The impact of cochlear implantation on speech and language outcomes in children with asymmetric sensorineural hearing loss.

INTRODUCTION: Cochlear implantation (CI) is considered in children with asymmetric sensorineural hearing loss (ASHL), or severe to profound sensorineural hearing loss in one ear, and better hearing contralaterally. The benefits of a CI in these children are not well established. This study investigated the impact of unilateral CI on speech and language outcomes in pediatric patients with ASHL. METHODS: The retrospective chart review identified pediatric patients who underwent cochlear implantation for ASHL at a tertiary single center institution between 2014 and 2017. Children who underwent cochlear implantation in the poorer ear and maintained a hearing aid in the better ear were included, while children with cognitive impairment or prior cochlear nerve deficiency and auditory neuropathy were excluded. Speech and language measures were evaluated prior to implantation and at regular six-month intervals postoperatively. Ear specific Audiometry was evaluated at every visit and varied developmentally appropriate speech recognition tasks, including questionnaires, closed-set, and open-set measures, accounted for advancing childhood milestones. Specific measures of speech articulation, expressive and receptive language, and vocabulary were assessed including: Goldman Fristoe Test of Articulation (GFTA-3), Clinical Evaluation of Language Fundamentals (CELF-P2 or CELF-5), Receptive One-Word Picture Vocabulary Test (ROWPVT) and Expressive One Word Picture Vocabulary Test (EOWPVT). The mean difference and standard deviation of speech and language outcomes at preoperative and postoperative evaluations were calculated. The change in outcomes were further assessed over each post-operative time point. RESULTS: Twenty-six children with asymmetric sensorineural hearing loss were included in the analysis, with 11 (42%) having bilateral enlarged vestibular aqueducts (EVA). At time of CI, unaided mean Pure Tone Average (PTA-4) for the better ear was 62Db HL, and worse ear was 92Db HL. There was an improvement in speech recognition in the implanted ear as expected. All preoperative speech and language evaluations were conducted within 7 months of cochlear implantation. Twenty-three patients had at least 1 postoperative re-evaluation. Fourteen children had preoperative and postoperative assessments with the same tool, with 13 patients (93%) showing improvement in at least 1 domain. For patients with repeated assessment within 12 months of surgery, we observed an average improvement in standard scores of: GFTA-3 (+11.2), CELF-P2 Core Language (+10.3), CELF-5 Core Language (+7.0), ROWPVT (+2.8) and EOWPVT (+4.5). Individual results are described. CONCLUSION: Improvement in speech and language measures can be demonstrated in children undergoing unilateral cochlear implantation for asymmetric sensorineural hearing losses. These children, who are not typical CI candidates, can benefit from a CI in the poorer ear.

Recognition and Management of Nonaccidental Esophageal Perforation.

Nonaccidental trauma is a common pediatric concern that often goes unrecognized. Although most patients present with bruising, burns, fractures, and head trauma, it is critical that physicians be able to diagnose and treat atypical presentations such as pharyngeal and esophageal trauma. In this report, we describe the presentation and management of a 5-week-old girl with an inflicted esophageal perforation.

An early experience on the effect of solid organ transplant status on hospitalized COVID-19 patients.

We compared the outcome of COVID-19 in immunosuppressed solid organ transplant (SOT) patients to a transplant naïve population. In total, 10 356 adult hospital admissions for COVID-19 from March 1, 2020 to April 27, 2020 were analyzed. Data were collected on demographics, baseline clinical conditions, medications, immunosuppression, and COVID-19 course. Primary outcome was combined death or mechanical ventilation. We assessed the association between primary outcome and prognostic variables using bivariate and multivariate regression models. We also compared the primary endpoint in SOT patients to an age, gender, and comorbidity-matched control group. Bivariate analysis found transplant status, age, gender, race/ethnicity, body mass index, diabetes, hypertension, cardiovascular disease, COPD, and GFR <60 mL/min/1.73 m2 to be significant predictors of combined death or mechanical ventilation. After multivariate logistic regression analysis, SOT status had a trend toward significance (odds ratio [OR] 1.29; 95% CI 0.99-1.69, p = .06). Compared to an age, gender, and comorbidity-matched control group, SOT patients had a higher combined risk of death or mechanical ventilation (OR 1.34; 95% CI 1.03-1.74, p = .027).

