The Body Mass Index Paradox in Head and Neck Cancer: A Systematic Review and Meta-Analysis.

The body mass index (BMI) paradox describes that among patients with certain cancers, higher pretreatment BMI may be associated with improved survival. We examine the impact of BMI on overall survival (OS) in head and neck squamous cell carcinoma (HNSCC) patients. A literature search was performed, and articles using hazard ratios to describe the prognostic impact of BMI on OS in HNSCC were included. Random-effects DerSimonian and Laird methods were employed for meta-analysis. Meta-analysis of OS indicated a lower hazards of death in the overweight (BMI: 25 kg/m2-30 kg/m2) compared to the normal weight (BMI: 18.5 kg/m2-25 kg/m2). This protective relationship loses significance when BMI exceeds 30 kg/m2. Underweight patients (BMI < 18.5 kg/m2) demonstrate higher hazards of death compared to normal weight patients. Compared to HNSCC patients with normal weight, being overweight up to a BMI of 30 kg/m2 is a positive predictor of OS, while being underweight confers a prognostic disadvantage. Further studies are needed to determine the mechanisms by which increased body mass influences survival outcomes in HNSCC.

Is mandibular osteomyelitis a sequela of SSRI-induced dental implant failure? A systematic review & case report.

BACKGROUND: To determine if the utilization of selective serotonin reuptake inhibitors (SSRIs) increases the risk of osteomyelitis as a sequela of dental implant failure. We also report the case of a patient on long-term SSRIs who presented with dental implant failure and subsequently developed mandibular osteomyelitis. METHODS: We performed a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) in PubMed, Google Scholar and Embase, for all records pertaining to SSRIs, dental implants, and mandibular osteomyelitis. RESULTS: SSRIs are associated with increased risk of dental implant failure, and our results suggest that they may be independently associated with mandibular osteomyelitis in the setting of implant failure. Though there was no evidence of mandibular osteomyelitis specifically following SSRI-related dental implant failure, there were a few case reports on osteomyelitis resulting from failed dental implant osseointegration. CONCLUSIONS: In the context of long-term SSRI utilization, our findings suggest that osteomyelitis should be considered in the differential diagnosis of patients with recent dental implant placement or failure.

Metastatic Meningioma of the Neck: A Case Report and Systematic Review.

BACKGROUND: Although meningiomas are the most common central nervous system neoplasms, extracranial metastases are exceedingly rare. There are even fewer reports of metastatic meningiomas to the neck. METHODS: We described a patient with multiply recurrent orbital meningioma with metastasis to the neck found incidentally during neck exploration for composite resection and free tissue reconstruction. We performed a systematic review for all records pertaining to metastatic meningiomas to the cervical regions. RESULTS: We found 9 previous reports of cervical metastatic meningiomas. Almost all cases underwent extensive local resection. There was no evidence of an association between the histological grade of the tumor and risk of metastasis to the neck. Cervical lymph node dissemination is more common in patients presenting after previous primary tumor resection. CONCLUSIONS: In the context of a neck mass, our findings suggest that metastatic meningioma should be included in the differential diagnosis, especially in patients with previous resections.

Anterolateral thigh osteomyocutaneous flap in head and neck: Lessons learned.

BACKGROUND: Concerns regarding iatrogenic femur fracture may deter adoption of the anterolateral thigh osteomyocutaneous (ALTO) flap as an alternative reconstructive technique for large composite defects of the head and neck. We describe the evolution of our experience with this flap and the lessons learned in femur management. METHODS: Records from a prospective database (July 2009-January 2020) were reviewed to identify patients with composite osseous free tissue reconstructions. Venous thromboembolic events (VTE), femur fracture, estimated blood loss (EBL), procedure time, blood transfusions, and length of stay (days) were compared for ALTO flaps prior to and after the adoption of intramedullary fixation protocol. RESULTS: ALTO represented 10.5% (n = 23) of total osseus (n = 219) flaps. For large composite reconstructions with either ALTO flap, double flap (n = 2), or subscapular mega flaps (n = 14), ALTO flaps were most frequently used (59%, n = 23/59). There were no differences in operative time prior to and after implementation of prophylactic fixation [median (range): 5.4 (1.7-19.2) vs. 5.8 (1.7-15.0), p = .574]. Additionally, there were no differences in VTE, femur fracture, EBL, blood transfusion, or length of stay (p > .05) with adoption of prophylactic intramedullary fixation. CONCLUSIONS: The ALTO flap represents a useful tool to consider in the armamentarium of reconstructive options for large through and through defects of the head and neck. In our experience, the ALTO flap is a reasonable alternative to subscapular or double flap reconstructions and especially in the setting of unusable fibular flaps or when bone need exceeds that available from the scapula.

