'It's a fragile open door'-enhancing COVID-19 vaccination rates in people receiving treatment for substance use disorder.

BACKGROUND: People with substance use disorder are at high risk of harms from COVID-19 infection. Vaccine hesitancy is common in this population and compounds pre-existing barriers to accessing health care. A drug and alcohol service in Sydney, Australia introduced strategies to enhance COVID-19 vaccination in people receiving opioid agonist treatment (OAT). We report vaccination outcomes and staff experiences of this. METHODS: This mixed methods study (i) retrospectively evaluated vaccine uptake in people accessing OAT and (ii) explored perceptions of staff who delivered vaccination interventions through surveys and semi-structured interviews. RESULTS: Of the 984 patients receiving OAT on 9 December 2021, 90.9% had received the first COVID-19 vaccination and 86.7% the second. Australia wide vaccination rates on that date were 93.1% and 88.7% for first and second doses, respectively. Staff commented that having a deep knowledge, understanding and connection with the patient group drove implementation and success of vaccination interventions. This was further supported by staff engagement with the vaccination interventions, and communication and sharing information, both between staff and with patients. CONCLUSION: High rates of COVID-19 vaccination can be achieved in a vulnerable population. Engaged staff providing information and facilitating access to healthcare underpin this success.

A model explaining refugee experiences of the Australian healthcare system: a systematic review of refugee perceptions.

BACKGROUND: Refugees have significant unmet health needs. Delivering services to refugees continues to be problematic in the Australian healthcare system. A systematic review and thematic synthesis of the literature exploring refugee perceptions of the Australian healthcare system was performed. METHODS: Titles and abstracts of 1610 articles published between 2006 and 2019 were screened, and 147 articles were read in full text. Depending on the type of study, articles were appraised using the Modified Critical Appraisal Tool (developed by authors), the Mixed Methods Appraisal Tool, or the JBI Appraisal Checklist for Systematic Reviews. Using QSR NVivo 11, articles were coded into descriptive themes and synthesised into analytical themes. An explanatory model was used to synthesise these findings. Confidence in the review findings were assessed with GRADE-CERQual approach. RESULTS: The final synthesis included 35 articles consisting of one systematic review, 7 mixed methods studies, and 27 qualitative studies. Only one study was from a regional or rural area. A model incorporating aspects of engagement, access, trust, and privacy can be used to explain the experiences of refugees in using the Australian healthcare system. Refugees struggled to engage with health services due to their unfamiliarity with the health system. Information sharing is needed but this is not always delivered effectively, resulting in disempowerment and loss of autonomy. In response, refugees resorted to familiar means, such as family members and their pre-existing cultural knowledge. At times, this perpetuated their unfamiliarity with the broader health system. Access barriers were also encountered. Trust and privacy are pervasive issues that influenced access and engagement. CONCLUSIONS: Refugees face significant barriers in accessing and engaging with healthcare services and often resorted to familiar means to overcome what is unfamiliar. This has implications across all areas of service provision. Health administrators and educators need to consider improving the cultural competency of staff and students. Policymakers need to consider engaging communities and upscale the availability and accessibility of professional language and cultural supports. Research is needed on how these measures can be effectively delivered. There is limited research in remote areas and further evidence is needed in these settings.

Atypical retinal vaso-occlusion with structural and functional resolution.

PURPOSE: The purpose is to report a patient with primary open-angle glaucoma that developed sudden painless unilateral vision loss, a sequential ophthalmoscopic appearance with features of both central retinal artery and later central retinal vein occlusion, and objective visual system dysfunction in the form of a relative afferent pupil defect, who spontaneously recovered vision along with complete resolution of the pupillary defect over several weeks. CASE REPORT: A 50-year-old woman with a long-standing history of glaucoma presented with acute, painless vision loss in one eye, a pallid retina with a cherry red macula, diffuse retinal hemorrhages, and a relative afferent pupil defect. Spectral domain optical coherence tomography and fluorescein angiography were essentially normal with neither retinal edema nor retinal ischemia to account for the visual dysfunction. Over the course of 2 months, the patient regained vision and the relative afferent pupil defect, typically a permanent manifestation of retinal destruction, resolved. CONCLUSIONS: Not all retinal vaso-occlusive phenomena can be completely attributed to a central retinal vein or artery occlusion. In the patient presented, there was no objective diagnostic testing that revealed a cause for the patient's vision loss or relative afferent pupillary defect. This combined with the complete recovery of vision and resolution of the relative afferent pupillary defect underscores a lack of comprehensive understanding of retinal vaso-occlusive disease.

