Patient Satisfaction with Nonopioid Postoperative Analgesia in Head and Neck Surgery: A Prospective Randomized Trial.

OBJECTIVE: To evaluate patients' satisfaction with opioid versus opioid-sparing postoperative analgesia in patients undergoing outpatient head and neck surgery. STUDY DESIGN: Prospective randomized trial. SETTING: Tertiary care academic hospital. METHODS: Adult patients undergoing outpatient head and neck surgery were randomly assigned to 1 of 3 analgesic regimens. First- and second-line medications were the following by group (1) Hydrocodone-acetaminophen with ibuprofen, (2) ibuprofen with hydrocodone-acetaminophen, and (3) ibuprofen with acetaminophen. Preoperative counseling was provided to patients regarding expected pain and proper medication use. Postoperative questionnaires were administered to assess satisfaction. RESULTS: One hundred three patients were enrolled in the study (mean age, 56.5 years; women, 75 [73%]). The mean satisfaction score with the pain regimen assigned was similar between the 3 groups (scale 0-10, [7.7, 8.3, 8.5, P = .46]). A similar percentage of patients in each group reported that surgery was more painful than anticipated (25%, 32%, 26%, P = .978), and a similar percentage of patients reported willingness to utilize the same analgesic regimen following future surgeries (75%, 83%, 76%, P = .682). Additional questions evaluating the side effect profile, maximum and minimum pain scores, and difficulty of recovery were not statistically different between the 3 groups. CONCLUSION: In the postoperative population for outpatient head and neck surgeries, there was no significant difference in patient satisfaction and pain control between the opioid and nonopioid arms. Providers should discuss opioid-sparing regimens preoperatively with patients and describe them as effective in providing adequate pain control without a significant impact on patient's perception of care.

Artificial intelligence-based epigenomic, transcriptomic and histologic signatures of tobacco use in oral squamous cell carcinoma.

Oral squamous cell carcinoma (OSCC) biomarker studies rarely employ multi-omic biomarker strategies and pertinent clinicopathologic characteristics to predict mortality. In this study we determine for the first time a combined epigenetic, gene expression, and histology signature that differentiates between patients with different tobacco use history (heavy tobacco use with ≥10 pack years vs. no tobacco use). Using The Cancer Genome Atlas (TCGA) cohort (n = 257) and an internal cohort (n = 40), we identify 3 epigenetic markers (GPR15, GNG12, GDNF) and 13 expression markers (IGHA2, SCG5, RPL3L, NTRK1, CD96, BMP6, TFPI2, EFEMP2, RYR3, DMTN, GPD2, BAALC, and FMO3), which are dysregulated in OSCC patients who were never smokers vs. those who have a ≥ 10 pack year history. While mortality risk prediction based on smoking status and clinicopathologic covariates alone is inaccurate (c-statistic = 0.57), the combined epigenetic/expression and histologic signature has a c-statistic = 0.9409 in predicting 5-year mortality in OSCC patients.

Health screenings with a medical interpreter in a required Ambulatory Care Introductory Pharmacy Practice Experience.

BACKGROUND AND PURPOSE: This study aimed to assess second year student pharmacists' (P2) confidence in communicating with patients with limited English proficiency before and after a required community-based health screening experience. EDUCATIONAL ACTIVITY AND SETTING: All P2s were required to complete a 0.5 credit hour Ambulatory Care Introductory Pharmacy Practice Experience (IPPE). As part of this experience, P2s conducted blood pressure (BP) and blood glucose (BG) screenings with a medical interpreter at a low-income apartment building that has a large Mandarin-speaking population. Each student was required to attend one health screening event. Between September 2022 and April 2023,we administered paper questionnaires to P2s and community members to obtain feedback about the experience. Quantitative data was analyzed using descriptive statistics, chi-squared tests, and paired t-tests while a content analysis was conducted on qualitative data. FINDINGS: P2s (n = 82, 100%) conducted an average of 5.7 (SD 2.6) BP and 5.9 (SD 2.7) BG screenings per two-hour event. P2s reported higher confidence in conducting assessments, communicating via a medical interpreter, and working on a team at the end of the event. P2s agreed that it should be kept as part of the IPPE (99%). Community members (n = 55, 22%) participated in a bilingual paper-based questionnaire. Community members reported positive experiences and a desire to continue to participate. SUMMARY: At the end of the health screening event, P2s were more confident in their ability to communicate with older adult community members using translated written documents and verbally with a medical interpreter. P2s and community members supported continuation of the program.