A Retrospective Study Analyzing the Lack of Symptom Benefit With Antimicrobials at the End of Life.

BACKGROUND: Infections are common in terminally ill patients (pts), and although antibiotics are frequently prescribed, their benefit for symptom relief is not clear. Antimicrobials at the end of life (EOL) may increase the risk of antimicrobial resistance and Clostrioides difficile infection. Our aim was to determine the frequency of symptom occurrence at the EOL when comparing pts who did or did not receive antibiotics (AB+ or AB-). METHODS: We reviewed electronic medical records of pts admitted to a palliative care unit of a quarternary care hospital between 01/09/2017 and 07/16/2017 and assessed antimicrobial use in the last 14 days of life. Differences in demographics and symptom control between AB+ and AB- pts were analyzed using chi-square analyses; p-values were computed using Mann-Whitney tests. RESULTS: Of a total of 133 pts included, 90 (68%) received antimicrobials (AB+). The indication for antibiotics was documented in only 12% of pts. The AB+ and AB- groups were similar with respect to demographics, including sex, and Charleston Comorbidity Index except for age (p = 0.01) and race (p = 0.03). Documented infections were similar between AB+ and AB- groups, except urinary tract infections. No statistically significant differences were noted in documented symptoms including pain, dyspnea, fever, lethargy, and alteration of mental state or length of stay. CONCLUSION: Our study did not show differences in frequencies of documented symptoms with use of antimicrobials at EOL. Antimicrobial stewardship programs and further research can help with developing EOL care antimicrobial guidelines supporting patients and providers through shared decision-making.

Electrocochleography Observations in a Series of Cochlear Implant Electrode Tip Fold-Overs.

OBJECTIVE: Tip fold-over is a rare but serious complication of cochlear implant (CI) surgery. The purpose of this study was to present intraoperative electrocochleography (ECochG) observations in a series of CI electrode tip fold-overs. PATIENTS: Five pediatric subjects undergoing CI surgery through a round window (RW) approach with a perimodiolar electrode array, who were diagnosed with either auditory neuropathy spectrum disorder or enlarged vestibular aqueduct. INTERVENTIONS: Intraoperative RW ECochG during CI surgery: tone burst stimuli were presented from 95 to 110 dB SPL. MAIN OUTCOME MEASURES: Magnitude and phase characteristics of ECochG responses obtained intraoperatively before and immediately after electrode insertion were examined for patients with and without tip fold-over. RESULTS: Three subjects presented with tip fold-over and two formed the control group. Among fold-over cases, one participant exhibited an inversion in the starting phase of the cochlear microphonic response and a decrease in spectral magnitude from pre- to postinsertion. Both subjects who did not exhibit a change in phase had an increase in the ECochG-total response (ECochG-TR) magnitude. No case in the control group exhibited a change in starting phase. In regard to the ECochG-TR, all controls showed a decrease in the magnitude. CONCLUSIONS: Despite the small number of patients, heterogeneous ECochG response patterns were observed within the fold-over group. Though these results are not conclusive, they can serve as a framework to begin to understand ECochG's utility in detecting intraoperative tip fold-over.

Segmentation of Temporal Bone Anatomy for Patient-Specific Virtual Reality Simulation.