Mucosal-sparing posterior septectomy for endoscopic endonasal approach to the craniocervical junction.

Recent technological advances and developments in surgical technique have made the craniocervical junction (CCJ) accessible through the transnasal surgical corridor. Endoscopic endonasal transclival and transodontoid approaches have been previously described in the literature. Traditionally, these approaches entail a posterior bony and mucosal septectomy. This posterior bony and mucosal septectomy can compromise the integrity of the posterior septum and damage the vascularized pedicled nasoseptal flap (PNSF), a robust reconstructive option. With the possibility of an intraoperative cerebrospinal fluid (CSF) leak and the reported success of the PNSF for repair of these defects, preserving the integrity of the PNSF is beneficial during the endoscopic endonasal approach to the CCJ. Here, we present a new variation which preserves the mucosal integrity of the posterior nasal septum and PNSF. This mucosal-sparing variation of the traditional endoscopic endonasal transclival and transodontoid approaches allows for the preservation of posterior mucosal nasoseptal integrity, and salvages a reconstructive option for future usage. This is accomplished at no expense to visualization, surgical access, or maneuverability.

Squamous cell carcinoma of the parotid gland: a population-based analysis of 2545 cases.

PURPOSE: Squamous cell carcinoma (SCC) of the parotid gland is an uncommon tumor, which generally affects older patients. In this study, we explore various aspects of this entity using a national population-based database. METHODS: The Surveillance, Epidemiology, and End Results (SEER) registry was used to extract data on frequency, incidence, and disease-specific survival (DSS) from 1973 to 2009. Variables analyzed included age, gender, race, histologic grade, stage and treatment. Cox proportional hazards analysis was conducted. RESULTS: A total of 2545 cases were identified. Parotid SCC was most common in males (79.8%), whites (92.9%), and patients aged ≥75 years (51.4%). Incidence increased slightly over the past three decades (annual percent change 1.90%, p<0.05). Overall 5-year DSS was 54.4%. Statistically significant poor prognostic factors included black race, age ≥75 years, tumor T3 or greater, and higher clinical stage at diagnosis. Elective neck dissection (END) in patients staged N0 was associated with higher DSS (78.3% versus 51.1%, p<0.0001). The omission of END was associated with a three-fold greater hazard of death (hazard ratio 3.19, 95% confidence interval 1.53-7.26, p=0.0016), regardless of whether or not radiotherapy was given. CONCLUSION: Parotid SCC is uncommon, and data on treatment decisions are limited. Our study profiles the demographic, clinicopathologic, incidence, and survival features of this entity. Perhaps most notably, our results support the practice of END of the N0 neck.

Beyond the operating room: a look at legal liability in body contouring procedures.

BACKGROUND: Malpractice claims affect the cost and quality of health care. OBJECTIVE: In this study, the authors examine legal litigation following body contouring surgery and identify factors influencing malpractice litigation outcomes. METHODS: The Westlaw legal database was searched for jury verdict and settlement reports related to body contouring procedures and medical malpractice. Cases included for analysis were examined for year of report, geographic location, patient demographics, procedure performed, alleged injury, causes of action, verdict, and indemnity payments. RESULTS: Of 113 cases, the most common injuries sustained were disfigurement (33.6%) and the necessitation of a revision procedure (33.6%). The most common cause of action cited was negligence (84.1%). Median plaintiff ages differed significantly (P = .003) between cases favoring the defendant (44.5 years) and those favoring the plaintiff (36 years). Of the alleged injuries, those cases citing an iatrogenic injury were 2.5 times more likely to result in either damages awarded or settlement (relative risk [RR], 2.5; 95% confidence interval [CI], 1.66-3.80). Cases that cited disfigurement were 87% more likely to result in damages awarded to the plaintiff (RR, 1.87; 95% CI, 1.08-3.26). CONCLUSIONS: Based on this study of body contouring litigation, younger plaintiff age and iatrogenic injury strongly favored plaintiffs in either awarded damages or a settlement. Disfigurement favored plaintiffs only in awarded damages. Our study emphasizes the need for adequate communication with the patient explaining realistic aesthetic results and risks of the procedure. In addition, iatrogenic organ injury must be handled expeditiously. Incorporating these recommendations into clinical practice may promote an improved physician-patient relationship while reducing litigatious health care costs.

