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OBJECTIVE: Understand vaccination knowledge and barriers to vaccination among minority adults. STUDY DESIGN: Cross-sectional survey. SETTING: Otolaryngology clinics at a safety net hospital and a tertiary academic center and a head and neck cancer screening event. METHODS: Survey was administered to consenting patients. Descriptive statistics and significance testing were used to characterize the data, with non-minority respondents as controls. Multivariate logistic regression was used to understand factors associated with vaccination. RESULTS: HPV vaccination among our 241 respondents (n = 41, 17.67 %) and their qualifying children (n = 52, 33.55 %) was low. Non-vaccinated minorities were significantly more likely to express interest in HPV vaccination (28.66 % vs 8.66 %, p = 0.016). Minority patients were significantly less knowledgeable about HPV causing cervical (88.64 % vs 72.45 %, p = 0.024) and head and neck (68.18 % vs 44.90 %, p = 0.005) cancer and were also less aware of HPV infection (95.45 % vs 81.12 %, p = 0.020) among non-women. Lack of knowledge about the HPV vaccine was the most cited reason why minority patients did not or were uninterested in vaccination for themselves or their children. In a multivariable logistic regression of factors associated with HPV vaccination, only increased age demonstrated a significant association with vaccination likelihood (OR = 0.91, 95 % CI = [0.88-0.95], p < 0.001). CONCLUSION: Reported HPV vaccination rates were low for both white and minority patients but did not significantly vary on univariate or multivariate analysis. However, minority respondents were significantly less knowledgeable about HPV and its manifestations; they most often cited inadequate knowledge as why did not receive or were uninterested in HPV vaccination. As such, HPV vaccination educational interventions may raise vaccination rates among minority populations.
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Importance: Cannabis is the most commonly used illicit substance worldwide. Whether cannabis use is associated with head and neck cancer (HNC) is unclear. Objective: To assess the clinical association between cannabis use and HNC. Design, Setting, and Participants: This large multicenter cohort study used clinical records from a database that included 20 years of data (through April 2024) from 64 health care organizations. A database was searched for medical records for US adults with and without cannabis-related disorder who had recorded outpatient hospital clinic visits and no prior history of HNC. Propensity score matching was performed for demographic characteristics, alcohol-related disorders, and tobacco use. Subsequently, relative risks (RRs) were calculated to explore risk of HNC, including HNC subsites. This analysis was repeated among those younger than 60 years and 60 years or older. Exposure: Cannabis-related disorder. Main Outcomes and Measures: Diagnosis of HNC and any HNC subsite. Results: The cannabis-related disorder cohort included 116â¯076 individuals (51â¯646 women [44.5%]) with a mean (SD) age of 46.4 (16.8) years. The non-cannabis-related disorder cohort included 3â¯985â¯286 individuals (2â¯173â¯684 women [54.5%]) with a mean (SD) age of 60.8 (20.6) years. The rate of new HNC diagnosis in all sites was higher in the cannabis-related disorder cohort. After matching (n = 115â¯865 per group), patients with cannabis-related disorder had a higher risk of any HNC (RR, 3.49; 95% CI, 2.78-4.39) than those without HNC. A site-specific analysis yielded that those with cannabis-related disorder had a higher risk of oral (RR, 2.51; 95% CI, 1.81-3.47), oropharyngeal (RR, 4.90; 95% CI, 2.99-8.02), and laryngeal (RR, 8.39; 95% CI, 4.72-14.90) cancer. Results were consistent when stratifying by older and younger age group. Conclusions and Relevance: This cohort study highlights an association between cannabis-related disorder and the development of HNC in adult patients. Given the limitations of the database, future research should examine the mechanism of this association and analyze dose response with strong controls to further support evidence of cannabis use as a risk factor for HNCs.