Neurotrophin Pathway Receptors NGFR and TrkA Control Perineural Invasion, Metastasis, and Pain in Oral Cancer.

Oral squamous cell carcinoma (OSCC) patients suffer from poor survival due to metastasis or locoregional recurrence, processes that are both facilitated by perineural invasion (PNI). OSCC has higher rates of PNI than other cancer subtypes, with PNI present in 80% of tumors. Despite the impact of PNI on oral cancer prognosis and pain, little is known about the genes that drive PNI, which in turn drive pain, invasion, and metastasis. In this study, clinical data, preclinical, and in vitro models are leveraged to elucidate the role of neurotrophins in OSCC metastasis, PNI, and pain. The expression data in OSCC patients with metastasis, PNI, or pain demonstrate dysregulation of neurotrophin genes. TrkA and nerve growth factor receptor (NGFR) are focused, two receptors that are activated by NGF, a neurotrophin expressed at high levels in OSCC. It is demonstrated that targeted knockdown of these two receptors inhibits proliferation and invasion in an in vitro and preclinical model of OSCC, and metastasis, PNI, and pain. It is further determined that TrkA knockdown alone inhibits thermal hyperalgesia, whereas NGFR knockdown alone inhibits mechanical allodynia. Collectively the results highlight the ability of OSCC to co-opt different components of the neurotrophin pathway in metastasis, PNI, and pain.

Dysphagia Severity and Outcomes Following Iatrogenic High Vagal Nerve Injury.

OBJECTIVE: To examine severity of dysphagia and outcomes following iatrogenic high vagal nerve injury. METHODS: Retrospective chart review of all patients with iatrogenic high vagal nerve injury that were seen at a tertiary referral center from 2012 to 2020. RESULTS: Of 1304 patients who met criteria for initial screening, 18 met all inclusion criteria. All 18 required intervention to address postoperative dysphagia. Eleven required enteral feeding tubes with 7 eventually able to advance to exclusively per oral diets. Fourteen underwent vocal fold injection and 6 underwent laryngeal framework surgery. Sixteen pursued swallowing therapy with speech language pathology. Patients lost a mean of 8.6 kg of weight in the 6 months following the injury. Swallowing function on the Functional Outcome Swallowing Scale (FOSS) and Functional Oral Intake Scale (FOIS) was 4.4 and 2.4 respectively immediately following the injury and improved to 1.9 and 5.3 at the last follow-up. No patients had complete return of normal swallowing function at last follow up. CONCLUSION: Iatrogenic high vagal injury causes significant lasting dysphagia which improves with intervention but does not completely resolve. Interventions such as vocal fold injection, medialization laryngoplasty, cricopharyngeal myotomy, or swallowing therapy may be required to reestablish safe swallowing in these patients.

Brush swab as a noninvasive surrogate for tissue biopsies in epigenomic profiling of oral cancer.

