Guideline familiarity predicts variation in self-reported use of routine surveillance PET/CT by physicians who treat head and neck cancer.

BACKGROUND: Use of routine surveillance testing beyond guideline recommended levels is common in many oncologic disciplines, including head and neck cancer. The impact of guideline familiarity and other physician characteristics on surveillance imaging use are not well understood. METHODS: A cross-sectional national survey was performed of physicians responsible for surveillance of patients with head and neck squamous cell carcinoma (HNSCC). The primary outcome was self-reported use of routine surveillance PET/CT in asymptomatic patients. A secondary outcome was familiarity with guideline recommendations. Using multivariable regression, the impact of guideline familiarity and other physician characteristics on PET/CT use was examined. RESULTS: Of the 502 responders, 79% endorsed ever using PET/CT scans for routine surveillance imaging, and 39% were high imaging users (used PET/CT scans on more than half of their asymptomatic patients); 76% were familiar with the NCCN Clinical Practice Guidelines in Oncology for Head and Neck Cancers recommending against routine surveillance PET/CT scans. Although guideline familiarity was associated with being a low imaging user or a never-user, among those who were familiar with guidelines, 31% were nonetheless high imaging users and 73% endorsed ever using PET/CT scans. In multivariable analysis controlling for physician characteristics, guideline familiarity was the strongest predictor of PET/CT use. CONCLUSIONS: Familiarity with the NCCN Guidelines predicts self-reported routine surveillance PET/CT use among physicians who treat patients with HNSCC. However, given the observed variation and high levels of imaging even among physicians who are familiar with the guidelines, further research should examine the reasons physicians choose to use surveillance PET/CT scans.

Inpatient Decongestive Therapy for Lymphedema in Acute Postsurgical Head and Neck Cancer Patients.

Introduction Head and neck lymphedema is an omnipresent morbidity related to head and neck cancer therapies. Studies on therapy for these patients in the acute postsurgical population have not been published to date. Objective To assess changes in the measurements of lymphedema in surgical head and neck cancer patients during the hospital stay with implementation of modified decongestive therapy (MDT). Methods Patients aged > 18 years undergoing neck dissection with or without primary-site resection or laryngectomy between 2016 and 2019 were included. Facial measurements were obtained prior to beginning MDT and again prior to discharge. A total facial composite measurement was calculated and used to assess change over time. Rates ≥ 2% of change were considered significant. Results A total of 38 patients were included (subsites: larynx = 27; thyroid = 4; oral cavity = 3; and neck = 4). The mean number of days between surgery and the start of lymphedema therapy was 3.0 days. The mean number of days between measurements was 5.2 days. Reduction in the total composite score was observed in 37 (97%) patients, and 35 (92%) patients had a total composite reduction score > 2%. Tumor subsite and surgery type did not portend toward greater percent change, except for those patients treated with total laryngectomy, regional flap reconstruction, and neck dissection ( p = 0.02). Conclusion Acute postsurgical inpatient MDT was associated with reduced total composite measurements in patients after head and neck surgery. As the first published study on lymphedema therapy in this acute postsurgical period, further prospective case-control studies are warranted to explore further benefits of acute therapy.

Advanced Computed Tomographic Localization Techniques for Primary Hyperparathyroidism: A Systematic Review and Meta-analysis.