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BACKGROUND: There are no guidelines on when to more strongly recommend sentinel lymph node biopsy (SLNB) for T1b melanomas. OBJECTIVE: To examine whether anatomic locations of T1b melanomas and patient age influence metastases. METHODS: We conducted a retrospective study using data from two hospitals in Los Angeles County from January 2010 through January 2020. RESULTS: Out of 620 patients with primary melanomas, 566 melanomas were staged based on the American Joint Committee on Cancer 8th edition melanoma staging. Forty-one were T1b, of which 13 were located on the face/ear/scalp and 28 were located elsewhere. T1b melanomas located on the face/ear/scalp had an increased risk of lymph node or distant metastasis compared with other anatomic sites (31% vs 3.6%, P=0.028). For all melanomas, the risk of lymph node or distant metastasis decreased with age of 64 years or greater (P<0.001 and P=0.034). For T1b melanomas, the risk of distant metastasis increased with increasing age (P=0.047). LIMITATIONS: Data were from a single county. Conclusion: T1b melanomas of the face/ear/scalp demonstrated a higher risk of lymph node or distant metastasis and may help guide the recommendation of SLNB, imaging, and surveillance. Younger patients may be more strongly considered for SLNB and older patients with T1b melanomas may warrant imaging. J Drugs Dermatol. 2024;23(5):306-310. doi:10.36849/JDD.7667.
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Lymphatic Metastasis , Melanoma , Neoplasm Staging , Sentinel Lymph Node Biopsy , Skin Neoplasms , Humans , Melanoma/pathology , Melanoma/diagnosis , Melanoma/epidemiology , Retrospective Studies , Female , Skin Neoplasms/pathology , Skin Neoplasms/diagnosis , Skin Neoplasms/epidemiology , Male , Middle Aged , Aged , Age Factors , Lymphatic Metastasis/diagnosis , Adult , Aged, 80 and over , Los Angeles/epidemiology , Young AdultABSTRACT
INTRODUCTION: Gay and bisexual males and other LGBTQ+ communities are more frequently exposed to factors associated with an increased risk of human papillomavirus (HPV) acquisition. Vaccination is critical to protect against HPV+ head and neck cancer (HNC). We characterized the association of perceived level of risk of contraction with HPV knowledge, and vaccine decision-making. STUDY DESIGN: Cross-sectional cohort. SETTING: LGBTQ and general survey Reddit forums (control). METHODS: A survey was shared amongst the online forums. Descriptive statistics characterized the data. Multivariable logistic regression was used to understand factors associated with vaccination, self-perceived high risk, and knowledge of HPV + HNC. RESULTS: Of 718 respondents, most were female (41.09%), Caucasian (59.89%), college-educated (33.01%), and insured (77.15%) with a mean age of 30.75 years. Half were vaccinated (49.16%), with most unvaccinated endorsing interest (60.58%). Few dependents were vaccinated (25.91%), with interest in vaccination among parents of unvaccinated children (38.58%). Knowledge of HIV's association with HPV (62.95%), HPV causing HNC (55.57%), and the vaccine's efficacy against HNC (55.57%) was also moderate. Identifying female (P = .042), a self-perceived high-risk (P < .001), and having vaccinated children (P < .001) increased vaccination likelihood; transgender (P = .021), or lesbian or gay sexual identity (P < .001) decreased likelihood. Personal HNC diagnosis (P < .001), self-vaccination (P < .001), having vaccinated children (P < .001), having anal sex (P = .001) or no knowledge of past HPV status (P < .001) increased likelihood of high self-perceived risk. CONCLUSION: Efforts to improve public education regarding the association between HPV and HNC and vaccination efficacy are required to better inform vaccine decision-making among individuals at risk for HPV infection.
