Decline in circulating viral and human tumor markers after resection of head and neck carcinoma.

BACKGROUND: DNA sequencing panels can simultaneously quantify human and viral tumor markers in blood. We explored changes in levels of plasma tumor markers following surgical resection of head and neck carcinoma. METHODS: In preresection and postresection plasmas, targeted DNA sequencing quantified variants in 28 human cancer genes and levels of oncogenic pathogens (human papillomavirus [HPV], Epstein-Barr virus [EBV], Helicobacter pylori) from 21 patients with head and neck squamous cell carcinoma. RESULTS: Preresection, 11 of 21 patients (52%) had detectable tumor markers in plasma, most commonly TP53 mutation or HPV genome. Several days postresection, levels fell to undetectable in 8 of 10 evaluable patients, while two high-stage patients retained circulating tumor markers. CONCLUSIONS: Modern sequencing technology can simultaneously quantify human gene variants and oncogenic viral genomes in plasma. Falling levels of cancer-specific markers upon resection can help identify viral and human markers to track at subsequent timepoints as a means to evaluate efficacy of interventions.

Multimodal Analgesia Protocol after Head and Neck Surgery: Effect on Opioid Use and Pain Control.

OBJECTIVE: To assess the effect that implementation of a multimodal analgesic plan has on opioid requirements and pain control in head and neck (H&N) surgery patients. STUDY DESIGN: Prospective cohort. SETTING: Tertiary academic hospital. SUBJECTS AND METHODS: An institutional review board (IRB)-approved quality improvement initiative was undertaken to implement a multimodal analgesic protocol for all admitted H&N surgery patients starting November 2017. Postprotocol data from January to May 2018 were compared to preprotocol data from May to October 2017. Data were obtained from the electronic health records as well as through preoperative and postoperative surveys. Average pain scores and opioid use in morphine milligram equivalents (MMEs) before and after protocol implementation were compared. RESULTS: In total, 139 postprotocol patients were compared to 89 preprotocol patients. The adjusted MMEs in the first 24 hours after surgery decreased significantly from 93.7 mg to 58.6 mg (P = .026) with protocol implementation. When averaged over the length of stay (MME/hospital day), the change was no longer statistically significant (57.9 vs 46.8 mg, P = .211). The average pain score immediately after surgery and on day of discharge did not change with protocol implementation. CONCLUSION: Implementation of a multimodal analgesia plan reduced opioid use immediately after surgery but not over the course of hospitalization without any change in reported pain scores. This study shows that multimodal opioid-sparing analgesia after H&N surgery is feasible. Future studies are needed further refine the optimal analgesic strategy for H&N patients and assess the long-term efficacy, safety, and cost of such regimens.

Oral tongue carcinoma among young patients: An analysis of risk factors and survival.

INTRODUCTION: The incidence of oral tongue squamous cell carcinoma (OTSCC) in younger adults has rapidly increased over the past two decades. While tobacco and alcohol use may be less likely to cause these tumors, it remains controversial whether differences also exist in their prognosis. Our aim is to examine the risk factors for cancer among young (<45 years old) OTSCC patients at our institution, and to compare their recurrence and survival with older patients in a matched cohort. MATERIALS AND METHODS: All OTSCC patients seen at our institution between 2000 and 2015 were reviewed. Patients under 45 who with sufficient treatment information were matched 1:1 on race, T-stage, and N-stage with patients 45 and older. Three-year recurrence and survival were determined in stratified and adjusted Cox regression models. RESULTS: Of 397 OTSCC patients were seen at our institution, 117 (29%) were less than 45 years old. Younger patients were significantly more likely to be female, (50% vs. 39%; p = 0.04) and to abstain from tobacco (51% vs. 39%; p < 0.01). Young patients in the matched cohort were significantly more likely to have a recurrence (HR 3.9 95% CI 1.4-10.5). There was no difference in overall survival. CONCLUSION: Younger OTSCC patients in a matched cohort were more likely to recur within 3 years, although there was no difference in overall mortality. Differences in risk factors and recurrence between older and younger patients suggest that some cancer among younger patients may be distinct from traditional OTSCC.