Review of a medical student-run surgery lecture series and skills lab curriculum.

Evidence suggests that early exposure to surgical techniques, surgical knowledge and mentors strongly correlates with students' interest, knowledge and confidence in general surgery as a postgraduate career choice. Preclerkship exposure to surgery and implementation of a formal surgical curriculum is often restricted owing to attending surgeon time commitments and cost limitations. To promote earlier exposure to surgery, a group of senior medical students at McMaster University, Hamilton, Ont., developed and implemented a novel pilot program with a surgical lecture series and a surgical skills laboratory for preclerkship students. This commentary discusses the effectiveness of these initiatives.

Impact of cytomegalovirus on outcomes in acute severe ulcerative colitis: a retrospective observational study.

Background: Concomitant cytomegalovirus (CMV) is highly prevalent in acute severe ulcerative colitis (ASUC) but data for outcomes of CMV positivity in ASUC and the benefit of antiviral therapy remain unclear. Objectives: We aim to determine the impact of CMV positivity, and antiviral therapy, on outcomes such as colectomy-free survival, length of hospital stay and readmission rate, among hospitalized patients with ASUC. Design: This is a retrospective, multicentre study of patients admitted with ASUC. Methods: CMV positivity was diagnosed from blood CMV DNA and inpatient colonic biopsies. Background demographics and disease characteristics, clinical characteristics and outcomes during admission and long-term outcomes were obtained from electronic medical records and compared according to the presence of CMV and the use of antiviral therapy. Results: CMV was detected in 40 (24%) of 167 ASUC admissions. Previous steroid exposure was the only clinical predictor of CMV positivity on multivariate analysis. Outcomes of greater requirement for rescue therapy (60% versus 33%), longer hospital stay (14.3 versus 9.9 days) and higher readmission rates at 3 and 12 months were associated with CMV positivity. No difference was found in the rate of colectomy or colectomy-free survival. Antiviral therapy was not associated with a lower risk of colectomy but did extend the time to colectomy (126 versus 36 days). Conclusion: CMV positivity was associated with worse outcomes of need for rescue therapy, hospital stay and readmissions. Antiviral therapy was not found to reduce the risk of colectomy but did extend the time to colectomy. Further prospective studies will be required to more clearly determine its benefit in patients with concomitant CMV and ASUC.

Cytomegalovirus reactivation in acute severe ulcerative colitis Cytomegalovirus (CMV) is a highly prevalent virus that may result in concominant reactivation in patients with acute severe ulcerative colitis and potentially worsen their outcomes. Our study aims to determine the impact of presence of CMV in patients with acute severe ulcerate colitis requiring hospitalisation and its association with outcomes including risk of surgical resection of colon, length of hospital stay, readmission rate, as well as effect of outcomes amongst those treated with antivirals for CMV. Our results did not find a significant association between detection of CMV on surgical risk, though outcomes including longer hospital stays, higher readmission rate were found. Antiviral use was not associated with lower risk of surgery but was found to prolong time to surgery. Given that our study was based on retrospective data, further prospective studies will be required to examine the benefit of antiviral use in outcomes for those with concominant CMV and acute severe ulcerative colitis. We conclude from our study that while having concomitant CMV with acute severe uclerative colitis may not necessarily increase risk for surgery, patients may still have worse outcomes in other areas therefore the detection of CMV should be considered a significant and clinically relevant result.