Importance: Emerging computed tomographic (CT) imaging techniques for the localization of primary hyperparathyroidism (PHPT) may be superior to the current imaging standard, thus necessitating a critical review and pooling of available evidence. Objective: Primary hyperparathyroidism requires accurate imaging to guide definitive surgical management. Advanced techniques including 4-dimensional computed tomographic (4D-CT) scan have been investigated over the past decade. We sought to evaluate the efficacy of these emerging imaging techniques through pooled analysis of the existing evidence. Data Sources: PubMed, Embase, and Web of Science databases were queried for original English articles without any restrictions on date. Study Selection: We included comparative observational studies but excluded animal studies, case reports, and case series. Overall, 353 abstracts were screened independently by 2 investigators along with a third reviewer to resolve conflicts. A total of 26 full-text articles were included in this review. Data Extraction and Synthesis: This review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. Data was independently extracted by 2 investigators and subsequently pooled into a meta-analysis using a random-effects model. Main Outcomes and Measures: Measures of imaging diagnostic performance such as sensitivity, specificity, positive predictive value, and negative predictive value were the primary outcomes of interest. Results: Overall, of 34 articles screened, 26 met criteria for qualitative synthesis, and 23 of these were appropriate for meta-analysis. Of the 26 studies included, there were 5845 patients, of which 4176 were women (79.2%). The average of mean ages reported in 23 studies was 60.9 years. Meta-analysis in all patients with PHPT revealed pooled sensitivity that was greater with 4D-CT (81%; 95% CI, 77%-84%; I2 = 88%) compared with the current first-line modality of sestamibi-single-photon emission CT (SPECT/CT) (65%; 95% CI, 59%-70%; I2 = 93%). For patients with recurrent PHPT requiring reoperation, 4D-CT pooled sensitivity was 81% (95% CI, 64%-98%; I2 = 93%) in contrast to 53% (95% CI, 35%-71%; I2 = 81%) for sestamibi-SPECT/CT. The overall quality of the 26 studies was moderate with a median (range) Methodological Index for Nonrandomized Studies score for all included studies of 15.5 (13-19). Conclusions and Relevance: The findings of this systematic review and with meta-analyses of numerous studies from the past decade suggest that the 4D-CT can be more sensitive and specific than sestamibi-SPECT/CT in localizing PHPT. More research is needed to determine the clinical significance of this improvement in localization.

Referral Patterns of Outpatient Palliative Care among the Head and Neck Cancer Population.

Introduction Patients with head and neck cancer (HNC) experience unique physical and psychosocial challenges that impact their health and quality of life. Early implementation of palliative care has been shown to improve various health care outcomes. Objective The aim of the present study was to evaluate the patterns of referral of patients with HNC to outpatient palliative care as they relate to utilization of resources and end-of-life discussions. Methods We performed a retrospective review of 245 patients with HNC referred to outpatient palliative care services at two Louisiana tertiary care centers from June 1, 2014, to October 1, 2019. The control group consisted of those that were referred but did not follow-up. Reasons for referral were obtained, and outcome measures such as emergency department (ED) visits, hospital readmissions, and advance care planning (ACP) documentation were assessed according to predictive variables. Results There were 177 patients in the treatment group and 68 in the control group. Patients were more likely to follow up to outpatient palliative care services if referred for pain management. Hospital system, prior inpatient palliative care, and number of outpatient visits were associated with an increased likelihood for ED visits and hospital readmissions. Those in the palliative care treatment group were also more likely to have ACP discussions. Conclusion Early implementation of outpatient palliative care among patients with HNC can initiate ACP discussions. However, there are discrepancies in referral reasons to palliative care and continued existing barriers to its effective utilization.

First Detection of SARS-CoV-2 Delta (B.1.617.2) Variant of Concern in a Dog with Clinical Signs in Spain.

Several cases of naturally infected dogs with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been reported despite the apparently low susceptibility of this species. Here, we document the first reported case of infection caused by the Delta (B.1.617.2) variant of concern (VOC) in a dog in Spain that lived with several household members suffering from Coronavirus Infectious Disease 2019 (COVID-19). The animal displayed mild digestive and respiratory clinical signs and had a low viral load in the oropharyngeal swab collected at the first sampling. Whole-genome sequencing indicated infection with the Delta variant, coinciding with the predominant variant during the fifth pandemic wave in Spain. The dog seroconverted, as detected 21 days after the first sampling, and developed neutralizing antibodies that cross-neutralized different SARS-CoV-2 variants. This study further emphasizes the importance of studying the susceptibility of animal species to different VOCs and their potential role as reservoirs in the context of COVID-19.