Factors related to persisting perforations after ventilation tube insertion.

OBJECTIVE: Over a million ventilation tubes are placed annually in the United States, making this one of the most commonly performed procedures in the field of medicine. Certain factors increase the risk of persistent tympanic membrane perforation following the extrusion of short term ventilation tubes. Persistent perforations may fail to heal on their own, necessitating surgical closure to avoid conductive hearing loss. It is important to detect factors that may predict children who are at increased risk for persistent perforations. METHODS, OUTCOMES DATA AND STATISTICAL ANALYSIS: This study was a retrospective chart review that involved 757 patients between 2003 and 2008. The patients studied were within the age of 2 months-17 years, and all had short term tubes placed. The chart data also included demographic information, comorbidities, and information related to tube insertion and follow-up care. Chi-square, t-test, and multivariate logistic regression were conducted to compare variables between patients with perforations and those without. RESULTS: Data from 757 patients was analyzed, showing that perforation rate is associated with rhinorrhea, operative tube removal, aural polyps, and otorrhea (OR 1.72, 8.16, 4.69, and 1.72 respectively). The absence of otorrhea decreased the likelihood of TM perforations and no significant differences were found in gender, total number of sets of tubes, type of tube, use of nasal steroids, adenoidectomy, or nasal congestion. CONCLUSION: Our findings suggest that children with rhinorrhea, otorrhea, aural polyps, or prolonged intubation requiring operative tube removal should be identified clinically as children at risk of persisting perforation.

Validation of the CAS neonatal NIRS system by monitoring vv-ECMO patients: preliminary results.

The CAS neonatal NIRS system determines absolute regional brain tissue oxygen saturation (SnO2) and brain true venous oxygen saturation (SnvO2) non-invasively. Since NIRS-interrogated tissue contains both arterial and venous blood from arterioles, venules, and capillaries, SnO2 is a mixed oxygen saturation parameter, having values between arterial oxygen saturation (SaO2) and cerebral venous oxygen saturation (SvO2). To determine a reference for SnO2, the relative contribution of SvO2 to SaO2 drawn from a brain venous site vs. systemic SaO2 is approximately 70:30 (SvO2:SaO2). If the relationship of the relative average contribution of SvO2 and SaO2 is known and does not change to a large degree, then NIRS true venous oxygen saturation, SnvO2, can be determined non-invasively using SnO2 along with SaO2 from a pulse oximeter.

Primary use of the venovenous approach for extracorporeal membrane oxygenation in pediatric acute respiratory failure.

OBJECTIVES: To describe a single center's experience with the primary use of venovenous cannulation for supporting pediatric acute respiratory failure patients with extracorporeal membrane oxygenation (ECMO). DESIGN: Retrospective chart review of all patients receiving extracorporeal life support at a single institution. SETTING: Pediatric intensive care unit at a tertiary care children's hospital. PATIENTS: Eighty-two patients between the ages of 2 wks and 18 yrs with severe acute respiratory failure. INTERVENTIONS: ECMO for acute respiratory failure. MEASUREMENTS AND MAIN RESULTS: From January 1991 until April 2002, 82 pediatric patients with acute respiratory failure were cannulated for ECMO support. Median duration of ventilation before ECMO was 5 days (range, 1-17 days). Sixty-eight of these patients (82%) initially were placed on venovenous ECMO. Fourteen patients were initiated and remained on venoarterial support, including six in whom venovenous cannulae could not be placed. One patient was converted from venovenous to venoarterial support due to inadequate oxygenation. Venoarterial patients had significantly greater alveolar-arterial oxygen gradients and lower PaO(2)/FIO(2) ratios than venovenous patients (p <.03). Fifty-five of 81 venovenous patients received additional drainage cannulae (46 of 55 with an internal jugular cephalad catheter). Thirty-five percent of venovenous patients and 36% of venoarterial patients required at least one vasopressor infusion at time of cannulation (p = nonsignificant); vasopressor dependence decreased over the course of ECMO in both groups. Median duration on venovenous ECMO for acute hypoxemic respiratory failure was 218 hrs (range, 24-921). Venovenous ECMO survivors remained cannulated for significantly shorter time than nonsurvivors did (median, 212 vs. 350 hrs; p =.04). Sixty-three of 82 ECMO (77%) patients survived to discharge-56 of 68 venovenous ECMO (81%) and nine of 14 venoarterial ECMO (64%). CONCLUSIONS: Venovenous ECMO can effectively provide adequate oxygenation for pediatric patients with severe acute respiratory failure receiving ECMO support. Additional cannulae placed at the initiation of venovenous ECMO could be beneficial in achieving flow rates necessary for adequate oxygenation and lung rest.