Adaptive clinical trials in surgery: A scoping review of methodological and reporting quality.

IMPORTANCE: Adaptive surgical trials are scarce, but adopting these methods may help elevate the quality of surgical research when large-scale RCTs are impractical. OBJECTIVE: Randomized-controlled trials (RCTs) are the gold standard for evidence-based healthcare. Despite an increase in the number of RCTs, the number of surgical trials remains unchanged. Adaptive clinical trials can streamline trial design and time to trial reporting. The advantages identified for ACTs may help to improve the quality of future surgical trials. We present a scoping review of the methodological and reporting quality of adaptive surgical trials. EVIDENCE REVIEW: We performed a search of Ovid, Web of Science, and Cochrane Collaboration for all adaptive surgical RCTs performed from database inception to October 12, 2023. We included any published trials that had at least one surgical arm. All review and abstraction were performed in duplicate. Risk of bias (RoB) was assessed using the RoB 2.0 instrument and reporting quality was evaluated using CONSORT ACE 2020. All results were analyzed using descriptive methods. FINDINGS: Of the 1338 studies identified, six trials met inclusion criteria. Trials were performed in cardiothoracic, oral, orthopedic, and urological surgery. The most common type of adaptive trial was group sequential design with pre-specified interim analyses planned for efficacy, futility, and/or sample size re-estimation. Two trials did use statistical simulations. Our risk of bias evaluation identified a high risk of bias in 50% of included trials. Reporting quality was heterogeneous regarding trial design and outcome assessment and details in relation to randomization and blinding concealment. CONCLUSION AND RELEVANCE: Surgical trialists should consider implementing adaptive components to help improve patient recruitment and reduce trial duration. Reporting of future adaptive trials must adhere to existing CONSORT ACE 2020 guidelines. Future research is needed to optimize standardization of adaptive methods across medicine and surgery.

Determining efficacy of dynamic multimedia bowel preparation instructions versus standard instructions on adenoma detection and patient reported measures (DIGICLEAN trial): a study protocol for a multicentre, colonoscopist-blinded, randomised controlled trial.

INTRODUCTION: Colonoscopy plays important roles in bowel cancer screening and treatment. Poor bowel preparation occurs in 20-25% of colonoscopies. This negatively impacts adenoma and sessile serrated lesion detection rates, procedural time, requirement for repeat colonoscopies, healthcare costs and likelihood of patient withdrawal from screening programmes. It is unclear whether a combination of multimedia modalities can improve bowel preparation quality, adenoma detection rates and patient-reported measures in those undergoing colonoscopy assessment. METHODS: The DIGICLEAN trial is a prospective, parallel, multicentre, colonoscopist-blinded, randomised controlled trial. The trial will enrol 1294 participants aged 45 years and older who are indicated for a colonoscopy as an outpatient with a positive faecal occult blood test, iron deficiency anaemia or rectal bleeding. Participants will be randomised into the interventional arm, where bowel preparation instructions are delivered via a web-based application which uses scheduled short messaging service, regular patient survey assessment, email and videos; or the control arm, where routine standard written, verbal or emailed instructions are administered. The web-based application will assess patient-reported bloating, constipation and dietary adherence leading up to the colonoscopy. Depending on patient responses, additional aperients may be encouraged digitally in the interventional arm with same instructions made available in written format for the control arm. Patient-reported measures will be collected in both arms the day after the procedure using the validated Newcastle ENDOPREM questionnaire. In some sites, participants will undergo digital pre-anaesthetic screening as well. The co-primary endpoints are the adenoma detection rates and patient-reported measures taken after the colonoscopy. ETHICS AND DISSEMINATION: Ethics approval for this study was obtained from the Western Sydney Local Health District Human Research Ethics Committee (2022/ETH00059). Findings will be reported at national and international gastroenterology meetings and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: ACTRN12622000747729.