BACKGROUND: Oral squamous cell carcinoma (OSCC) has poor survival rates. There is a pressing need to develop more precise risk assessment methods to tailor clinical treatment. Epigenome-wide association studies in OSCC have not produced a viable biomarker. These studies have relied on methylation array platforms, which are limited in their ability to profile the methylome. In this study, we use MethylCap-Seq (MC-Seq), a comprehensive methylation quantification technique, and brush swab samples, to develop a noninvasive, readily translatable approach to profile the methylome in OSCC patients. METHODS: Three OSCC patients underwent collection of cancer and contralateral normal tissue and brush swab biopsies, totaling 4 samples for each patient. Epigenome-wide DNA methylation quantification was performed using the SureSelectXT Methyl-Seq platform. DNA quality and methylation site resolution were compared between brush swab and tissue samples. Correlation and methylation value difference were determined for brush swabs vs. tissues for each respective patient and site (i.e., cancer or normal). Correlations were calculated between cancer and normal tissues and brush swab samples for each patient to determine the robustness of DNA methylation marks using brush swabs in clinical biomarker studies. RESULTS: There were no significant differences in DNA yield between tissue and brush swab samples. Mapping efficiency exceeded 90% across all samples, with no differences between tissue and brush swabs. The average number of CpG sites with at least 10x depth of coverage was 2,716,674 for brush swabs and 2,903,261 for tissues. Matched tissue and brush swabs had excellent correlation (r = 0.913 for cancer samples and r = 0.951 for normal samples). The methylation profile of the top 1000 CpGs was significantly different between cancer and normal samples (mean p-value = 0.00021) but not different between tissues and brush swabs (mean p-value = 0.11). CONCLUSIONS: Our results demonstrate that MC-Seq is an efficient platform for epigenome profiling in cancer biomarker studies, with broader methylome coverage than array-based platforms. Brush swab biopsy provides adequate DNA yield for MC-Seq, and taken together, our findings set the stage for development of a non-invasive methylome quantification technique for oral cancer with high translational potential.

The REASON score: an epigenetic and clinicopathologic score to predict risk of poor survival in patients with early stage oral squamous cell carcinoma.

BACKGROUND: Oral squamous cell carcinoma (OSCC) is a capricious cancer with poor survival rates, even for early-stage patients. There is a pressing need to develop more precise risk assessment methods to appropriately tailor clinical treatment. Genome-wide association studies have not produced a viable biomarker. However, these studies are limited by using heterogeneous cohorts, not focusing on methylation although OSCC is a heavily epigenetically-regulated cancer, and not combining molecular data with clinicopathologic data for risk prediction. In this study we focused on early-stage (I/II) OSCC and created a risk score called the REASON score, which combines clinicopathologic characteristics with a 12-gene methylation signature, to predict the risk of 5-year mortality. METHODS: We combined data from an internal cohort (n = 515) and The Cancer Genome Atlas (TCGA) cohort (n = 58). We collected clinicopathologic data from both cohorts to derive the non-molecular portion of the REASON score. We then analyzed the TCGA cohort DNA methylation data to derive the molecular portion of the risk score. RESULTS: 5-year disease specific survival was 63% for the internal cohort and 86% for the TCGA cohort. The clinicopathologic features with the highest predictive ability among the two the cohorts were age, race, sex, tobacco use, alcohol use, histologic grade, stage, perineural invasion (PNI), lymphovascular invasion (LVI), and margin status. This panel of 10 non-molecular features predicted 5-year mortality risk with a concordance (c)-index = 0.67. Our molecular panel consisted of a 12-gene methylation signature (i.e., HORMAD2, MYLK, GPR133, SOX8, TRPA1, ABCA2, HGFAC, MCPH1, WDR86, CACNA1H, RNF216, CCNJL), which had the most significant differential methylation between patients who survived vs. died by 5 years. All 12 genes have already been linked to survival in other cancers. Of the genes, only SOX8 was previously associated with OSCC; our study was the first to link the remaining 11 genes to OSCC survival. The combined molecular and non-molecular panel formed the REASON score, which predicted risk of death with a c-index = 0.915. CONCLUSIONS: The REASON score is a promising biomarker to predict risk of mortality in early-stage OSCC patients. Validation of the REASON score in a larger independent cohort is warranted.

Combined endoscopic and transoral resection of a high-staged juvenile nasopharyngeal angiofibroma: A pictorial essay.