A look inside the courtroom: an analysis of 292 cosmetic breast surgery medical malpractice cases.

BACKGROUND: Malpractice claims affect the cost and quality of health care. OBJECTIVE: The authors examine litigation in cosmetic breast surgery and identify factors influencing malpractice litigation outcomes. METHODS: The Westlaw database was searched for jury verdict and settlement reports related to medical malpractice and cosmetic breast surgeries. Cases included for analysis were examined for year, geographic location, patient demographics, procedure performed, alleged injury, causes of action, verdict, and indemnity payments. RESULTS: Of 292 cases, the most common injury sustained was disfigurement (53.1%). Negligent misrepresentation had a 98% greater chance of resolution in favor of the plaintiff (relative risk [RR], 1.98; 95% confidence interval [CI], 1.41-2.79), and fraud had a 92% greater chance of disposition in favor of the plaintiff (RR, 1.92; 95% CI, 1.32-2.80). The most common causes of action cited were negligence (88.7%) and lack of informed consent (43.8%). One hundred sixty-nine (58.3%) cases resulted in favor of the defendant and 121 (41.7%) cases were disposed in favor of the plaintiff; 97 (33.4%) cases resulted in damages awarded and 24 (8.3%) cases resulted in settlement. No significant difference was found between the medians of indemnity payments awarded to plaintiffs ($245 000) and settlements ($300 000). CONCLUSIONS: Based on this study, negligent or intentional misrepresentation strongly favors plaintiffs in either awarded damages or settlements in cases of cosmetic breast surgery litigation. This study emphasizes that transparency and adequate communication are at the crux of the physician-patient relationship and are tools by which plastic surgeons may reduce the frequency of litigations, thereby containing health care costs at a minimum.

Sentinel lymph node biopsy for head and neck malignancies utilizing simultaneous radioisotope gamma probe and indocyanine green fluorescence navigation.

We depict an innovative surgical approach for sentinel lymph node biopsy (SLNB) in head and neck malignancies that utilizes both near-infrared (NIR) imaging with indocyanine green (ICG) dye and hand-held gamma probe intraoperatively to isolate and excise SLNs. Twenty-one patients presented to our institution with cutaneous melanoma, cutaneous squamous cell carcinoma (SCC), and oral cavity SCC tumors that met criteria for SLNB based on tumor depth and histology. The video offers a step-by-step approach for this technique along with descriptions of recommended equipment. Among 21 patients, two patients had positive SLNs on final pathology. One patient developed a local recurrence over an average of 16.2 months of follow-up (SD = 15.6). SLNB with ICG and radionucleotide co-localization may enhance the identification of sentinel nodes without compromising outcomes in the hands of surgeons well-versed in the technique.

CyberKnife Stereotactic Radiosurgery for Growing Vestibular Schwannoma: Longitudinal Tumor Control, Hearing Outcomes, and Predicting Post-Treatment Hearing Status.

OBJECTIVES: (1) To determine tumor control rates for treating growing vestibular schwannoma (VS) with CyberKnife stereotactic radiosurgery (CK SRS); (2) to determine hearing outcomes after CK SRS; (3) to propose a set of variables that could be used to predict hearing outcomes for patients receiving CK SRS for VS. STUDY DESIGN: Retrospective case series review. METHODS: 127 patients who received CK SRS for radiographically documented growing VS were reviewed. Tumors were monitored for post-procedure growth radiographically with linear measurements and three-dimensional segmental volumetric analysis (3D-SVA). Hearing outcomes were reviewed for 109 patients. Cox proportional hazard modeling was used to identify variables correlated with hearing outcomes. RESULTS: Tumor control rate was 94.5% for treating VS with CK SRS. Hearing outcomes were categorized using the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) classification system. As of their last available audiogram, 33.3% of patients with pre-treatment class A and 26.9% of patients with class B retained their hearing in that class. 15.3% of patients starting with class A or B with extended follow-up (>60 months), maintained hearing within this same grouping. Our final model proposed to predict hearing outcomes included age, fundal cap distance (FCD), tumor volume, and maximum radiation dose to the cochlea; however, FCD was the only statistically significant variable. CONCLUSION: CK SRS is an effective treatment for control of VS. Hearing preservation by class was achieved in a third of patients. Finally, FCD was found to be protective against hearing loss. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:S1-S12, 2024.