Perceived value drives use of routine asymptomatic surveillance PET/CT by physicians who treat head and neck cancer.

BACKGROUND: Why physicians use surveillance imaging for asymptomatic cancer survivors despite recommendations against this is not known. METHODS: Physicians surveilling head and neck cancer survivors were surveyed to determine relationships among attitudes, beliefs, guideline familiarity, and self-reported surveillance positron-emission-tomography/computed-tomography use. RESULTS: Among 459 responses, 79% reported using PET/CT on some asymptomatic patients; 39% reported using PET/CT on more than half of patients. Among attitudes/beliefs, perceived value of surveillance imaging (O.R. 3.57, C.I. 2.42-5.27, P = <.0001) was the strongest predictor of high imaging, including beliefs about outcome (improved survival) and psychological benefits (reassurance, better communication). Twenty-four percent of physicians were unfamiliar with guideline recommendations against routine surveillance imaging. Among physicians with high perceived-value scores, those less familiar with guidelines imaged more (O.R. 3.55, C.I. 1.08-11.67, P = .037). CONCLUSIONS: Interventions to decrease routine surveillance PET/CT use for asymptomatic patients must overcome physicians' misperceptions of its value. Education about guidelines may modify the effect of perceived value.

Post-Katrina: study in crisis-related program adaptability.

OBJECTIVE: To discuss disaster planning, didactic reorganization, and clinical realignments useful in rebuilding academic otolaryngology residency programs after disaster. SUMMARY: We describe our reorganization and analysis of objective measures in resident education before and after Hurricane Katrina. Post-Katrina, the number of full-time faculty and part-time clinical instructors/gratis faculty has decreased (4 vs 9 and 36 vs 43, respectively), but the number of part-time LSU faculty (private-academic partnership) has increased (0 vs 3) with overall improved resident supervision. Resident complement decreased by 9.3%. Surgical case loads are essentially unchanged. Reorganization of the didactic schedule has increased attendance and maintained examination scores above national averages. Establishment of two new practice sites provided an adequate number of patients for residency training. CONCLUSION: Poststorm reorganization has maintained or exceeded pre-Katrina performance standards. Establishment of communication and data retrieval proved irreplaceable and demand advance preparation.

Inpatient Decongestive Therapy for Lymphedema in Acute Postsurgical Head and Neck Cancer Patients

Abstract Introduction Head and neck lymphedema is an omnipresent morbidity related to head and neck cancer therapies. Studies on therapy for these patients in the acute postsurgical population have not been published to date. Objective To assess changes in the measurements of lymphedema in surgical head and neck cancer patients during the hospital stay with implementation of modified decongestive therapy (MDT). Methods Patients aged > 18 years undergoing neck dissection with or without primary-site resection or laryngectomy between 2016 and 2019 were included. Facial measurements were obtained prior to beginning MDT and again prior to discharge. A total facial composite measurement was calculated and used to assess change over time. Rates ≥ 2% of change were considered significant. Results A total of 38 patients were included (subsites: larynx = 27; thyroid =4; oral cavity = 3; and neck = 4). The mean number of days between surgery and the start of lymphedema therapy was 3.0 days. The mean number of days between measurements was 5.2 days. Reduction in the total composite score was observed in 37 (97%) patients, and 35 (92%) patients had a total composite reduction score > 2%. Tumor subsite and surgery type did not portend toward greater percent change, except for those patients treated with total laryngectomy, regional flap reconstruction, and neck dissection (p = 0.02). Conclusion Acute postsurgical inpatient MDT was associated with reduced total composite measurements in patients after head and neck surgery. As the first published study on lymphedema therapy in this acute postsurgical period, further prospective case-control studies are warranted to explore further benefits of acute therapy.

Can Helicobacter pylori Eradication Treatment Modify the Metabolic Response to Bariatric Surgery?