Intraoperative parathyroid hormone monitoring in parathyroidectomy for hyperparathyroidism: a protocol for a network meta-analysis of diagnostic test accuracy.

Intraoperative parathyroid hormone (iPTH) monitoring is standard-of-care in the surgical management of hyperparathyroidism. It involves real-time determination of circulating PTH levels to guide parathyroid gland excision. There exists several iPTH monitoring criteria, such as the Miami criteria, and a lack of standardization in the timing of post-parathyroid gland excision samples. We present a protocol of a systematic review and network meta-analysis of diagnostic test accuracy to identify the iPTH criteria and post-gland excision timepoint that best predicts surgical cure in hyperparathyroidism. The database search strategy will be developed in conjunction with a librarian specialist. We will perform a search of Medline (Ovid), EMBASE (Ovid), CINAHL, Cochrane Collaboration, and Web of Science from 1990-present. Studies will be eligible if they include adult patients diagnosed with hyperparathyroidism who undergo parathyroidectomy with iPTH monitoring. We will only include studies that report diagnostic test properties for iPTH criteria and/or post-excision sampling timepoints. All screening, full-text review, data extraction, and critical appraisal will be performed in duplicate. Critical appraisal will be performed using QUADAS-2 instrument. A descriptive analysis will present study and critical appraisal characteristics. We will perform evaluation of between-study heterogeneity using I2 and Cochrane Q and where applicable, we will perform sensitivity analysis. Our network meta-analysis will include Bayesian hierarchical framework with random effects using multiple models. Ethics approval is not required. This proposed systematic review will utilize a novel Bayesian network meta-analysis model to help standardize iPTH monitoring in hyperparathyroidism, thereby optimizing patient outcomes and healthcare expenditures.

Dual biologic therapy with ocrelizumab for multiple sclerosis and vedolizumab for Crohn's disease: A case report and review of literature.

BACKGROUND: Little is known about the safety and efficacy of using two or more biologics for the treatment of immune-mediated diseases, including Crohn's disease (CD). CASE SUMMARY: This case report and narrative review demonstrate the potential safety of dual biologic therapy (DBT) in a 45-year-old female with two separate immune-mediated diseases. She had a history of multiple sclerosis for which she was receiving treatment with ocrelizumab, and she had been recently diagnosed with CD after presenting with diarrhoea. The CD diagnosis was confirmed radiologically, endoscopically, histologically, and biochemically. The patient received treatment with vedolizumab, a gut-specific inhibitor of the α4ß7 integrin on leukocytes. No adverse reactions were observed for the duration of treatment. The safety of ocrelizumab and vedolizumab for the treatment of different immune-mediated diseases was demonstrated. CONCLUSION: DBT may be a safe and effective option for the treatment of refractory disease or multiple immune-mediated diseases. Newer biologics, which have improved safety profiles and gut specificity, may provide promising avenues for treatment. However, caution must be exercised in the appropriate selection of biologics given their inherent immunosuppressive properties, side effects, and efficacy profiles. Current evidence suggests that biologic therapy is not associated with a worse prognosis in patients with coronavirus disease 2019, but treatment decisions should be made in a multidisciplinary setting. Further research from controlled trials is needed to better understand the safety profile of DBT in CD. The immunopathological mechanisms underlying DBT also remain to be clarified.

Out-of-pocket costs associated with head and neck cancer treatment.