Screening for Financial Toxicity Among Patients With Cancer: A Systematic Review.

OBJECTIVE: Despite the pervasiveness and adverse impacts of financial toxicity (FT) in cancer care, there are no definitive measures for FT screening that have been widely integrated into clinical practice. The aim of this review is to evaluate current methods of assessing FT among patients with cancer and confirm factors associated with higher risk of FT. METHODS: A systematic review was performed according to PRISMA guidelines. We included peer-reviewed studies that cross-sectionally, longitudinally, or prospectively measured the self-reported financial impact of patients undergoing cancer care in the United States. RESULTS: Out of 1,085 identified studies, 51 met final inclusion criteria. Outcomes evaluated included FT measures or tools, time and setting of screening, FT prevalence, and sociodemographic or clinical patient-level associated factors. Our findings demonstrate that there is wide variability in FT screening practices including in the timing (diagnosis versus treatment versus survivorship), setting (clinic-based, online, telephone or mail), tools used (21 unique tools, 7 previously validated), and interpretations of screening results (varying FT score cutoffs defining high versus low FT). Younger age, lower income, lower education, non-White race, employment status change, advanced cancer stage, and systemic or radiation therapy were among factors associated with worse FT across the studies. DISCUSSION: FT screening remains heterogenous within the United States. With the ever-escalating cost of cancer care, and the strong association between FT and poor patient outcomes, universal and routine FT screening is imperative in cancer care. Further research and multifaceted interventions identifying best practices for FT screening are needed.

Increasing radiation therapy and lower survival for human papillomavirus-related oropharynx cancer associated with a shift to community cancer center care.

BACKGROUND: Studies have shown lower overall survival for patients with head and neck cancer treated at low-volume or community cancer centers. As the incidence of human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma steadily rises in the United States, we hypothesized that a greater proportion of patients with HPV-related oropharyngeal squamous cell carcinoma is being treated at community cancer centers, with a shift toward primary nonsurgical treatment. METHODS: This cohort study included patients from the US National Cancer Database who received a diagnosis of HPV-related oropharyngeal squamous cell carcinoma from 2010 to 2019 and underwent treatment at a community cancer center or academic cancer center. The proportion of patients with HPV-related oropharyngeal squamous cell carcinoma treated at community cancer centers and receiving primary nonsurgical treatment was analyzed over time. Four-year overall survival was compared between community cancer centers and academic cancer centers. RESULTS: The majority (67.4%) of 20 298 patients were treated at an academic cancer center, yet the proportion of patients treated at community cancer centers increased by 10% from 2010 to 2019 (P < .01 for trend). The proportion of patients undergoing primary nonsurgical treatment increased from 62.1% to 73.7% from 2010 to 2019 (P < .01 for trend), and patients were statistically significantly more likely to undergo nonsurgical treatment at community cancer centers than at academic cancer centers (adjusted odds ratio = 1.20, 95% confidence interval = 1.18 to 1.22). Treatment at community cancer centers was associated with worse survival overall (adjusted hazard ratio = 1.19, 95% confidence interval = 1.09 to 1.31), specifically for patients receiving primary nonsurgical treatment (adjusted hazard ratio = 1.22, 95% confidence interval = 1.11 to 1.34). CONCLUSIONS: Treatment of HPV-related oropharyngeal squamous cell carcinoma has recently shifted to community cancer centers, with an increase in the proportion of nonsurgical treatment and worse overall survival at these centers compared with academic cancer centers. Concentration of care for HPV-related oropharyngeal squamous cell carcinoma at academic cancer centers and dedicated head and neck cancer centers may increase access to all available treatment modalities and improve survival.

Degrees of Inflammation in the Treatment of Subglottic Stenosis in a Rabbit Model: Histopathological Assessment of a Novel Bioabsorbable Ultra-high Ductility Magnesium Alloy Stent.