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Health Knowledge, Attitudes, Practice , Papillomavirus Infections , Papillomavirus Vaccines , Sexual and Gender Minorities , Humans , Male , Female , Papillomavirus Vaccines/administration & dosage , Cross-Sectional Studies , Papillomavirus Infections/prevention & control , Adult , Sexual and Gender Minorities/statistics & numerical data , Sexual and Gender Minorities/psychology , Vaccination/statistics & numerical data , Vaccination/psychology , Surveys and QuestionnairesABSTRACT
Objective: This study aimed to characterize the quality of laryngectomy-related patient education on YouTube and understand factors impacting video content quality. Study Design: Cross-sectional cohort analysis. Setting: Laryngectomy-related videos on YouTube. Methods: YouTube was anonymously queried for various laryngectomy procedure search terms. Video quality was evaluated using the validated DISCERN instrument which assesses treatment-related information quality. Descriptive statistics were used to characterize our cohort. Univariate and multivariable linear regression were used to assess factors associated with increased DISCERN score. Significance was set at P < .05. Results: Our 78-video cohort exhibited moderate levels of engagement, averaging 13,028.40 views (SD = 24,246.93), 69.79 likes (SD = 163.75), and 5.27 comments (SD = 18.81). Videos were most frequently uploaded to accounts belonging to physicians (43.59%) or health care groups (41.03%) and showcased operations (52.56%) or physician-led education (20.51%). Otolaryngologists were featured in most videos (85.90%), and most videos originated outside the United States (67.95%). Laryngectomy videos demonstrated poor reliability (mean = 2.35, SD = 0.77), quality of treatment information (mean = 1.92, SD = 0.86), and overall video quality (mean = 1.97, SD = 1.12). In multivariable linear regression, operative videos were associated with lower video quality relative to nonoperative videos (ß = -1.63, 95% confidence interval [CI] = [-2.03 to -1.24], P < .001); the opposite was true for videos from accounts with higher subscriber counts (ß = 0.02, 95% CI = [0.01-0.03], P = .005). Conclusion: The quality and quantity of YouTube's laryngectomy educational content is limited. There is an acute need to increase the quantity and quality of online laryngectomy-related content to better support patients and caregivers as they cope with their diagnosis, prepare for, and recover from surgery.
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OBJECTIVE: With burgeoning popularity of artificial intelligence-based chatbots, oropharyngeal cancer patients now have access to a novel source of medical information. Because chatbot information is not reviewed by experts, we sought to evaluate an artificial intelligence-based chatbot's oropharyngeal cancer-related information for accuracy. METHODS: Fifteen oropharyngeal cancer-related questions were developed and input into ChatGPT version 3.5. Four physician-graders independently assessed accuracy, comprehensiveness, and similarity to a physician response using 5-point Likert scales. Responses graded lower than three were then critiqued by physician-graders. Critiques were analyzed using inductive thematic analysis. Readability of responses was assessed using Flesch Reading Ease (FRE) and Flesch-Kincaid Reading Grade Level (FKRGL) scales. RESULTS: Average accuracy, comprehensiveness, and similarity to a physician response scores were 3.88 (SD = 0.99), 3.80 (SD = 1.14), and 3.67 (SD = 1.08), respectively. Posttreatment-related questions were most accurate, comprehensive, and similar to a physician response, followed by treatment-related, then diagnosis-related questions. Posttreatment-related questions scored significantly higher than diagnosis-related questions in all three domains (p < 0.01). Two themes of the physician critiques were identified: suboptimal education value and potential to misinform patients. The mean FRE and FKRGL scores both indicated greater than an 11th grade readability level-higher than the 6th grade level recommended for patients. CONCLUSION: ChatGPT responses may not educate patients to an appropriate degree, could outright misinform them, and read at a more difficult grade level than is recommended for patient material. As oropharyngeal cancer patients represent a vulnerable population facing complex, life-altering diagnoses, and treatments, they should be cautious when consuming chatbot-generated medical information. LEVEL OF EVIDENCE: NA Laryngoscope, 134:2252-2257, 2024.