BACKGROUND: Out-of-pocket costs (OOPC) associated with treatment have significant implications on quality of life and survival in cancer patients. Head and neck cancer patients face unique treatment-related challenges, but to date OOPC have been understudied in this population. AIMS: This study aims to identify and measure OOPC for patients with head and neck cancer (HNC) in Ontario. METHODS: HNC patients between 2015 and 2018 at Princess Margaret Cancer Centre in Toronto were recruited. Participants completed OOPC questionnaires and lost income questions during radiation, post-surgery, and 3, 6, 12, and 24 months after completion of treatment. Associations between OOPC and treatment modality and disease site were tested with multivariable hurdle regression. RESULTS: A total of 1545 questionnaires were completed by 657 patients. Median estimated OOPC for the total duration of treatment for participants undergoing chemoradiation was $1452 [$0-14 616], for surgery with adjuvant radiation or chemoradiation (C/RT) was $1626, for radiation therapy alone was $635, and for surgery alone was $360. The major expenses for participants at the mid-treatment time-point was travel (mean $424, standard error of the mean [SEM] $34) and meals, parking, and accommodations (mean $617, SEM $67). In multivariable analysis, chemoradiation, surgery with C/RT, and radiation were associated with significantly higher OOPC than surgery alone during treatment (791% higher, p < .001; 539% higher, p < .001; 370% higher, p < .001 respectively) among patients with non-zero OOPC. Participants with non-zero OOPC in the laryngeal cancer group paid 49% lower OOPC than those with oropharyngeal cancers in adjusted analysis (p = .025). CONCLUSIONS: Patients undergoing treatment for HNC pay significant OOPC. These costs are highest during treatment and gradually decrease over time. OOPC vary by patient demographics, clinical factors, and, in particular, treatment modality.

Refugee healthcare perceptions in regional northern Australia: transition through engagement, access, trust, privacy, the old, and the new.

Current Australian Government policy aims to resettle refugees in regional Australia, but little is known about their primary and hospital healthcare experiences in these settings. By taking an interpretive approach to a narrative inquiry methodology, a qualitative study was performed to examine refugee perceptions of health care in a regional centre of northern Queensland, Australia. Purposive sampling and an interview guide were developed in partnership with the local refugee resettlement agency. Semi-structured interviews were performed with 14 refugees and involved interpreters. Transcripts were thematically organised into a story, validated by participants. Using QSR NVivo 12, all researchers analysed the transcripts. Themes were validated at a community event. Six themes were described: service issues, self-advocacy, knowledge and understanding that changes with time, interpreter issues, regional-metropolitan differentials, and the influence of the past on present behaviour. A conceptual framework involving engagement, access, trust and privacy, and the old versus the new, can be used to describe refugees' experiences. Discrimination, transport, and reliance on family and peers may be experiences that are more prominent in regional Australia. Refugees require high-quality information-sharing practices, formal support systems, and better models of service delivery for interpreting support. Clinicians need to be culturally respectful with their interactions.

The Refugee Co-Location Model may be useful in addressing refugee barriers to care. What do refugees think?

Co-location of services for refugees may be beneficial in addressing barriers to care. This model of care involves support for a specialist refugee nurse service with general practice, as well as developing partnerships with settlement support agencies and Primary Health Networks. We consider published literature on refugee perceptions of co-location, different models of care, upcoming research and priorities in the area.

Prevalence, prognosis, and treatment implications of retropharyngeal nodes in unknown primary head and neck carcinoma.

OBJECTIVE: (1) To estimate the prevalence of radiographically positive Retro-Pharyngeal Lymph Nodes (RPLN) in unknown primary carcinoma of the head and neck and (2) to determine the prognostic implications of radiographically positive RPLN and other radiographic features (3) to identify patients at low risk for retropharyngeal metastasis. MATERIALS AND METHODS: The medical records of all 68 eligible patients treated at the Princess Margaret Cancer Centre between 2000 and 2014 were retrospectively reviewed for demographic, clinical, pathologic, and radiologic data. Radiologic data included: RPLN, extra capsular spread (ECS), neck staging and cystic/necrotic or matted neck nodes. LRR, DR, DFS and OS were estimated using the competing risk methods and the Kaplan-Meier method. RESULTS: Seven patients had concerning RPLN (10.3%). Forty-four patients were p16 positive (65%). RPLN status did not have any effect on LRR, DFS, DR and OS. Radiological ECS and p16 (neg.) status were found to be significant predictors of LRR (p = 0.023; p = 0.014). Matted nodes, radiological ECS and p16 (neg.) status were found to be significant predictors of DFS (p = 0.012; p < 0.001; p = 0.014). Matted nodes and radiological ECS were found to be significant predictors of OS (p = 0.017; p = 0.0036). Only radiological ECS was found to be a significant predictor of distant recurrence (p = 0.0066). CONCLUSIONS: 10% of CUP patients will harbor radiological positive RPLN. A large proportion of CUP patients are positive for p16. Radiologic features such as ECS and matted nodes can predict worse outcomes.