OBJECTIVES: Virtual reality (VR) simulation for patient-specific pre-surgical planning and rehearsal requires accurate segmentation of key surgical landmark structures such as the facial nerve, ossicles, and cochlea. The aim of this study was to explore different approaches to segmentation of temporal bone surgical anatomy for patient-specific VR simulation. METHODS: De-identified, clinical computed tomography imaging of 9 pediatric patients aged 3 months to 12 years were obtained retrospectively. The patients represented normal anatomy and key structures were manually segmented using open source software. The OTOPLAN (CAScination AG, Bern, Switzerland) otological planning software was used for guided segmentation. An atlas-based algorithm was used for computerized, automated segmentation. Experience with the different approaches as well as time and resulting models were compared. RESULTS: Manual segmentation was time consuming but also the most flexible. The OTOPLAN software is not designed specifically for our purpose and therefore the number of structures that can be segmented is limited, there was some user-to-user variation as well as volume differences compared with manual segmentation. The atlas-based automated segmentation potentially allows a full range of structures to be segmented and produces segmentations comparable to those of manual segmentation with a processing time that is acceptable because of the minimal user interaction. CONCLUSION: Segmentation is fundamental for patient-specific VR simulation for pre-surgical planning and rehearsal in temporal bone surgery. The automated segmentation algorithm currently offers the most flexible and feasible approach and should be implemented. Further research is needed in relation to cases of abnormal anatomy. LEVEL OF EVIDENCE: 4.

Effect of Remdesivir vs Standard Care on Clinical Status at 11 Days in Patients With Moderate COVID-19: A Randomized Clinical Trial.

Importance: Remdesivir demonstrated clinical benefit in a placebo-controlled trial in patients with severe coronavirus disease 2019 (COVID-19), but its effect in patients with moderate disease is unknown. Objective: To determine the efficacy of 5 or 10 days of remdesivir treatment compared with standard care on clinical status on day 11 after initiation of treatment. Design, Setting, and Participants: Randomized, open-label trial of hospitalized patients with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and moderate COVID-19 pneumonia (pulmonary infiltrates and room-air oxygen saturation >94%) enrolled from March 15 through April 18, 2020, at 105 hospitals in the United States, Europe, and Asia. The date of final follow-up was May 20, 2020. Interventions: Patients were randomized in a 1:1:1 ratio to receive a 10-day course of remdesivir (n = 197), a 5-day course of remdesivir (n = 199), or standard care (n = 200). Remdesivir was dosed intravenously at 200 mg on day 1 followed by 100 mg/d. Main Outcomes and Measures: The primary end point was clinical status on day 11 on a 7-point ordinal scale ranging from death (category 1) to discharged (category 7). Differences between remdesivir treatment groups and standard care were calculated using proportional odds models and expressed as odds ratios. An odds ratio greater than 1 indicates difference in clinical status distribution toward category 7 for the remdesivir group vs the standard care group. Results: Among 596 patients who were randomized, 584 began the study and received remdesivir or continued standard care (median age, 57 [interquartile range, 46-66] years; 227 [39%] women; 56% had cardiovascular disease, 42% hypertension, and 40% diabetes), and 533 (91%) completed the trial. Median length of treatment was 5 days for patients in the 5-day remdesivir group and 6 days for patients in the 10-day remdesivir group. On day 11, patients in the 5-day remdesivir group had statistically significantly higher odds of a better clinical status distribution than those receiving standard care (odds ratio, 1.65; 95% CI, 1.09-2.48; P = .02). The clinical status distribution on day 11 between the 10-day remdesivir and standard care groups was not significantly different (P = .18 by Wilcoxon rank sum test). By day 28, 9 patients had died: 2 (1%) in the 5-day remdesivir group, 3 (2%) in the 10-day remdesivir group, and 4 (2%) in the standard care group. Nausea (10% vs 3%), hypokalemia (6% vs 2%), and headache (5% vs 3%) were more frequent among remdesivir-treated patients compared with standard care. Conclusions and Relevance: Among patients with moderate COVID-19, those randomized to a 10-day course of remdesivir did not have a statistically significant difference in clinical status compared with standard care at 11 days after initiation of treatment. Patients randomized to a 5-day course of remdesivir had a statistically significant difference in clinical status compared with standard care, but the difference was of uncertain clinical importance. Trial Registration: ClinicalTrials.gov Identifier: NCT04292730.