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Laryngoscopes , Oropharyngeal Neoplasms , Humans , Artificial Intelligence , Software , Oropharyngeal Neoplasms/diagnosis , Oropharyngeal Neoplasms/therapy , Educational StatusABSTRACT
OBJECTIVE: To determine the cost-effectiveness of surveillance imaging with PET/CT scan among patients with human papillomavirus-positive oropharyngeal squamous cell carcinoma. STUDY DESIGN: Cost-effectiveness analysis. SETTING: Oncologic care centers in the United States with head and neck oncologic surgeons and physicians. METHODS: We compared the cost-effectiveness of 2 posttreatment surveillance strategies: clinical surveillance with the addition of PET/CT scan versus clinical surveillance alone in human papillomavirus-positive oropharyngeal squamous cell carcinoma patients. We constructed a Markov decision model which was analyzed from a third-party payer's perspective using 1-year Markov cycles and a 30-year time horizon. Values for transition probabilities, costs, health care utilities, and their studied ranges were derived from the literature. RESULTS: The incremental cost-effectiveness ratio for PET/CT with clinical surveillance versus clinical surveillance alone was $89,850 per quality-adjusted life year gained. Flexible fiberoptic scope exams during clinical surveillance would have to be over 51% sensitive or PET/CT scan cost would have to exceed $1678 for clinical surveillance alone to be more cost-effective. The willingness-to-pay threshold at which imaging surveillance was equally cost-effective to clinical surveillance was approximately $80,000/QALY. CONCLUSION: Despite lower recurrence rates of human papillomavirus-positive oropharyngeal cancer, a single PET/CT scan within 6 months after primary treatment remains a cost-effective tool for routine surveillance when its cost does not exceed $1678. The cost-effectiveness of this strategy is also dependent on the clinical surveillance sensitivity (flexible fiberoptic pharyngoscopy), and willingness-to-pay thresholds which vary by country.
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Head and Neck Neoplasms , Oropharyngeal Neoplasms , Humans , Positron Emission Tomography Computed Tomography , Squamous Cell Carcinoma of Head and Neck , Cost-Effectiveness Analysis , Cost-Benefit Analysis , Oropharyngeal Neoplasms/diagnostic imaging , Oropharyngeal Neoplasms/therapy , Human Papillomavirus Viruses , Quality-Adjusted Life YearsABSTRACT
IMPORTANCE: While minorities represent around 20 % of all HNC patients, these demographics are largely understudied. Furthermore, trends in national studies may not always be fully replicated in locoregional populations, indicating a need for more nuanced study. OBJECTIVE: To better understand our patient population, we sought to understand differences in presentation, management, and outcome between Caucasians and minority groups with HNC. DESIGN: Retrospective cohort analysis of the Los Angeles County Surveillance Epidemiology and End Results (SEER) database. SETTING: Los Angeles County. PARTICIPANTS: All patients in Los Angeles County diagnosed with cancer of the head and neck from January 1, 1988 to December 31, 2018. MAIN OUTCOMES AND MEASURES: The primary outcome in our study was significant differences between racial and ethnic groups in age of diagnosis, sex, socioeconomic quintile, insurance status, stage at diagnosis, treatment modality, time to first treatment, and cancer-specific cause of death. RESULTS: Our 18,510-patient cohort was largely male (64.35 %), white (69.57 %), and were on average 62.84 years old (SD = 20.07). When stratifying patients by race and ethnicity, significant differences were found in average age at diagnosis, sex, socioeconomic quintile, insurance status, and stage at diagnosis, treatment modalities utilized, and time to first treatment (all p < 0.001). Relative to all other head and neck patients, minority groups were significantly younger, had lower proportions of male patients, were less likely to pursue surgery, were more likely to pursue chemotherapy or radiation, and endorsed longer time to first treatment (all p < 0.001). The distribution of socioeconomic quintile (all p < 0.001), insurance status (all p < 0.001), and stage at diagnosis (all p < 0.05) also significantly varied between minority and reference groups. Only African Americans exhibited significantly higher rates of cancer-specific cause of death relative to non-African Americans (p < 0.001). CONCLUSIONS AND RELEVANCE: Pervasive socioeconomic disparities between Caucasian HNC patients and those of other minority racial and ethnic groups in Los Angeles County that likely and significantly impact the diagnosis and management of HNC and its resultant outcomes. We encourage others to similarly examine their local populations to tailor the quality of care provided to patients.
