studies and 1 validation study. Air trapping (odds ratio [OR], 8.3; 95% CI, 4.4-15.5), unilateral reduced air entry (OR, 4.8; 95% CI, 3.5-6.5), witnessed choking (OR, 3.1; 95% CI, 1.0-9.6), wheezing (OR, 2.5; 95% CI, 1.2-5.2), and suspicious findings suggestive of FBA on radiography (OR, 18.5; 95% CI, 5.0-67.7) were the most commonly used predictor variables. Model performance varied, with discrimination scores (C statistic) ranging from 0.74 to 0.88. The pooled weighted C statistic score of all models was 0.86 (95% CI, 0.80-0.92). All studies were deemed to be at high risk of bias, with overfitting of models and lack of validation as the most pertinent concerns. Conclusions and Relevance: This systematic review and meta-analysis suggests that existing CPMs for FBA in children are at a high risk of bias and have not been adequately validated. No current models can be recommended to guide clinical decision-making. Future CPM studies that adhere to recognized standards for development and validation are required.

Applications of intraoperative angiography in head and neck reconstruction.

OBJECTIVE: Laser-assisted angiography with indocyanine green (LAIG) allows objective intraoperative evaluation of tissue vascularity. We endeavored to describe our experience with this technique in the head and neck region. METHODS: A retrospective review from February 2016 till October 2018 was conducted. We included patients who underwent head and neck procedures in which LAIG was employed. The main outcome was postoperative wound complications. We analysed the influence of LAIG results in intraoperative decision-making process. RESULTS: Nineteen patients were included, and follow-up was for at least 6 months. LAIG was employed in 11 local flaps, 9 free flaps and 6 cases of pharyngeal closure during total laryngectomies. Wound complications occurred in two cases with distal tip flap necrosis. LAIG findings resulted in changes in decision making intraoperatively in 84% of procedures, which consisted in trimming poorly perfused tissues. There were no pharyngocutaneous fistulas. CONCLUSIONS: This represents a descriptive report on the use of LAIG on diverse head and neck reconstruction cases, with important impact on the decision-making process. A low number of postoperative wound complications were observed.

Association of the Implementation of a Standardized Thyroid Ultrasonography Reporting Program With Documentation of Nodule Characteristics.

Importance: Although most thyroid nodules are benign, the potential for malignant neoplasms is associated with unnecessary workup in the form of imaging, fine-needle aspiration, and diagnostic surgery. The American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) is commonly used to assess the malignant neoplasm risk potential of thyroid nodules imaged by ultrasonography. However, standardized reporting of ACR TI-RADS descriptors is inconsistent. Objective: To increase the documentation rate of ACR TI-RADS thyroid nodule characteristics to 80% in 18 months. Design, Setting, and Participants: This prospective interrupted time series quality improvement study was conducted from December 1, 2018, to March 31, 2020, at a tertiary outpatient head and neck clinic among 229 patients who had at least 1 documented thyroid nodule identified on bedside clinic ultrasonography. Data analysis was performed throughout the entire study period because this was a quality improvement study with iterative small cycle changes; final analysis of the data was performed in April 2020. Main Outcomes and Measures: The primary outcome was the documentation rates of 6 ACR TI-RADS ultrasonographic descriptors. Secondary outcomes included nodule fine-needle aspiration biopsy rate and physician-reported clinic flow efficiency. Results: A total of 229 patients had at least 1 documented thyroid nodule and were included in the analysis. Size was the most frequently documented nodule characteristic (72 of 74 [97.3%]) at baseline, followed by echogenic foci (31 of 74 [41.9%]), composition (23 of 74 [31.1%]), echogenicity (17 of 74 [23.0%]), margin (6 of 74 [8.1%]), and shape (1 of 74 [1.4%]). After 3 Plan, Do, Study, Act (PDSA) cycles, the final intervention consisted of a standardized ultrasonography reporting form and educational initiatives for surgical trainees. After the third PDSA cycle (n = 36), reporting of nodule size, echogenic foci, and composition increased to 100%. Similarly, reporting of echogenicity (34 of 36 [94.4%]), shape (28 of 36 [77.8%]), and margin (25 of 36 [69.4%]) all increased. This represented a cumulative 90.3% documentation rate (195 of 216), a 56.5% increase from baseline (95% CI, 50.0%-61.9%). The standardized reporting form was used in 83.3% of eligible thyroid ultrasonography cases (30 of 36) after PDSA cycle 3, demonstrating good fidelity of implementation. There were no unintended consequences associated with clinic workflow, as a balancing measure, reported by staff surgeons. Conclusions and Relevance: This study suggests that implementation of an ACR TI-RADS-based reporting form in conjunction with educational initiatives improved documentation of ultrasonographic thyroid nodule characteristics, potentially allowing for improved bedside risk stratification and communication among clinicians.

Mindfulness and hemodynamics in asians: a literature review.

INTRODUCTION: Mindfulness interventions have been increasingly incorporated into clinical settings. Evidence supporting mindfulness practices are predominantly established in Western populations. Neurophysiological evidence has not been established to support the effectiveness of mindfulness practice in Asian populations. Greater understanding of the neurophysiological mechanisms underlying mindfulness would enable hemodynamics as measured by fNIRS to be used to monitor mindfulness practice as an adjunct to psychotherapy with Asian clients. METHOD: Research relating to fNIRS and hemodynamics for mindfulness in Asians was reviewed. The inclusion criteria for this review were recent publications in peer-reviewed journals from 2008 to 2018, with the search terms 'fNIRS', 'hemodynamics' and 'mindfulness', for studies in Asia. FINDINGS: Databases included Medline, PubMed, PSYCINFO, Google Scholar and SCOPUS. Initial searches yielded 86 results. Five duplicated articles were removed, and remaining abstracts were screened; and assessed for eligibility against the structured performa. Three full text papers which fit the inclusion criteria were included in the current review. CONCLUSION: This review highlighted the paucity of rigorous empirically validated research for hemodynamics as measured with fNIRS for mindfulness practice in Asia.