Speech and swallowing outcomes after laryngectomy for the dysfunctional irradiated larynx.

PURPOSE: To characterize outcomes of total laryngectomy for the dysfunctional larynx after radiation. METHODS: Retrospective case series of all subjects who underwent total laryngectomy for the irradiated dysfunctional larynx between 2000 and 2018 at an NCI-designated comprehensive cancer center at a single tertiary care academic medical center. Main outcomes included enteral tube feeding dependency, functional tracheoesophageal speech, and number and timing of postoperative pharyngeal dilations. RESULTS: Median time from radiation to laryngectomy was 2.8 years (range 0.5-27 years). Functional outcomes were analyzed for the 32 patients with 1-year follow-up. Preoperatively, 81% required at least partial enteral tube feeding, as compared to 34% 1-year postoperatively (p = 0.0003). At 1 year, 81% had achieved functional tracheoesophageal speech, which was associated with cricopharyngeal myotomy (p = 0.04, HR 0.04, 95% CI 0.002-0.949). There were 34% of subjects who required at least one pharyngeal dilation for stricture by 1 year postoperatively. Over half (60%) of the cohort were dilated over the study period. CONCLUSIONS: Laryngectomy for the dysfunctional larynx improves speech and swallowing outcomes in many patients. Cricopharyngeal myotomy is associated with improved postoperative voice. While the need for enteral feeding is decreased, persistent postoperative swallowing dysfunction is common. Careful patient selection and education regarding functional expectations are paramount.

Predictors and Prevalence of Nodal Disease in Salvage Oropharyngectomy.

BACKGROUND: Patients with recurrent oropharyngeal cancer often require extensive salvage surgery. For patients with clinically N0 necks, the indication for concurrent neck dissection remains unclear. This study aimed to determine predictors, prevalence, and distribution of nodal disease in patients treated with salvage oropharyngectomy. METHODS: In a case series with data collection at a single tertiary academic National Cancer Institute (NCI)-designated comprehensive cancer center, this study analyzed patients treated with prior radiation or chemoradiation who had persistent, recurrent, or second primary squamous cell carcinoma of the oropharynx requiring oropharyngeal resection between 1998 and 2017 (n = 95). Clinical and oncologic characteristics and treatment outcomes were collected, and statistical analyses were performed. RESULTS: The overall rate of nodal positivity was 21% (24/95), and the rate of occult nodal disease was 6% (4/65). Ipsilateral and contralateral level 2 were the most common areas harboring positive nodes. Bivariate analysis showed female sex (p = 0.01), initial overall stage (p = 0.02), and N status (p = 0.03), as well as recurrent overall and T stage (p = 0.05) to be predictors of nodal disease. In the multivariate analysis, recurrent T stage continued to be significantly predictive of pathologic nodal disease. Both computed tomography (CT) and positron emission tomography-CT were moderately accurate in predicting nodal disease in the salvage setting (area under the curve, 0.79 and 0.80, respectively). CONCLUSION: Occult nodal disease is observed in few patients undergoing salvage oropharyngeal resection. This study identified factors predictive of nodal disease in patients undergoing salvage oropharyngectomy and appropriate diagnostic tests in this setting.

From VA Larynx to the future of chemoselection: Defining the role of induction chemotherapy in larynx cancer.

Organ preservation protocols utilizing induction chemotherapy as a selection agent have played a critical role in the treatment of advanced laryngeal squamous cell carcinoma (LSCC). The selection of patients who will have a good response to chemoradiation allows for organ preservation in a significant group of patients and minimizes the rate of surgical salvage. While there remains debate regarding its utility when compared to surgery or other organ preservation regimens, the data does suggest an important role for induction chemotherapy in LSCC. In addition, there are continued opportunities to identify pretreatment biomarkers for induction chemotherapy, whether genetic, epigenetic or cellular, that could predict response to treatment and select patients to therapy (whether organ preservation or surgery). As our understanding of the biology of larynx cancer advances, induction paradigms have utility for the development and adoption of novel agents and therapeutics. The background of induction chemotherapy as a selection agent and future directions of this approach are discussed.

CMF (cyclophosphamide, methotrexate, 5-fluorouracil) versus cnf (cyclophosphamide, mitoxantrone, 5-fluorouracil) as adjuvant chemotherapy for stage II lymph-node positive breast cancer: a phase III randomized multicenter study.

A multicenter phase III randomized study compared the efficacies of two adjuvant polychemotherapeutic regimens in 145 patients with stage II node-positive breast cancer. The standard chemotherapy combination, CMF (cyclophosphamide, methotrexate, 5-fluorouracil), was administered to 77 women. The experimental protocol, CNF (cyclophosphamide, mitoxantrone, 5-FU), in which mitoxantrone (Novantrone) replaced methotrexate, was given to 68 patients. Follow-up of the 145 patients by six participating hospitals showed no statistically significant difference (p = 0.6) between the two treatment regimens during a median follow-up of 4.5 years in terms of overall survival. There was, however, a significant advantage (p = 0.04) in the disease-free survival for those receiving mitoxantrone (mean survival 4.4 years for CNF versus 2.7 years for CMF). Toxic side effects associated with CNF (particularly alopecia and myelotoxicity) were relatively more frequent but acceptable and did not lead to dose reduction. In light of its association with improved disease-free survival in this study, larger studies should be undertaken on the role of mitoxantrone as adjuvant treatment in stage II breast cancer.

Enhanced antibody response in cattle against Leptospira hardjo by intradermal vaccination.