OBJECTIVE: Utilizing a novel histopathological scoring system and subglottic stenosis (SGS) rabbit model, we aimed to compare degrees of inflammation and severity of narrowing in the subglottis between two minimally invasive therapeutic modalities: endoscopic balloon dilation (EBD) alone versus EBD with placement of a bioabsorbable ultra-high ductility magnesium (UHD-Mg) alloy stent. METHODS: SGS was induced endoscopically via microsuspension laryngoscopy in 23 New Zealand white rabbits. The control group (n = 11) underwent EBD alone, the study arm (n = 12) underwent EBD with implantation of bioabsorbable UHD-Mg alloy stents. Rabbits were euthanized at 2-, 3-, and 6-weeks after SGS induction, coinciding with wound healing stages. Using Optical Coherence Tomography (OCT), cross-sectional areas of airways were compared to calculate the mean percentage of intraluminal area at sequential time points. A novel histopathological scoring system was used to analyze frozen sections of laryngotracheal complexes. The degree of inflammation was quantified by scoring changes in inflammatory cell infiltration, epithelial ulceration/metaplasia, subepithelial edema/fibrosis, and capillary number/dilation. Univariate analysis was utilized to analyze these markers. RESULTS: We found rabbits implanted with the bioabsorbable UHD-Mg alloy stent had statistically significantly higher scores in categories of hyperplastic change (stents vs controls: 1.48 vs 0.46 p < 0.001), squamous metaplasia (22 vs 5 p < 0.001), and neutrophils/fibrin in lumen (31 vs 8, p < 0.001). Rabbits who received EBD alone had higher scores of subepithelial edema and fibrosis (2.70 vs 3.49, p < 0.0256). The stented rabbits demonstrated significantly increased mean percent stenosis by intraluminal mean area compared to controls at 2 weeks (88.56 vs 58.98, p = 0.032), however at all other time points there was no significant difference between intraluminal subglottic stenosis by mean percent stenosis area. DISCUSSION: Rabbits with SGS treated with UHD-Mg alloy stents demonstrated histopathologic findings suggestive of lower levels of tracheal fibrosis. This could indicate a reduced tendency towards the development of stenosis when compared to EBD alone. There was not a difference in luminal size between stent and non-stented rabbits at the six-week end point. Histologically, however, overall the use of bioabsorbable UHD-Mg alloy stenting elicited a greater tissue response at the level of the superficial mucosa rather than fibrosis of the lamina propria seen in the stented rabbits. This suggests more favorable healing and less of a tendency towards fibrosis and stenosis even though there may not be a benefit from a luminal size standpoint during this early healing period. Compared to known complications of currently available non-bioabsorbable metal or silicone-based stents, this proof-of-concept investigation highlights the potential use of a novel biodegradable UHD-Mg stent as a therapeutic modality for pediatric SGS.

Effects of socioeconomic status on enrollment in clinical trials for cancer: A systematic review.

BACKGROUND: To achieve equitable access to cancer clinical trials (CCTs), patients must overcome structural, clinical, and attitudinal barriers to trial enrollment. The goal of this systematic review was to study the relationship between socioeconomic status (SES), assessed either by direct or proxy measures, and CCT enrollment. METHODS: The review team and medical librarian developed search strategies for each database to identify studies for this systematic review, which was conducted according to PRISMA guidelines. Inclusion criteria were as follows: studies published in relevant scientific journals between January 2000 and July 2022, primary sources, English literature, and studies conducted in the US. Sixteen studies fulfilled the inclusion criteria and were reviewed. The risk of bias assessment was conducted independently by two reviewers using the Newcastle Ottawa scale. RESULTS: The initial search yielded 4070 citations, and 16 studies were included in our review. Four of the studies included used patient reported annual income as a measure of SES, while the remaining 12 studies used patient zip code as a proxy measurement of SES. Consistent with our hypothesis, 13 studies showed a positive association between high SES (patient-reported or proxy measurement) and CCT enrollment. Two studies showed a negative association, and one study showed no relationship. CONCLUSIONS: The existing literature suggests that low SES is associated with lower participation in CCT. The small number of studies identified on this topic highlights the need for additional research on SES and other barriers to CCT participation.

Autonomous System for Tumor Resection (ASTR) - Dual-Arm Robotic Midline Partial Glossectomy.