Onodi cell mucocele: Case report and review of the literature.

Onodi cell mucoceles are rare entities that can cause devastating ocular complications if not treated promptly. Delays in the diagnosis are possible because of the wide range of differential diagnoses of unilateral retrobulbar optic neuropathy. We describe a new case of Onodi cell mucocele in a 39-year-old woman, and we present a comprehensive review of the literature on this entity. To the best of our knowledge, no review of Onodi cell mucoceles has been previously published. Our review found that 69% of patients with an Onodi cell mucocele experienced an improvement in vision after surgical decompression. The vast majority of these patients underwent endoscopic decompression; the timing of surgical decompression did not appear to affect outcomes in terms of vision. Onodi cell mucocele requires a high degree of clinical suspicion for diagnosis and a multidisciplinary approach to management that involves primary care physicians, ophthalmologists, and otolaryngologists. Early surgical treatment via an endoscopic approach is recommended for most patients, regardless of the duration of their ophthalmologic signs and symptoms.

A novel treatment adjunct for aspirin exacerbated respiratory disease: the low-salicylate diet: a multicenter randomized control crossover trial.

BACKGROUND: Aspirin-exacerbated respiratory disease (AERD) is a clinical triad consisting of aspirin/acetylsalicylic acid (ASA) sensitivity, bronchial asthma, and nasal polyposis. Although respiratory reactions following ingestion of ASA and other nonsteroidal anti-inflammatory drugs (NSAIDs) are considered a hallmark of the condition, respiratory inflammation persists despite patients' avoidance of NSAIDs. Treatment of this condition remains challenging and includes both medical and surgical options. METHODS: A prospective crossover single-blind multicenter study involving 4 tertiary rhinology care centers (n = 30) was conducted in which patients were randomized to start with either 6 weeks of a regular diet or 6 weeks of a low-salicylate diet and then crossed-over for a total study duration of 12 weeks. Patients were evaluated at baseline, 6 weeks (at crossover) and 12 weeks using subjective measures (22-item Sino-Nasal Outcome Test-22 [SNOT-22], Nasal Sinus Symptom Scale [NSSS], and 7-item Asthma Control Questionnaire [ACQ-7]) and objective outcome instruments (Perioperative Sinus Evaluation [POSE] and Lund-Kennedy Endoscopic Score [LKES]). RESULTS: Data was analyzed for 30 patients. Wilcoxon rank sum tests determined that patients had improvement in their median difference in scores, which were all statistically significant, when they followed the low-salicylate diet compared to their regular diet: SNOT-22: 15 (95% confidence interval [CI], 10 to 23.25), p < 0.001; NSSS: 3 (95% CI, 1.75 to 4), p < 0.001; ACQ-7: 4.5 (95% CI, 1.5 to 8.5), p < 0.001; POSE 6 (95% CI, 2.5 to 10), p < 0.001; and LKES: 2.5 (95% CI, 1.5 to 4), p < 0.001). CONCLUSION: The low-salicylate diet may offer a novel treatment adjunct to the current management of AERD. Clinically and statistically significant improvements on both subjective and objective outcome measures were noted for the upper and lower respiratory tracts.

Impact of p16 expression, nodal status, and smoking on oncologic outcomes of patients with head and neck unknown primary squamous cell carcinoma.