A commercial killed Leptospira hardjo vaccine (with adjuvant) and non-adjuvanted preparation of the same vaccine were used in comparison of the effectiveness of the intradermal (i.d.) and subcutaneous (s.c.) routes for these vaccines. The tests were conducted in 50 females aged 6-14 months. After the first vaccination, both types of vaccine elicited a very poor antibody response by both routes of vaccination. However, after booster vaccination, the commercial vaccine (with adjuvant) elicited a remarkable immune response which was twice as high by i.d. compared with s.c. vaccination. No local or general adverse reactions were observed after i.d. vaccination with the adjuvanted commercial vaccine (potassium aluminium sulphate).

Reporting on QI efforts for internal and external customers.

BACKGROUND: In April 1993 the Methodist Hospital of St Louis Park, Minnesota, released its first internal quality report on outcomes and quality improvement (QI) initiatives. When a local television news reporter mentioned the report in a segment on health care quality, public interest led the hospital to launch an annual series of external quality reports in addition to its internal quality reports. When the eight-page external report was first released in 1994, consumer response was weak, but the report generated a strong response from the mass media, trade publications, the business community, and other health care organizations nationwide. DATA COLLECTION AND USE: Data on sentinel events and outcomes analysis of a variety of clinical and administrative functions have assisted in identifying opportunities for improvement. For example, the hospital monitors the five-year survival rate for patients with myocardial infarction. With the adoption of treatment with streptokinase, data indicated frequent hypotension. Increase of infusion from 30 to 60 minutes led to a decrease in hypotension. THE REPORTS: The external report included, in shorter and simpler form, almost all the sections in the internal report, such as QI activities (teams, training, critical paths), clinical outcome measures, community health, patient satisfaction, value, and accreditation. The indicators included in the external report were selected to minimize potential misinterpretation by public audiences. CONCLUSIONS: By increasing the visibility of QI within the hospital, the internal quality reports have helped generate further QI activity, and the external report augmented further positive publicity among the local health care press. The reports are proven effective tools for communicating the hospital's ability to sustain and improve the quality of its services over time.

A lactogenic-immune-deficiency-syndrome in cows: unexplained phenomenon.

The majority of adult cows in a certain dairy herd, were found to have very low levels of immunoglobulins (Igs) in their colostrum. This phenomenon was defined by us as Lactogenic-Immune-Deficiency-Syndrome (LIDS). The mean IgG levels were 44.5 and 57.2 mg ml-1 respectively (on two different occasions) as compared to that of a control group which was 103.4 mg ml-1. The levels of Igs in the colostra of heifers from the same herd were found to be higher than those of adult cows. The degree of LIDS was found to be closely related to the age of cows in the herd. The low levels of Igs in the colostra were not directly linked to their concentrations in the sera of the affected cows. The relatively low amount of IgA in the affected colostra suggests that the local production in the lymph tissue associated with the mammary glands is impaired as well. In order to investigate the etiology of the phenomenon, tests were carried out to reveal whether bovine leucosis virus (BLV) infection or immune complexes were involved in the pathogenesis of LIDS. The results were negative. The etiology of LIDS remains for the time being unknown.

Does 360 ml of apple juice ingested before elective surgery worsen gastric volume and acidity in patients given acid aspiration prophylaxis?

STUDY OBJECTIVE: To evaluate whether 360 ml of oral clear liquids consumed within 4 hours of elective surgery worsens gastric volume and acidity in patients given acid aspiration prophylaxis. DESIGN: Randomized, unblinded study. SETTING: Main operating room at a U.S. military hospital. PATIENTS: Eighty-three adult inpatients scheduled to receive general anesthesia for elective surgery. INTERVENTIONS: Nineteen patients (Group 1) were given 150 mg of oral ranitidine (two doses), 10 mg of metoclopramide, and 360 ml of apple juice 3 hours before the scheduled start of surgery. Thirty-four patients (Group 2) fasted before surgery but received acid aspiration prophylaxis identical to that given to Group 1. Twenty-three additional patients (Group 3) received no oral fluids or acid aspiration prophylaxis before surgery. MEASUREMENTS AND MAIN RESULTS: The residual gastric volume (RGV) and the pH of Group 1 patients were compared with measurements obtained in the two groups of patients who fasted. RGV measurements in Group 1 (14 +/- 3 ml) were similar to those in Group 2 (11 +/- 2 ml) and were significantly less than (p less than 0.05) those in Group 3 (26 +/- 4 ml). Gastric pH was significantly higher (p less than 0.001) in Group 1 (5.16 +/- 0.69) and Group 2 (5.78 +/- 0.43) than in Group 3 (1.97 +/- 0.27). CONCLUSIONS: Three hundred and sixty ml of apple juice consumed within 4 hours of elective surgery by patients given ranitidine and metoclopramide did not worsen gastric volume and acidity.

Evaluation of some benzenesulphonylhydrazones of aryl aldehydes and ketones as antiepileptic agents.

Benzaldehyde benzenesulphonamide was shown to have comparable anticonvulsant activity to valproic acid in the maximal electroshock seizure test. Molecular modification of this compound was developed principally to explore whether a correlation between planarity and anticonvulsant activity could be discerned. The interplanar angle (theta) between an aryl ring and the adjacent azomethine group of some representative compounds was measured by electronic absorption spectroscopy. However, the structural alterations of benzaldehyde benzenesulphonamide undertaken in this work led to compounds bereft of anticonvulsant activity.