Increased Plasma Levels of the TH2 chemokine CCL18 associated with low CD4+ T cell counts in HIV-1-infected Patients with a Suppressed Viral Load.

The chemokine (C-C motif) chemokine ligand 18 (CCL18) is a structural homolog of CCL3 primarily produced by monocyte-derived cells with an M2 phenotype. Elevated levels of CCL18 have been observed in several diseases associated with malignancies and chronic inflammation. The role of CCL18 in Human Immunodeficiency Virus (HIV-1) infection remains unknown. We analyzed expression levels of T helper cell-mediated (TH2) chemokines CCL18, CCL17, and CCL22 by ELISA in plasma collected from HIV-1-infected and healthy donors. In HIV-1-infected individuals, plasma viral loads were monitored by NucliSense HIV-1 QT assay and T cell counts and expression of the activation marker CD38 were determined by flow cytometry. Our data showed a significant increase in plasma levels of CCL18 in HIV-1-infected individuals compared to uninfected controls (p < 0.001) and a significant correlation between CCL18 levels and viral load in untreated patients. No significant difference of CCL18 levels was detected among the HIV-1-infected patients treated with combined antiretroviral therapy (cART) and HIV-1-untreated patients.CCL18 values are negatively correlated with CD4+CD38+ cell numbers and total CD4+ T cell counts in patients with a suppressed viral load. Notably, plasma levels of the TH2 chemokines CCL17 and CCL22 are also elevated during HIV-1 infection. However, no correlation of CCL17 and CCL22 production with CD4+ T cell counts was detected. Presented data shows that the chemokines, CCL17, CCL18, and CCL22 are increased during HIV-1 infection. However, only increased levels of CCL18, a marker of M2 macrophages, correlate with low CD4+ T cell counts in patients with suppressed viral load, raising the possibility that CCL18 and/or CCL18-producing cells may interfere with their reconstitution in HIV-1-infected patients on cART.

Pediatric lateral graft tympanoplasty A review of 78 cases.

OBJECTIVES: The optimal timing and technique for repairing chronic tympanic membrane (TM) perforations in pediatric patients remains controversial. The objectives are to determine the surgical and hearing outcomes of pediatric lateral graft tympanoplasty at a tertiary teaching hospital. METHODS: A retrospective review was conducted for pediatric lateral graft tympanoplasties performed for chronic TM perforations by a single surgeon over a four-year period. Primary and secondary outcomes were graft failure rate and hearing outcomes, respectively. RESULTS: 78 cases were analyzed. The mean age at time of surgery was 10.3 years (range 5-18 years). Mean follow-up was 11.0 months; 27 patients had follow-up >1 yr. Most patients were non-syndromic (85.9%), had a history of bilateral Eustachian tube dysfunction (ETD) (59%) and presented with marked myringosclerosis (73.1%). Thirty-three percent of cases were revision tympanoplasties. A learner surgeon (resident or fellow) was present in 89.7% of cases. Successful closure of the TM was achieved in 97.4% (76/78) of cases and 92.6% (25/27) of cases with >1-year follow-up. No obvious difference in graft failure was noted with regards to age at time of surgery, perforation size, history of bilateral ETD, presence of a learner surgeon, myringosclerosis, presence of syndromic features, or history of prior tympanoplasty. Ninety-one percent of patients either improved hearing or preserved their conductive hearing deficit. Poorer hearing outcomes were only associated with post-operative blunting. CONCLUSIONS: Pediatric lateral graft tympanoplasty is effective in repairing chronic perforations with excellent hearing outcomes. Common quoted predictors of surgical outcome such as age at the time of surgery, syndromic features, history of previous myringoplasty, perforation size, and ETD dysfunction were not associated with graft failure in our series.