BACKGROUND: The prognostic significance of human papillomavirus (HPV) in the context of head and neck squamous cell carcinoma (HNSCC) of cancer of unknown primary (CUP) origin is unclear. METHODS: Patients treated for CUP at the Princess Margaret Cancer Centre between 2001 and 2013 were stratified by p16 status and retrospectively reviewed. RESULTS: Of the 73 patients included, those with p16-positive tumors (63%) had less advanced nodal status (N1-N2b; 52% vs 89%; p = .035) and less aggressive treatment. Patients with p16-positive tumors had improved 3-year disease-free survival (DFS; 79% vs 56%; p = .012) independent of nodal status and treatment in multivariable analysis (hazard ratio [HR] = 0.27; 95% confidence interval [CI] = 0.08-0.95). CONCLUSION: Among patients with CUP, p16-positive status is an independent predictor of DFS but not overall survival (OS). © 2016 Wiley Periodicals, Inc. Head Neck, 2016 © 2016 Wiley Periodicals, Inc. Head Neck 38: 1347-1353, 2016.

Radiotherapy Characteristics and Outcomes for Head and Neck Carcinoma of Unknown Primary vs T1 Base-of-Tongue Carcinoma.

Importance: Transoral robotic surgery- or transoral laser microsurgery-assisted lingual tonsillectomy may improve the identification rate of hidden base-of-tongue (BOT) carcinoma presenting as head or neck carcinoma of unknown primary (CUP) site. Objective: To evaluate the potential impact of lingual tonsillectomy in CUP site by comparing differences in radiotherapy volumes, dosimetry, and clinical outcomes for CUP site and T1-category BOT carcinoma. Design, Setting, and Participants: Retrospective study of 115 patients treated at a tertiary cancer center between January 1, 2005, and December 31, 2013, that included patients with BOT carcinoma (category T1N1-3M0) and CUP site (category T0N1-3M0) with known p16 status. Fifty-four patients with T1-category BOT carcinoma (50 [92.6%] p16-positive) were treated with definitive intensity-modulated radiotherapy (IMRT), including 34 (63%) who received concurrent chemotherapy. Sixty-one patients with CUP site (38 [62.3%] p16-positive) received definitive (42 [68.9%]) or postoperative (19 [31.1%]) IMRT, including 22 (36%) who received concurrent chemotherapy. Interventions: Definitive or postoperative IMRT, with or without concurrent chemotherapy. Main Outcomes and Measures: Characteristics of mucosal clinical target volume (CTV-T), nodal CTV, and organ-at-risk dosimetry; local, regional, and distant control; cause-specific and overall survival; and Radiation Therapy Oncology Group grade 3 or higher late toxic effects. Results: Of 115 participants, 104 (90.4%) were male; mean (SD) age was 59 (10) years. High-dose CTV-T was prescribed in all 54 patients with BOT carcinoma and 23 (37.7%) with CUP site (effect size [Δ], 62%; 95% CI, 50%-74%). Low-dose CTV-T included mucosal pharyngeal sites outside the oropharynx in no patients with BOT carcinoma and 26 (42.6%) (95% CI, 30%-54%) with CUP site, with greater low-dose CTV-T volume in CUP site than BOT carcinoma (113 vs 84 cm3; Δ, 30 cm3; 95% CI, 10-49 cm3). Bilateral neck irradiation was used in 53 of 54 patients (98.1%) with BOT carcinoma and 46 of 61 (75.4%) with CUP site (Δ, 23%; 95% CI, 12% to 34%). Patients with BOT carcinoma received a higher maximum dose to the mandible (71 vs 67.2 Gy; Δ, 3.8 Gy; 95% CI, 1.6 to 6 Gy), with a nonsignificantly higher maximum dose (66.1 vs 62.8 Gy; 3.2 Gy; 95% CI, -0.1 to 6.5 Gy) and lower mean dose to the larynx (43.8 vs 47.1 Gy; 3.3 Gy; 95% CI, -0.3 to 6.9 Gy). There were no significant differences in local control, regional control, distant control, cause-specific survival, and overall survival between the BOT carcinoma and CUP site groups stratified by p16 status. Grade 3 Radiation Therapy Oncology Group late toxic effects occurred in 2 patients (3.3%) with CUP site (both neck fibrosis) and 5 (9.3%) with BOT carcinoma (2 neck fibrosis, 2 osteoradionecrosis, and 1 dysphagia). Conclusions and Relevance: Intensity-modulated radiotherapy for CUP site or T1-category BOT carcinoma had similar clinical outcomes. Identifying hidden BOT primary carcinoma with novel approaches (eg, transoral robotic surgery and transoral laser microsurgery) may lead to changes in the radiotherapy target volume and dose prescription. Studies are needed to investigate the effect of these differences on quality of life and functional outcomes.