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Head and Neck Neoplasms , Minority Groups , Humans , Male , Middle Aged , Los Angeles/epidemiology , Retrospective Studies , Ethnicity , Head and Neck Neoplasms/diagnosis , Head and Neck Neoplasms/epidemiology , Head and Neck Neoplasms/therapyABSTRACT
Although modified radical neck dissections have increased in popularity to reduce morbidity secondary to intraoperative accessory nerve damage, inadvertent injury still often occurs. As this phenomenon is thought to be due to anatomic variation in the trapezius branch of the accessory nerve, it is imperative to better understand the nuances of these anatomic variations to better inform surgical decision-making. A total of 24 accessory nerves were dissected, exposed, and traced in 15 cadavers. Three aspects of the accessory nerve were identified and recorded: the course of the trapezius branch in relation to the sternocleidomastoid, the number of trapezius branches at muscle insertion, and the number of cervical rootlet contributions. Four different anatomic patterns for the trapezius branch were identified, with the most common being where the trapezius branch separates from the main accessory nerve just medial to the sternocleidomastoid and courses deep to the sternocleidomastoid (58.3%). Most (75%) trapezius branches entered the muscle as a single nerve, whereas some (21%) were inserted as two separate nerves. The number of cervical rootlet contributions for each trapezius branch varied from zero to three. Bilateral anatomic variations were also noted. Even when the accessory nerve and its branches are thought to be spared during neck dissection, patients may postoperatively present with different degrees of accessory nerve damage. There may be unrecognized anatomic pathways that the nerve takes that may confer a higher risk of unintentional damage, especially those that have greater exposure within the anterior triangle unprotected by the sternocleidomastoid.
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Accessory Nerve , Superficial Back Muscles , Humans , Superficial Back Muscles/innervation , Neck/innervation , Neck Muscles/innervation , Neck DissectionABSTRACT
INTRODUCTION: Coronavirus disease 2019 (COVID-19) affects the vascular system, subjecting patients to a hypercoagulable state. This is of particular concern for the success of microvascular free flap reconstruction. This study aims to report head and neck free flap complications in patients with COVID-19 during the perioperative period. We believe these patients are more likely to experience flap complications given the hypercoagulable state. METHODS: This is a multi-institutional retrospective case series of patients infected with COVID-19 during the perioperative period for head and neck free flap reconstruction from March 2020 to January 2022. RESULTS: Data was collected on 40 patients from 14 institutions. Twenty-one patients (52.5%) had a positive COVID-19 test within 10 days before surgery and 7 days after surgery. The remaining patients had a positive test earlier than 10 days before surgery. A positive test caused a delay in surgery for 16 patients (40.0%) with an average delay of 44.7 days (9-198 days). Two free flap complications (5.0%) occurred with no free flap deaths. Four patients (10.0%) had surgical complications and 10 patients had medical complications (25.0%). Five patients (12.5%) suffered from postoperative COVID-19 pneumonia. Three deaths were COVID-19-related and one from cancer recurrence during the study period. CONCLUSION: Despite the heightened risk of coagulopathy in COVID-19 patients, head and neck free flap reconstructions in patients with COVID-19 are not at higher risk for free flap complications. However, these patients are at increased risk of medical complications. LEVEL OF EVIDENCE: 4 Laryngoscope, 2023.
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Objective: To characterize the users of the head and neck cancer (HNC) online support group (OSG) and describe the perceived benefits of membership. Study Design: Cross-sectional. Setting: Online. Methods: An administered survey with questions asking about demographics, cancer history, treatment choices, and feelings about OSGs was posted on the 5 largest HNC OSGs on Facebook. Results: A total of 97 participants completed the survey. Mean age was 57.8 years old (standard deviation = 10.7 years). Most participants were female (50.5%) and Caucasian (92.8%). This cohort was well educated with 65.5% holding at least a college degree. Annual income was high with 41.8% reporting annual income of $100,000 or greater. The most common treatment modality was radiation (88.7%). The most common surgery was neck dissection (46.4%). Most participants preferred OSGs (70.8%) over other support group types. OSGs were heavily utilized with our cohort reporting using the OSG at least several times a week (80.0%). The top reasons for joining the OSG were sharing one's experience of HNC (76.3%) and gaining support from others with HNC (85.6%). OSGs were ranked as the #3 source of medical information for HNC behind otolaryngologists and oncologists. Membership in a HNC OSG had a minimal impact on decision-making. Conclusion: HNC OSGs appear to provide a beneficial community for HNC patients. Otolaryngologists should consider incorporating HNC OSG as a possible supplemental resource for their HNC patients.