BACKGROUND: Helicobacter pylori (HP) colonization is common in severely obese patients undergoing bariatric surgery. HP eradication treatment could influence the evolution of weight loss and metabolic markers after bariatric surgery. OBJECTIVE: To assess the influence of HP eradication in the clinical course of morbid obesity patients treated with bariatric surgery (gastric bypass (LRYGB) and sleeve gastrectomy (LSG)) METHODS: Retrospective analysis of a prospective cohort of 229 patients that underwent bariatric surgery between 2010 and 2013 in Hospital del Mar. HP infection was tested preoperatively by gastric biopsy and, if positive, treated with omeprazole, clarithromycin, and amoxicillin for 14 days. Patients were followed at 3, 6, 12, 18, and 24 months after bariatric surgery. Short-term weight loss and metabolic outcomes were evaluated. RESULTS: HP treated (HPt) patients had a greater reduction in BMI at 3 months after LSG (ΔBMI (kg/cm2) 8.5 ± 4.1 vs 11.3 ± 3.05 kg/m2; p = 0.004) and a reduction in the evolution of triglyceride levels from baseline to 12 months (p = 0.014) compared to HP-negative (HP-) subjects. Also, non-diabetic HPt patients had a greater reduction in glucose levels at all time points that was maintained up to 24 months after LRYGB (p = 0.003). No differences were observed in total and LDL cholesterol levels, HOMA-IR, or HbA1C. CONCLUSIONS: Preoperative HP eradication has a short-term influence on some metabolic parameters after bariatric surgery.

Survivorship: Morbidity, Mortality, Malignancy.

Survivorship encompasses the entire therapeutic, psychosocial, functional, and financial experience of living with and through a cancer diagnosis. The period of survivorship starts on the day of the cancer diagnosis and lasts until the end of the survivor's life, regardless of the cause of death. The National Cancer Institute's Office of Cancer Survivorship expands the term "survivor" to include, importantly, caregivers, family, and friends close to the survivor who also live through this period.

Referral Patterns of Outpatient Palliative Care among the Head and Neck Cancer Population

Abstract Introduction Patients with head and neck cancer (HNC) experience unique physical and psychosocial challenges that impact their health and quality of life. Early implementation of palliative care has been shown to improve various health care outcomes. Objective The aim of the present study was to evaluate the patterns of referral of patients with HNC to outpatient palliative care as they relate to utilization of resources and end-of-life discussions. Methods We performed a retrospective review of 245 patients with HNC referred to outpatient palliative care services at two Louisiana tertiary care centers from June 1, 2014, to October 1, 2019. The control group consisted of those that were referred but did not follow-up. Reasons for referral were obtained, and outcome measures such as emergency department (ED) visits, hospital readmissions, and advance care planning (ACP) documentation were assessed according to predictive variables. Results There were 177 patients in the treatment group and 68 in the control group. Patients were more likely to follow up to outpatient palliative care services if referred for pain management. Hospital system, prior inpatient palliative care, and number of outpatient visits were associated with an increased likelihood for ED visits and hospital readmissions. Those in the palliative care treatment group were also more likely to have ACP discussions. Conclusion Early implementation of outpatient palliative care among patients with HNC can initiate ACP discussions. However, there are discrepancies in referral reasons to palliative care and continued existing barriers to its effective utilization.

Entrapment of recent thymic emigrants in lymphoid tissues from HIV-infected patients: association with HIV cellular viral load.