Treatment of aspirin exacerbated respiratory disease with a low salicylate diet: a pilot crossover study.

OBJECTIVE: Aspirin exacerbated respiratory disease (AERD) is comprised of aspirin/acetylsalicylic acid (ASA) sensitivity, bronchial asthma, and nasal polyposis. Treatment of this condition is challenging and may include topical/systemic steroids, endoscopic sinus surgery, and/or aspirin desensitization. STUDY DESIGN: A prospective crossover pilot study (n = 10) was conducted in which patients were randomized into either of 2 groups with 6 weeks of regular diet (R) or 6 weeks of a low salicylate diet (LS). SETTING: The study was conducted in a tertiary otolaryngology clinic. SUBJECTS: Patients with AERD were enrolled in the study. METHODS: Subjective (Sino-nasal Outcome Test-22 [SNOT-22], Nasal Sinus Symptom Scale [NSSS], and the Asthma Control Questionnaire-7 [ACQ-7]) and objective outcome instruments (Peri-Operative Sinus Evaluation [POSE] and Lund-Kennedy Endoscopic Score [LKES]) were used to evaluate patients at baseline, 6 weeks (at crossover), and 12 weeks. RESULTS: Wilcoxon rank sum tests demonstrated that patients on the low salicylate diet had improved scores compared to their regular diet when evaluated by 4 of the 5 outcome measures (SNOT-22 pLS = 0.0059, NSSS pLS = 0.0195, LKES pLS = 0.0039, POSE pLS = 0.005). CONCLUSION: Results of the pilot study indicate that implementation of a low salicylate diet improves the nasal symptoms and nasal endoscopy findings of individuals with AERD. Further research is required to support these findings.

A systematic review of complication and recurrence rates of musculocutaneous, fasciocutaneous, and perforator-based flaps for treatment of pressure sores.

BACKGROUND: Management of pressure sores poses a significant reconstructive challenge for plastic surgeons. Currently, there is no consensus on whether musculocutaneous, fasciocutaneous, or perforator-based flaps provide superior results for treating pressure sores. METHODS: The following databases were searched: Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, LILACS (January of 1950 to November of 2010), MEDLINE (January of 1950 to November of 2010), and EMBASE (January of 1980 to November of 2010). Only articles reporting on the use of musculocutaneous, fasciocutaneous, and perforator-based flaps were included. The primary study outcomes were complication and recurrence rates. RESULTS: Fifty-five articles were included in the final analysis (kappa = 0.78). From this total, 28 were categorized as pertaining to musculocutaneous flaps, 13 studied fasciocutaneous flaps, and 14 evaluated perforator-based flaps. The authors' review revealed recurrence and complication rates of 8.9 and 18.6 percent, respectively, following reconstruction with musculocutaneous flaps, 11.2 and 11.7 percent following reconstruction with fasciocutaneous flaps, and 5.6 and 19.6 percent following reconstruction with perforator-based flaps. Overall, statistical analysis revealed no significant difference in complication or recurrence rates among these three techniques. CONCLUSIONS: The authors' review revealed that there was no statistically significant difference with regard to recurrence or complication rates among musculocutaneous, fasciocutaneous, or perforator-based flaps. This suggests that surgeons performing such reconstructive procedures may choose to consider the advantages of a specific approach rather than the complication and recurrence rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.