Head and neck cancers are the seventh most common cancers worldwide, with squamous cell carcinoma being the most prevalent histologic subtype. Surgical resection is a primary treatment modality for many patients with head and neck squamous cell carcinoma, and accurately identifying tumor boundaries and ensuring sufficient resection margins are critical for optimizing oncologic outcomes. This study presents an innovative autonomous system for tumor resection (ASTR) and conducts a feasibility study by performing supervised autonomous midline partial glossectomy for pseudotumor with millimeter accuracy. The proposed ASTR system consists of a dual-camera vision system, an electrosurgical instrument, a newly developed vacuum grasping instrument, two 6-DOF manipulators, and a novel autonomous control system. The letter introduces an ontology-based research framework for creating and implementing a complex autonomous surgical workflow, using the glossectomy as a case study. Porcine tongue tissues are used in this study, and marked using color inks and near-infrared fluorescent (NIRF) markers to indicate the pseudotumor. ASTR actively monitors the NIRF markers and gathers spatial and color data from the samples, enabling planning and execution of robot trajectories in accordance with the proposed glossectomy workflow. The system successfully performs six consecutive supervised autonomous pseudotumor resections on porcine specimens. The average surface and depth resection errors measure 0.73±0.60 mm and 1.89±0.54 mm, respectively, with no positive tumor margins detected in any of the six resections. The resection accuracy is demonstrated to be on par with manual pseudotumor glossectomy performed by an experienced otolaryngologist.

Readability of Patient Education Materials in Head and Neck Cancer: A Systematic Review.

Importance: Patient education materials (PEMs) can promote patient engagement, satisfaction, and treatment adherence. The American Medical Association recommends that PEMs be developed for a sixth-grade or lower reading level. Health literacy (HL) refers to an individual's ability to seek, understand, and use health information to make appropriate decisions regarding their health. Patients with suboptimal HL may not be able to understand or act on health information and are at risk for adverse health outcomes. Objective: To assess the readability of PEMs on head and neck cancer (HNC) and to evaluate HL among patients with HNC. Evidence Review: A systematic review of the literature was performed by searching Cochrane, PubMed, and Scopus for peer-reviewed studies published from 1995 to 2024 using the keywords head and neck cancer, readability, health literacy, and related synonyms. Full-text studies in English that evaluated readability and/or HL measures were included. Readability assessments included the Flesch-Kincaid Grade Level (FKGL grade, 0-20, with higher grades indicating greater reading difficulty) and Flesch Reading Ease (FRE score, 1-100, with higher scores indicating easier readability), among others. Reviews, conference materials, opinion letters, and guidelines were excluded. Study quality was assessed using the Appraisal Tool for Cross-Sectional Studies. Findings: Of the 3235 studies identified, 17 studies assessing the readability of 1124 HNC PEMs produced by professional societies, hospitals, and others were included. The mean FKGL grade ranged from 8.8 to 14.8; none of the studies reported a mean FKGL of grade 6 or lower. Eight studies assessed HL and found inadequate HL prevalence ranging from 11.9% to 47.0%. Conclusions and Relevance: These findings indicate that more than one-third of patients with HNC demonstrate inadequate HL, yet none of the PEMs assessed were developed for a sixth grade or lower reading level, as recommended by the American Medical Association. This incongruence highlights the need to address the readability of HNC PEMs to improve patient understanding of the disease and to mitigate potential barriers to shared decision-making for patients with HNC. It is crucial to acknowledge the responsibility of health care professionals to produce and promote more effective PEMs to dismantle the potentially preventable literacy barriers.

Geographic differences in academic promotion practices, fellowship training, and scholarly impact.

PURPOSE: Previous literature described how clinical fellowship training impacts scholarly production among academic otolaryngologists, finding that fellowship-trained practitioners had higher research productivity than their non-fellowship-trained peers, and head and neck (H&N) surgeons and otologists had the highest scholarly impact. In this analysis we investigate whether geographic differences in academic promotion and scholarly impact exist, and whether such differences are associated with emphasis on regional fellowship training patterns. METHODS: The Scopus database was used to determine scholarly impact (as measured by the h-index) of 1109 academic otolaryngologists from 97 departments. Online faculty listings were organized by fellowship training, academic rank, and location. RESULTS: Fellowship-trained practitioners had greater research productivity than non-fellowship-trained otolaryngologists (H=9.5 ± 0.26 SEM vs. 6.5 ± 0.43, p<0.001), a finding that persisted throughout except in the Mountain and East South Central Regions. H&N surgeons and otologists had the highest h-indices. Practitioners in the West had the highest h-index, with differences persisting upon examination of junior faculty. The West (62.1%) and Midwest (60.5%) had the highest proportions of senior faculty. Regional differences in scholarly impact and academic promotion were further noted upon organizing faculty by subspecialty fellowship training. CONCLUSIONS: Geographic differences in academic promotion and scholarly impact exist, most markedly among junior faculty. Practitioners in the West had high impact and were more represented at senior ranks. Upon examination by fellowship training status, fellowship-trained otolaryngologists had higher impact in most, but not all, geographic regions. Regional variations in promotion were noted upon organizing faculty by subspecialty, although association with scholarly impact differs by region.