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Abstract Introduction Patients at public county hospitals often have poorer access to healthcare with advanced disease on presentation. These factors, along with limited resources at county hospitals, may have an impact on outcomes for patients requiring complex head and neck reconstruction. Objectives To delineate differences in the frequency of complications in two different care settings, a public county hospital and a private university hospital. Methods Retrospective review of otolaryngology patients at a university hospital compared with a publicly-funded county hospital. The main outcome measure was major complications including total flap loss or unplanned reoperation in 30 days. Secondary outcome measures included medical complications, partial flap loss, and unplanned hospital readmission in 30 days. Results In the county hospital sample (n = 58) free flap failure or reoperation occurred in 20.7% of the patients, and minor complications, in 36.2% of the patients. In the university hospital sample (n = 65) flap failure or reoperation occurred in 9.2% of the patients, and minor complications, in 12.3% of the patients. Patients at the private hospital who had surgery in the oropharynx were least likely to have minor complications. Conclusions Patients at the county hospital had a higher but not statistically significant difference in flap failure and reoperation than those at a university hospital, although the county hospital experienced more minor postoperative complications. This is likely multifactorial, and may be related to poorer access to primary care preoperatively, malnutrition, poorly controlled or undiagnosed medical comorbidities, and differences in hospital resources.
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Ameloblastic carcinoma (AC) is a rare and aggressive malignant epithelial odontogenic tumor making up less than 1% of malignant head and neck tumors. The majority of cases occur in the mandible with a minority occurring in the maxilla. Most occur de novo, while rare cases of AC have resulted from transformation from ameloblastoma. Here, we present a case in which a 30-year-old man presented with proptosis and a recurrent right temporal mass, which had been previously diagnosed as ameloblastoma on surgical pathology. CT findings demonstrated local invasion, and he was subsequently taken to the operating room for right craniotomy, infratemporal and middle cranial fossa tumor resection, and right modified radical neck dissection with reconstruction. Final pathology, which included areas of early focal necrosis, loss of peripheral palisading, and hyperchromatism, confirmed the diagnosis of ameloblastoma with transformation to AC. We further discuss radiologic and histopathological signs of this rare tumor, as well as recommended treatment modalities.
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Introduction Patients at public county hospitals often have poorer access to healthcare with advanced disease on presentation. These factors, along with limited resources at county hospitals, may have an impact on outcomes for patients requiring complex head and neck reconstruction. Objective To delineate differences in the frequency of complications in two different care settings, a public county hospital and a private university hospital. Methods Retrospective review of otolaryngology patients at a university hospital compared with a publicly-funded county hospital. The main outcome measure was major complications including total flap loss or unplanned reoperation in 30 days. Secondary outcome measures included medical complications, partial flap loss, and unplanned hospital readmission in 30 days. Results In the county hospital sample ( n = 58) free flap failure or reoperation occurred in 20.7% of the patients, and minor complications, in 36.2% of the patients. In the university hospital sample ( n = 65) flap failure or reoperation occurred in 9.2% of the patients, and minor complications, in 12.3% of the patients. Patients at the private hospital who had surgery in the oropharynx were least likely to have minor complications. Conclusion Patients at the county hospital had a higher but not statistically significant difference in flap failure and reoperation than those at a university hospital, although the county hospital experienced more minor postoperative complications. This is likely multifactorial, and may be related to poorer access to primary care preoperatively, malnutrition, poorly controlled or undiagnosed medical comorbidities, and differences in hospital resources.