Juvenile nasopharyngeal angiofibromas (JNAs) are highly vascular and benign tumors that can expand into the skull base. Delay of treatment can result in intracranial invasion, requiring extensive open approaches such as a facial translocation, maxillary swing, or an orbitozygomatic craniotomy. We describe a single-stage, combined endoscopic and transoral approach on a 14-year-old male with extensive high-stage dumbbell-shaped JNA involving the infratemporal fossa, orbit, buccal space, and intracranial extension into Meckel's cave. Successful resection of the tumor and good postoperative outcome was achieved. A transoral approach allowed for greater access to the infratemporal fossa, where endonasal resection was not possible, allowing for improved visualization, greater traction, and dissection. In select highly staged JNAs with significant lateral extension and intracranial involvement, successful and complete resection may be accomplished with this combined approach. Utilization of this approach avoids the morbidity of more invasive open approaches.

Local Intraluminal Irrigation With Argatroban During Free Flap Repair in a Patient With Heparin-Induced Thrombocytopenia.

OBJECTIVE: This study describes a case of a successful free flap repair using argatroban for local intraluminal irrigation as a substitute to heparin in a patient with heparin-induced thrombocytopenia. METHODS: Case report and review of literature. RESULTS: The patient had an uneventful postoperative course, and the free flap survived without complications. CONCLUSIONS: The use of argatroban during microvascular surgery is likely to be safe and simple and may be effective in preventing micro-thrombotic complications during microvascular surgery, and it should be considered as an alternative to heparinized saline for local intraluminal irrigation.

Long-term results of canal wall reconstruction tympanomastoidectomy.

OBJECTIVES: This study was designed to evaluate the long-term results using the technique of canal wall reconstruction (CWR) tympanomastoidectomy with mastoid obliteration in the treatment of chronic otitis media with cholesteatoma. STUDY DESIGN: Institutional review board-approved retrospective case review. SETTING: Tertiary referral center. PATIENTS: Retrospective review was performed on consecutive patients undergoing CWR tympanomastoidectomy with mastoid obliteration at a single institution from 1997 to 2011. MAIN OUTCOME MEASURES: Status of tympanic membrane and ear canal anatomy, preoperative and postoperative audiometry,residual cholesteatoma at second look surgery, postoperative complications, recurrence rate, and location. RESULTS: Two hundred eighty-five ears in 273 patients underwent CWR tympanomastoidectomy with a mean age of 35 years with average follow-up of 4.29 years (median, 3.16 yr).A second-look ossiculoplasty was performed in 253 (89%). Recurrent retraction pocket formation occurred in 34 ears (13%). A secondary endaural atticotomy only was required to improve access for debridement in 16 of these 34 ears (5.8% of total ears).Only 7 ears (2.6%) required a revision open cavity mastoidectomy(n = 5) or subtotal petrosectomy (n = 2) for recurrent cholesteatoma. Those undergoing second-look ossiculoplasty demonstrated a small improvement in preoperative versus postoperative air-bone gap (ABG), 28 dB versus 23 dB, respectively.Postoperative infection occurred in 16 patients(5.6%) with 1 patient requiring conversion to open cavity mastoidectomy. CONCLUSION: A CWR tympanomastoidectomy provides excellent intraoperative exposure of the middle ear and mastoid without the long-term disadvantages of a canal wall down mastoidectomy. Long-term follow-up demonstrates that there were only 2.6% failures requiring conversion to an open cavity or subtotal petrosectomy.

Long-term results of canal wall reconstruction tympanomastoidectomy.