Role of Coactivator Associated Arginine Methyltransferase 1 (CARM1) in the Regulation of the Biological Function of 1,25-Dihydroxyvitamin D3.

1,25-Dihydroxyvitamin D3 (1,25(OH)2D3), the hormonally active form of vitamin D, activates the nuclear vitamin D receptor (VDR) to mediate the transcription of target genes involved in calcium homeostasis as well as in non-classical 1,25(OH)2D3 actions. In this study, CARM1, an arginine methyltransferase, was found to mediate coactivator synergy in the presence of GRIP1 (a primary coactivator) and to cooperate with G9a, a lysine methyltransferase, in 1,25(OH)2D3 induced transcription of Cyp24a1 (the gene involved in the metabolic inactivation of 1,25(OH)2D3). In mouse proximal renal tubule (MPCT) cells and in mouse kidney, chromatin immunoprecipitation analysis demonstrated that dimethylation of histone H3 at arginine 17, which is mediated by CARM1, occurs at Cyp24a1 vitamin D response elements in a 1,25(OH)2D3 dependent manner. Treatment with TBBD, an inhibitor of CARM1, repressed 1,25(OH)2D3 induced Cyp24a1 expression in MPCT cells, further suggesting that CARM1 is a significant coactivator of 1,25(OH)2D3 induction of renal Cyp24a1 expression. CARM1 was found to act as a repressor of second messenger-mediated induction of the transcription of CYP27B1 (involved in the synthesis of 1,25(OH)2D3), supporting the role of CARM1 as a dual function coregulator. Our findings indicate a key role for CARM1 in the regulation of the biological function of 1,25(OH)2D3.

Prognosis.

Prognosis is defined as the likely outcome or course of a disease and is the result of a complex interplay between patient and tumor factors. Unfortunately, the prognosis of patients with laryngeal cancer has not changed significantly over the past several decades. However, as our understanding of these patient and tumor factors becomes more nuanced and the resulting treatment options become more precise, there is the potential to improve the prognosis for these patients.

CIC-DUX4 Sarcoma Involving the Skull Base: A Rare Presentation and Review of the Literature.

Background CIC-DUX4 sarcoma is a rare, aggressive tumor that is difficult to diagnose. Although it is closely related to Ewing's sarcoma, each is a distinct pathologic entity and both have been previously reported in the skin, lymph nodes, and viscera. We report the first description of CIC-DUX4 involving the posterior cranial fossa and review the distinctive symptomatology, morphology, immunoprofile, and genetic signature that differentiate this rare tumor. Case Report A 32-year-old man presented with an enlarging right lateral neck mass, progressive hoarseness, and orofacial pain. Biopsy revealed a high-grade undifferentiated malignant neoplasm. Imaging demonstrated an 8-cm mass in the right neck extending to the skull base and abutting the carotid sheath, in addition to pulmonary nodules and pelvic lymphadenopathy. Despite initial response to chemotherapy, he experienced disease progression and underwent surgical resection, radical neck dissection, and brachytherapy. Definitive pathologic diagnosis was achieved with next-generation sequencing. Within weeks of treatment, he developed symptoms reflecting progression of disease involving the neck, posterior cranial fossa, and lung. Adjuvant chemotherapy was planned, but the patient succumbed to his disease prior to initiation of further therapy. Conclusion CIC-DUX4 sarcomas are uncommon and can progress rapidly. Diagnosis requires either fluorescence in situ hybridization or next-generation sequencing. Due to its rarity, there is no standard-of-care treatment for this tumor and further investigations are needed to understand disease behavior and develop targeted therapeutic modalities.