OBJECTIVE(S): Depletion of thymus derived naive T-cells is a feature of HIV infection. Here the impact of HIV infection on the compartmentalization of recent thymic emigrants of (RTE) and naive T-cells was examined. METHODS: Peripheral blood mononuclear cells (PBMC) and lymphoid tissue (LT) from 43 HIV-infected patients and 12 controls were examined for RTE distribution by measuring coding joint T-cell receptor excisional circles (cjTREC) by PCR and naive and memory T-cell subsets and adhesion molecules (L-selection, LFA-1) by flow cytometry. RESULTS: In HIV-infected patients, the RTE as quantified by cjTRECs in CD4 LT cells were significantly higher than in PBMC. Their values, however, were less than in control subjects, in both the LT and PBMC compartments. This was associated with an increase in L-selectin and LFA-1 expression on LT derived T cells. In PBMC, a significant positive relationship between TREC and naive CD4 cells and an inverse relationship between TREC and cellular viral load (CVL) was observed. Whereas in LT, there was a positive relationship between cjTREC and both naive CD4 cell percentage and CVL. CONCLUSIONS: Collectively, the data suggests that LT is a significant reservoir for RTE. The RTE appeared to be entrapped in LT from HIV-infected subjects. Such entrapment is probably a response to the high viral load in these tissues. These observations may partially explain the decline in RTE observed in the peripheral blood of HIV-infected patients, and the delay in recovery of naive cells in blood after initiation of HAART.

Inverting papilloma of the temporal bone.

OBJECTIVES: Inverting papilloma of the temporal bone is exceedingly rare. The objective is to familiarize the clinician with the clinical presentation and prognosis of this entity. STUDY DESIGN: Retrospective case study and literature review. METHODS: Published reports of inverting papillomas originating in the temporal bone were reviewed in conjunction with two cases presenting at the University of Texas Medical Branch (Galveston, TX). RESULTS: Inverting papillomas of the temporal bone are frequently associated with persistent middle ear effusion and ipsilateral sinonasal tumors and display a higher incidence of malignancy. CONCLUSIONS: Successful management of these tumors requires an aggressive surgical resection. Adjuvant radiation therapy is recommended in patients with malignant changes.

Cystic metastasis versus branchial cleft carcinoma: a diagnostic challenge.

OBJECTIVES: There is controversy regarding the existence of branchial cleft carcinomas. The objectives are to familiarize the clinician with the presentation and treatment of cystic metastases from head and neck primary sites and differentiate these from primary branchial cleft cyst carcinomas. STUDY DESIGN: Retrospective case study and literature review. METHODS: Published reports of branchial cleft carcinomas were reviewed in conjunction with a unique case presenting at the University of Texas Medical Branch (Galveston, TX). RESULTS: Most cases of branchial cleft carcinomas are probably cystic metastases from head and neck primary sites. Cutaneous involvement with primary branchial cleft carcinomas is rare but may occur in recurrent lesions. CONCLUSIONS: The diagnosis of a primary branchial cleft cyst carcinoma requires the fulfillment of strict criteria. Cystic metastases from head and neck primaries can mimic branchial cleft carcinomas histologically. Correct diagnosis is important so that appropriate surgical and radiotherapeutic treatment can be delivered.

Obstructive supraglottic schwannoma: a case report and review of the literature.

OBJECTIVE: At the conclusion of the current presentation, the participants should be able to describe the etiology, presentation, histopathologic identification, and treatment options for schwannoma of the larynx. OBJECTIVES: Nerve sheath tumors rarely occur within the larynx. The goal of the current report is to acquaint the clinician with the presentation and treatment options for this disease. STUDY DESIGN: Retrospective case report and review of the literature. METHODS: We report one case of schwannoma of the supraglottic larynx at the Department of Otolaryngology, University of Texas Medical Branch (Galveston, TX). In addition, we review English-language publications regarding laryngeal nerve sheath tumors. RESULTS: Laryngeal nerve sheath tumors have an insidious course, commonly involve the supraglottic larynx, and can lead to upper airway obstruction. Cure is achieved by complete surgical excision. CONCLUSIONS: Median thyrotomy has proven to be safe and successful in the treatment of supraglottic schwannoma.

Update on new biomaterials and their use in reconstructive surgery.