Real-Time Intracochlear Electrocochleography Obtained Directly Through a Cochlear Implant.

HYPOTHESIS: Utilizing the cochlear implant to record electrophysiologic responses during device placement is a feasible and efficacious technique for monitoring near real-time cochlear physiology during and following electrode insertion. BACKGROUND: Minimizing intracochlear trauma during cochlear implantation has emerged as a highly researched area to help improve patient performance. Currently, conventional cochlear implant technology allows for the recording of electrically evoked compound action potentials (eCAPs). Acoustically evoked potentials may be more sensitive in detecting physiologic changes occurring as a result of electrode insertion. Electrocochleography obtained from within the cochlea allows hair cell and neural response monitoring along the cochlear spiral at locations where changes most likely would occur. METHODS: Intracochlear electrocochleography (ECochG) was recorded from the cochlear implant during surgery in 14 subjects. A long acquisition time (54.5 ms), capable of measuring potentials from the low frequency-serving apical region of the cochlea (125 and 500 Hz) was employed. Two distinct intracochlear processing methods were used and compared in obtaining electrophysiologic data. RESULTS: Measureable intracochlear ECochG responses were obtained from all 14 participants. The 1st harmonic distortions (cochlear microphonic and auditory nerve neurophonic) generally increased steadily with electrode insertion. Electrode and frequency scan following insertion revealed that response amplitude varied based on location of recording electrode and frequency of stimulation. Exquisite sensitivity to manipulation during round window muscle packing was demonstrated. CONCLUSION: Intracochlear ECochG recorded from the electrode array of the cochlear implant is a highly feasible technique that sheds light on cochlear micromechanics during cochlear implant electrode placement.

Pseudomembranous tracheitis caused by Aspergillus fumigatus in the setting of high grade T-cell lymphoma.

Pseudomembranous tracheitis (PMT) is a rare condition most commonly caused by fungal or bacterial infection that is characterized by a pseudomembrane that partially or completely covers the tracheobronchial tree. PMT is most commonly found in immunocompromised patient populations, such as post-chemotherapy, AIDS, post-transplant and hematological malignancies. Due to its rarity, PMT is often not included in the differential diagnosis. This case describes a 65 year old male with persistent fever and refractory cough despite high dose empiric antibiotics. Subsequent bronchoscopy with biopsy revealed pseudomembranous tracheitis due to Aspergillus fumigatus in the setting of T-cell lymphoma. PMT should be considered in the differential diagnosis of refractory cough in the immunocompromised population. However, it has been described in patients with nonspecific respiratory symptoms such as dyspnea, cough, and other airway issues.

Clinical Features of Respiratory Viral Infections Among Inpatients at a Major US Tertiary Care Hospital.

OBJECTIVES: Respiratory viral illnesses (RVI) are reliably diagnosed by respiratory viral panel using polymerase chain reaction (RVP-PCR); however, owing to the scant data, clinical presentation alone is unreliable in establishing viral etiology. The primary objective of this study was to characterize signs and symptoms of RVI among inpatients in a major tertiary care hospital. METHODS: Between 2013 and 2015, adult inpatients with RVI undergoing RVP-PCR were prospectively enrolled in our study. Clinical data were collected by interviews and electronic medical record reviews. Data analysis was performed using χ(2) testing, analysis of variance for continuous variables, and logistic regression modeling. RESULTS: Of 421 patients analyzed, 175 (41.7%) had a positive RVP-PCR. Patients were evenly matched at baseline except for renal disease. Multivariate logistic regression modeling demonstrated the following positive correlations: positive RVP-PCR with renal disease (odds ratio [OR] 2.08), cough (OR 2.28), and wheezing (OR 1.8); influenza with cough (OR 5.04), and renal disease (OR 2.17); metapneumovirus with age older than 65 (OR 3.24); respiratory syncytial viruses with wheezing (OR 3.42) and immunosuppression (OR 3.11); and parainfluenza with smoking (OR 3.16). Negative correlations included influenza with anosmia (OR 0.41); rhinovirus/enterovirus with feeling confined to bed (OR 0.3); metapneumovirus with smoking (OR 0.29); and parainfluenza with male sex (OR 0.22). CONCLUSIONS: In this descriptive study, we noted specific viral associations with clinical signs and symptoms among 421 inpatients with RVIs. With increasing RVP-PCR use, studies similar to ours may be able to better define the clinical presentation of RVIs and lead to evidence-based, clinical presentation-guided diagnostic and management algorithms.