OBJECTIVES: This study was designed to evaluate the long-term results using the technique of canal wall reconstruction (CWR) tympanomastoidectomy with mastoid obliteration in the treatment of chronic otitis media with cholesteatoma. STUDY DESIGN: Institutional review board-approved retrospective case review. SETTING: Tertiary referral center. PATIENTS: Retrospective review was performed on consecutive patients undergoing CWR tympanomastoidectomy with mastoid obliteration at a single institution from 1997 to 2011. MAIN OUTCOME MEASURES: Status of tympanic membrane and ear canal anatomy, preoperative and postoperative audiometry, residual cholesteatoma at second look surgery, postoperative complications, recurrence rate, and location. RESULTS: Two hundred eighty-five ears in 273 patients underwent CWR tympanomastoidectomy with a mean age of 35 years with average follow-up of 4.29 years (median, 3.16 yr). A second-look ossiculoplasty was performed in 253 (89%). Recurrent retraction pocket formation occurred in 34 ears (13%). A secondary endaural atticotomy only was required to improve access for debridement in 16 of these 34 ears (5.8% of total ears). Only 7 ears (2.6%) required a revision open cavity mastoidectomy (n = 5) or subtotal petrosectomy (n = 2) for recurrent cholesteatoma. Those undergoing second-look ossiculoplasty demonstrated a small improvement in preoperative versus postoperative air-bone gap (ABG), 28 dB versus 23 dB, respectively. Postoperative infection occurred in 16 patients (5.6%) with 1 patient requiring conversion to open cavity mastoidectomy. CONCLUSION: A CWR tympanomastoidectomy provides excellent intraoperative exposure of the middle ear and mastoid without the long-term disadvantages of a canal wall down mastoidectomy. Long-term follow-up demonstrates that there were only 2.6% failures requiring conversion to an open cavity or subtotal petrosectomy. LEVEL OF EVIDENCE: 4.

Surgical infection prophylaxis for left ventricular assist device implantation.

BACKGROUND: Antimicrobial prophylaxis is commonly administered to patients undergoing left ventricular assist device (LVAD) surgeries to prevent infectious complications. However, optimal surgical infection prophylaxis (SIP) for LVAD surgeries is not well defined. METHODS: We conducted an electronic survey to characterize LVAD SIP used at different centers performing LVAD implantation. RESULTS: Responses were received from 23 of 85 centers (27%). Of 21 centers that provided usable data about their LVAD SIP regimens for nonpenicillin allergic patients, 42.9% reported using a four-drug regimen (three antibiotics plus fluconazole), 23.8% reported using a three-drug regimen (three antibiotics or two antibiotics plus fluconazole), 23.8% reported using a regimen of two antibiotics, and 9.5% reported using vancomycin alone. A similar pattern was observed among SIP regimens for penicillin-allergic patients. Criteria for discontinuation of SIP and use of decolonization strategies also varied widely across centers. CONCLUSIONS: Our results demonstrate wide variability in LVAD SIP regimens and underscore the lack of consensus regarding best practice.

Amiodarone for atrial fibrillation following cardiac surgery: development of clinical practice guidelines at a university hospital.

Atrial fibrillation (AF) usually develops within the first 72 h following cardiac surgery, and is often self-limiting. Within 48 h of acute onset of symptoms, approximately 50% of patients spontaneously convert to normal sinus rhythm. Thus, the relative risks and benefits of therapy must be carefully considered. The etiology of AF following cardiac surgery is similar to that in non-surgical patients except that pericardial inflammation and increased adrenergic tone play an increasingly important role. Further, AF after surgery may be associated with transient risk factors that resolve as the patient moves out from surgery, and the condition is less likely to recur compared to AF arising in other circumstances. Immediate heart rate control is important in preventing ischemia, tachycardia-induced cardiomyopathy, and left ventricular dilatation. At our institution, amiodarone is frequently used as a first-line drug for treating AF after cardiac surgery. Inconsistent prescribing practices, variable dosage regimens, and a lack of consensus regarding the appropriate use of amiodarone prompted the need for developing practice guidelines. Multidisciplinary collaboration between the departments of cardiac surgery, pharmacy, and anesthesiology led to the development of a protocol for postoperative AF. We review the clinical evidence from published trials and discuss our guidelines, defining amiodarone use for AF in the cardiac surgery setting.