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BACKGROUND: Whether pembrolizumab given both before surgery (neoadjuvant therapy) and after surgery (adjuvant therapy), as compared with pembrolizumab given as adjuvant therapy alone, would increase event-free survival among patients with resectable stage III or IV melanoma is unknown. METHODS: In a phase 2 trial, we randomly assigned patients with clinically detectable, measurable stage IIIB to IVC melanoma that was amenable to surgical resection to three doses of neoadjuvant pembrolizumab, surgery, and 15 doses of adjuvant pembrolizumab (neoadjuvant-adjuvant group) or to surgery followed by pembrolizumab (200 mg intravenously every 3 weeks for a total of 18 doses) for approximately 1 year or until disease recurred or unacceptable toxic effects developed (adjuvant-only group). The primary end point was event-free survival in the intention-to-treat population. Events were defined as disease progression or toxic effects that precluded surgery; the inability to resect all gross disease; disease progression, surgical complications, or toxic effects of treatment that precluded the initiation of adjuvant therapy within 84 days after surgery; recurrence of melanoma after surgery; or death from any cause. Safety was also evaluated. RESULTS: At a median follow-up of 14.7 months, the neoadjuvant-adjuvant group (154 patients) had significantly longer event-free survival than the adjuvant-only group (159 patients) (P = 0.004 by the log-rank test). In a landmark analysis, event-free survival at 2 years was 72% (95% confidence interval [CI], 64 to 80) in the neoadjuvant-adjuvant group and 49% (95% CI, 41 to 59) in the adjuvant-only group. The percentage of patients with treatment-related adverse events of grades 3 or higher during therapy was 12% in the neoadjuvant-adjuvant group and 14% in the adjuvant-only group. CONCLUSIONS: Among patients with resectable stage III or IV melanoma, event-free survival was significantly longer among those who received pembrolizumab both before and after surgery than among those who received adjuvant pembrolizumab alone. No new toxic effects were identified. (Funded by the National Cancer Institute and Merck Sharp and Dohme; S1801 ClinicalTrials.gov number, NCT03698019.).
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Antineoplastic Agents, Immunological , Melanoma , Neoadjuvant Therapy , Skin Neoplasms , Humans , Adjuvants, Immunologic , Disease Progression , Melanoma/drug therapy , Melanoma/pathology , Melanoma/surgery , Skin Neoplasms/drug therapy , Skin Neoplasms/pathology , Skin Neoplasms/surgery , Antineoplastic Agents, Immunological/administration & dosage , Antineoplastic Agents, Immunological/adverse effects , Antineoplastic Agents, Immunological/therapeutic use , Chemotherapy, AdjuvantABSTRACT
Objective: To compare postoperative pain scores and opioid consumption in patients after transoral robotic surgery (TORS). Study Design: Single institution retrospective cohort study. Setting: TORS was performed at a single academic tertiary care center. Methods: This study compared traditional opioid-based and opioid-sparing multimodal analgesia (MMA) regimens in patients with oropharyngeal and supraglottic malignancy after TORS. Data were obtained from the electronic health records from August 2016 to December 2021. The average postoperative pain scores and total opioid consumption in morphine milligram equivalents were calculated for postoperative days (PODs) 0 to 3. The secondary objectives were to quantify and characterize opioid prescriptions upon hospital discharge. Results: A total of 114 patients were identified for this study, 58 patients in the non-MMA cohort and 56 in the MMA cohort. Postoperative pain levels in the MMA cohort were statistically lower on POD 0 (p = 0.001), POD 1 (p = 0.001), and POD 3 (p = 0.004). Postoperative opioid consumption decreased significantly in the MMA cohort from 37.7 to 10.8 mg on POD 0 (p = 0.002), 65.9 to 19.9 mg on POD 1 (p < 0.001), 36.0 to 19.3 mg on POD 2 (p = 0.02), and 45.4 to 13.8 mg on POD 3 (p = 0.02). The number of patients discharged from the hospital with a prescription for narcotics was significantly lower in the MMA cohort (71.4%) compared with the non-MMA cohort (98.3%) (p < 0.001). Conclusion: Implementation of our MMA pain protocol reduced pain levels and narcotic consumption in the immediate postoperative period.