Computational fluid dynamics as surgical planning tool: a pilot study on middle turbinate resection.

Controversies exist regarding the resection or preservation of the middle turbinate (MT) during functional endoscopic sinus surgery. Any MT resection will perturb nasal airflow and may affect the mucociliary dynamics of the osteomeatal complex. Neither rhinometry nor computed tomography (CT) can adequately quantify nasal airflow pattern changes following surgery. This study explores the feasibility of assessing changes in nasal airflow dynamics following partial MT resection using computational fluid dynamics (CFD) techniques. We retrospectively converted the pre- and postoperative CT scans of a patient who underwent isolated partial MT concha bullosa resection into anatomically accurate three-dimensional numerical nasal models. Pre- and postsurgery nasal airflow simulations showed that the partial MT resection resulted in a shift of regional airflow towards the area of MT removal with a resultant decreased airflow velocity, decreased wall shear stress and increased local air pressure. However, the resection did not strongly affect the overall nasal airflow patterns, flow distributions in other areas of the nose, nor the odorant uptake rate to the olfactory cleft mucosa. Moreover, CFD predicted the patient's failure to perceive an improvement in his unilateral nasal obstruction following surgery. Accordingly, CFD techniques can be used to predict changes in nasal airflow dynamics following partial MT resection. However, the functional implications of this analysis await further clinical studies. Nevertheless, such techniques may potentially provide a quantitative evaluation of surgical effectiveness and may prove useful in preoperatively modeling the effects of surgical interventions.

The use of botulinum toxin for pediatric cricopharyngeal achalasia.

OBJECTIVES: Cricopharyngeal achalasia is an uncommon cause of feeding difficulties in the pediatric population, and is especially rare in infants. Traditional management options include dilation or open cricopharyngeal myotomy. The use of botulinum toxin has been preliminarily reported for cricopharyngeal achalasia in children as a modality for diagnosis and management. This study describes the use of botulinum toxin as a definitive treatment for pediatric cricopharyngeal achalasia. METHODS: A retrospective analysis was performed of three patients who were diagnosed with cricopharyngeal achalasia and underwent botulinum toxin injections to the cricopharyngeus muscle. The charts were reviewed for etiology, botulinum toxin dosage delivered, length of follow-up, postoperative need for nasogastric tube placement, and swallow studies. RESULTS: A total of 7 botulinum toxin injections into the cricopharyngeus muscle were performed in three infants with primary cricopharyngeal achalasia between April 2006 and February 2011. Mean dosage was 23.4 units per session (range: 10-44 units), or 3.1 U/kg (range: 1.4-5.3 U/kg). Mean interval period between injections was 3.3 months (range: 2.7-4.0 months). Mean follow-up period was 22.1 months (range: 3.4-44.5 months). One patient required hospital readmission after injection for presumed aspiration but recovered without need for surgical intervention. No long-term complications were noted post-operatively. All patients improved clinically and ultimately had their nasogastric feeding tubes removed. CONCLUSIONS: Botulinum toxin appears to be a safe and effective option in the management of primary cricopharyngeal achalasia in children, and may prevent the need for myotomy.

Isoniazid resistance among Bacillus Calmette Guerin strains: implications on bladder cancer immunotherapy related infections.