Systemic hypertension associated with venovenous extracorporeal membrane oxygenation for pediatric respiratory failure.

BACKGROUND/PURPOSE: Arterial hypertension (HTN) is common in neonates on venoarterial (VA) extracorporeal membrane oxygenation (ECMO), but HTN in pediatric venovenous (VV) ECMO has not been well described. The authors noted HTN in their VV ECMO experience and hypothesized that HTN was associated with fluid status, steroid use, and renal insufficiency. METHODS: Records of 50 patients receiving VV ECMO for respiratory failure were reviewed. HTN was defined as systolic blood pressure greater than 95th percentile for age for > or =1 hour, unresponsive to sedation/analgesia. Hypertensive index (HI) is defined as total hypertensive hours per total ECMO hours. Fluid status was estimated by a fluid index (FI = total fluid balance during ECMO per ECMO hours per weight). RESULTS: Forty-seven of 50 patients (94%) had HTN. Median HI was 0.21 (range, 0.01 to 1.0). Thirteen patients had renal insufficiency, 39 received steroids, and 23 received continuous venovenous hemofiltration (CVVH). There was no association between HI and FI, steroid use, or renal insufficiency. Thirty-three patients were treated for HTN, often requiring multiple agents. Bleeding complicated the course of 18 patients, and HI was significantly higher in those patients (P = .03). HI was not different between survivors (37 of 39 with HTN) and nonsurvivors (10 of 11 with HTN). CONCLUSIONS: Hypertension is a common complication associated with VV ECMO with unclear etiology. HTN was frequently difficult to control. This study emphasizes the need for the development of treatment protocols to decrease the incidence, severity, and associated morbidity. Improved insight into the etiology of HTN associated with pediatric VV ECMO, including evaluation of the renin-angiotensin system, would help guide therapy.

Fluid overload before continuous hemofiltration and survival in critically ill children: a retrospective analysis.

OBJECTIVE: Continuous venovenous hemofiltration (CVVH) is used for renal replacement and fluid management in critically ill children. A previous small study suggested that survival was associated with less percent fluid overload (%FO) in the intensive care unit (ICU) before hemofiltration. We reviewed our experience with a large series of pediatric CVVH patients to evaluate factors associated with outcome. DESIGN: Retrospective chart review. SETTING: Tertiary children's hospital. PATIENTS: CVVH pediatric ICU patients from November 1997 to January 2003. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: %FO was defined as total fluid input minus output (up to 7 days before CVVH for both hospital stay and ICU stay) divided by body weight. One hundred thirteen patients received CVVH; 69 survived (61%). Multiple organ dysfunction syndrome (MODS) was present in 103 patients; 59 survived (57%). Median patient age was 9.6 yrs (25th, 75th percentile: 2.5, 14.3). Median %FO was significantly lower in survivors vs. nonsurvivors for all patients (7.8% [2.0, 16.7] vs. 15.1% [4.9, 25.9]; p =.02] and in patients with > or =3-organ MODS (9.2% [5.1,16.7] vs. 15.5% [8.3, 28.6]; p =.01). The Pediatric Risk of Mortality Score III at CVVH initiation also was associated with survival in these groups, but by multivariate analysis, %FO was independently associated with survival in patients with > or =3-organ MODS (p =.01). CONCLUSIONS: Survival in critically ill children receiving CVVH in this large series was higher than in previous reports. CVVH survival may be associated with less %FO in patients with > or =3-organ MODS. Prospective studies are necessary to determine whether earlier use of CVVH to control fluid overload in critically ill children can improve survival.