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PURPOSE: Not much is known about how pre-operative psychosocial factors affect head and neck free flap outcomes. Hence, the objective of the study is to determine if a patient's pre-operative self-perception and quality of life affect post-operative complications and hospital length of stay after free flap surgery. MATERIALS AND METHODS: This was a prospective cohort study. Patients who underwent a free flap surgery at an academic tertiary care center between January 2021 and March 2022 were asked to fill out the Rosenberg Self Esteem Scale and the Short Form 36 Health Questionnaire before surgery. A chart review of their medical records was then performed. Analysis of the data was performed using Spearman Correlation, Fisher exact test, Mann-Whitney and Multivariate Logistic Regression on STATA 15. RESULTS: Sixty-one patients (73.8 % male; mean [SD; range] age: 60.9 [14.0, 23.1-86.8]) who underwent free flap surgery agreed to participate in the study. Most of the participants were not Caucasian (59 %). The most common indication for surgery was malignancy (93 %). The post-operative complication rate was 34.4 % and included 3 hematoma (4.9 %), 3 free flap failure (4.9 %), 9 wound dehiscence (14.8 %), 10 salivary fistulas (16.4 %), and 3 aspiration pneumonia or chyle leak (4.9 %). There were no mortalities. The mean role limitations due to physical health subscore [SD; range], social functioning subscore, pain subscore, and general health subscore of the SF-36 were 61.9 [39.2, 0-100], 70.7 [27.5, 0-100], 62.1 [25.7, 0-100], and 67.8 [20.3, 20-100], respectively. On univariate analysis, decreased physical limitations, better social functioning, less pain and better general health were associated with fewer overall post-operative complications, but was not correlated with length of stay. This held true for social functioning and general health even in multivariate analysis accounting for age and smoking history. The mean Rosenberg Self Esteem Scale score was 24.3 [4.1, 13-30]. CONCLUSIONS: In this study, patients with more limited social function and worse general health had more overall post-operative complications. It is important to continue to explore how pre-operative quality of life and other psychosocial factors can affect surgical outcomes.
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Free Tissue Flaps , Head and Neck Neoplasms , Plastic Surgery Procedures , Humans , Male , Middle Aged , Female , Plastic Surgery Procedures/adverse effects , Prospective Studies , Quality of Life , Head and Neck Neoplasms/surgery , Head and Neck Neoplasms/complications , Retrospective Studies , Postoperative Complications/epidemiology , Postoperative Complications/etiology , Tertiary Care Centers , Pain , Treatment OutcomeABSTRACT
OBJECTIVE: To evaluate open bedside tracheostomy (OBT) and compare it with open operating room (OR) tracheostomy and bedside percutaneous dilatational tracheostomy (PDT) in complications and cost. To determine the tracheostomy practice patterns of academic otolaryngology programs. STUDY DESIGN: Retrospective cohort study and cross-sectional study. SETTING: Public hospital and tertiary care hospital. METHODS: Otolaryngology program directors were surveyed to determine their institutions' tracheostomy practice patterns and the factors preventing the implementation of open bedside tracheostomies. A retrospective chart review was done of tracheostomies performed at our institutions from 2009 to 2019 for prolonged mechanical ventilation. Complications, length of intubation, comorbidities, body mass index, demographics, mortality rates, and decannulation rates were recorded. A cost analysis between OBT and PDT was conducted. RESULTS: Data from 802 patients were analyzed for 449 OBTs, 206 PDTs, and 147 open OR tracheostomies. Complication rates were low. PDTs were more likely to have perioperative tracheal bleeding (P = .028) and mucus plugging (P = .006). OBTs were performed on sicker patients with a higher Charlson Comorbidity Index than PDT and OR tracheostomies. The cost of OBT was less than that of PDT. The survey response rate of tracheostomy practice patterns was 46%. The otolaryngologists at the responding programs all conducted OR tracheostomies, while 52.7% did OBTs and 30.9% PDTs. CONCLUSION: OBT can be done safely in patients with multiple comorbidities and has a cost that can be less than PDT. Despite these benefits, only 50% of academic institutions routinely performed OBT.