Craniofacial reconstruction may be limited by the paucity of autologous materials available and donor site morbidity. Recent advances in the development of biomaterials have given the reconstructive surgeon new options for restoring form and function. There are now biomaterials (second generation) that can elicit a controlled action and reaction to the surrounding tissue environment (bioactive), and those that can exhibit a controlled chemical breakdown and resorption, with ultimate replacement by regenerating tissue (resorbable). Third-generation biomaterials are being designed to stimulate regeneration of living tissues using tissue engineering and in situ tissue regeneration methods. These techniques will lead to limitless possibilities for tissue regeneration and repair. At present, biomaterials that may find future use in craniofacial reconstruction include newly developed bone and skin substitutes and soft-tissue fillers.

Molecular events in the progression of recurrent respiratory papillomatosis to carcinoma.

CONTEXT: Identification of the type of human papillomavirus (HPV) by polymerase chain reaction and sequencing to determine coinfection or superinfection (by more than 1 HPV type) and other molecular events have not been reported in a series of patients exhibiting the morphologic spectrum of recurrent respiratory papillomatosis progressing to carcinoma. DESIGN: Four cases of juvenile-onset recurrent respiratory papillomatosis progressing to carcinoma (no history of smoking or irradiation in 2 cases) were studied. Morphologically distinct foci (squamous papilloma, pulmonary papillomatosis, squamous dysplasia subjacent to carcinoma, and squamous carcinoma) were subjected to laser capture microdissection and polymerase chain reaction amplification using general primers in addition to type-specific primers for HPV types 16 and 18. Direct sequencing of polymerase chain reaction products identified the type of HPV. The tissue sections were immunostained using antibodies to p53, pRb, p21(WAF1), and p16 proteins with a semiquantitative assessment. RESULTS: Human papillomavirus 11 was the only type of HPV identified in all lesions of all cases associated with recurrent respiratory papillomatosis. There was a marked increase in p53 protein expression in foci of dysplasia and carcinoma as compared to squamous papilloma and pulmonary papillomatosis. An inverse correlation between p53 and p21(WAF1) protein expression was noted in all lesions. pRb protein expression increased from the benign to the malignant end of the spectrum. p16 protein was expressed in all lesions. CONCLUSIONS: Infection by HPV-11 may be an early event associated with progression of recurrent respiratory papillomatosis to carcinoma. Increased expression of p53 and pRb proteins and a reduced expression of p21(WAF1) protein appear to be significant subsequent events.

Tracheal resection with primary anastomosis in cadavers: the effects of releasing maneuvers and length of tracheal resection on tension.

To determine the relationships among length of trachea resected, total tracheal length, and anastomotic tension when using various release maneuvers, we studied 10 adult human cadavers: 5 male and 5 female. The trachea was transected between rings 2 and 3. Precision, handheld spring tensiometers (Geneva Gage, LLC) were used to measure the tension required to approximate, and then overlap, the proximal segment relative to the distal segment, and the distal segment relative to the proximal segment after these maneuvers: no release, blunt dissection, neck flexion, suprahyoid release (SHR) without neck flexion, SHR with neck flexion, and right hilar release. After the tension measurements were recorded, the trachea was harvested and the total tracheal length was measured. Length-tension curves were plotted for both the superior and inferior tracheal segments after each release maneuver. The stiffness coefficient for the trachea and the resting load on the trachea following each release maneuver were calculated. An exponential length-tension relationship existed for the distal tracheal segment regardless of whether release maneuvers were performed. The proximal tracheal segment exhibited a linear length-tension relationship initially, but displayed an exponential relationship after SHR. We could resect 6.68 cm (range, 4.2 to 9.9 cm), 13.3 rings (range, 10 to 20 rings), or 65.5% (range, 42% to 100%) of the trachea without undue tension (<1,000 g) on the anastomosis. We conclude that various tracheal release maneuvers are effective in increasing the length of trachea that can be relatively safely resected. However, these maneuvers are not uniformly effective across subjects.