Bacillus Calmette Guerin (BCG) immunotherapy is widely used for treatment of superficial bladder transitional cell carcinoma. Infectious complications while rare can be serious and severe disseminated infections as well as sepsis has been reported. There are no standard guidelines to direct therapy of these complications. Isoniazid is a commonly and widely used component of the various treatment regimens. Various strains of BCG are used for treatment of bladder cancer as well as vaccinations. These strains have evolved because of repeated subcultures in various laboratories in the world and have been shown to exhibit phenotypic differences in their immunogenicity as well as recently in susceptibility to various antimycobacterial agents. In this article, we review the resistance of BCG strains to various antimycobacterial agents. Some of these strains including the BCG Connaught strain, which is widely used in the United States, Canada and some other parts of the world for bladder cancer therapy exhibit intrinsic resistance to isoniazid. Although the clinical relevance of these differences is unclear, recent studies have questioned the role of isoniazid in treatment of infections after vaccination with these strains. Also, use of isoniazid in combination therapy for these infections may lead to the development of resistance to other antimycobacterial agents. We conclude that isoniazid may not be a suitable agent for empiric treatment of infections related to intravesical immunotherapy for bladder cancer with these strains and further studies are needed to clarify its role.

Mycobacterial brain tuberculomas due to Bacille Calmette-Guérin intravesical chemotherapy for bladder cancer: A case report and literature review.

Bacille Calmette-Guérin (BCG) immunotherapy is widely used for the treatment of superficial bladder cancer. The authors believe that the present report is one of the first to document cerebral BCG tuberculoma in a 73-year-old immunocompetent man, three years after intra-vesical BCG immunotherapy. His workup revealed no identifiable extracranial source. He responded well to treatment with rifampin, ethambutol and moxifloxacin.Patients undergoing intravesical BCG therapy should be closely monitored for the development of this complication. Prolonged antitubercular therapy, possibly including moxifloxacin, appears to be beneficial in the treatment of central nervous system tuberculous infections.

Clinical, radiographic, and audiometric predictors in conservative management of vestibular schwannoma.

OBJECTIVE: Vestibular schwannomas (VS) can be managed by observation. The goals were to examine clinical, radiographic, and audiometric variables at presentation and during observation that may predict which patients fail conservative management. METHODS: A retrospective chart review was performed of 202 patients who elected observation primarily. Data collection included presenting symptoms, symptom progression, tumor size, audiologic measures, and global clinical outcomes. Univariate and multivariate analyses were performed. RESULTS: Follow-up ranged from 1 month to 16 years (mean, 2.48 yr). Nineteen patients (9.4%) in the study group failed. Disequilibrium as a presenting symptom appeared more often in patients who failed observation (58% versus 32%; p = 0.039), as did new-onset disequilibrium. Presenting tumor size differed for patients who failed conservative management, with a mean of 14.0 versus 8.4 mm (p = 0.0006). Neurotologic complications compared favorably to those treated with primary surgery or radiotherapy. CONCLUSION: Patients with subjective disequilibrium at presentation and subjective disequilibrium developed during observation may be more likely to fail conservative management. Increased tumor size at presentation also may indicate the same, although no threshold could be achieved.

Aesthetic considerations in mandibular reconstruction.

As free tissue transfer methods have improved, vascular bone grafting has become state of the art for reconstruction of mandibular defects. Prior studies have focused on flap survival and functional outcomes. The reconstructive surgeon should also strive to attain lofty aesthetic goals for this group of patients. The best results are achieved when patient factors, flap selection, treatment planning, and surgical techniques are all considered and properly selected.

Cryptococcal fungemia in a neutropenic patient with AIDS while receiving caspofungin.

Empiric choice of anti-fungal therapy in febrile neutropenia should be based upon a host's susceptibility to specific fungal pathogens. We present a case of a patient with multiple risk factors for fungemia including HIV infection, Hodgkin's disease, corticosteroid use and chemotherapy-induced neutropenia who developed disseminated cryptococcal infection while receiving caspofungin.