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 1085 identified studies, 51 met final inclusion criteria. Outcomes evaluated included FT measures/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 vs treatment vs survivorship), setting (clinic-based, online, telephone/mail), utilized tools (21 unique tools, 7 previously validated), and interpretations of screening results (varying FT score cutoffs defining high vs. low FT). Younger age, lower income, lower education, non-white race, employment status change, advanced cancer stage, and systemic/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.

Impact of Early Research Productivity on Future Academic Output Among Head and Neck Fellows.

OBJECTIVE: To examine the impact of pre-fellowship publications on future research productivity and career placement among head and neck (H&N) surgery fellowship graduates. METHODS: H&N surgery fellowship graduates between 2014 and 2022 were identified from publicly available data. Timing of fellowship graduation, number of publications during each stage of education and training, and number of first authorship publications were analyzed for association with scholarly productivity and academic career placement. RESULTS: In our analysis of 409 H&N fellowship graduates, there was a strong positive correlation between the year of fellowship graduation and the average number of publications in residency (R2 = 0.82) and fellowship (R2 = 0.79). Graduates producing more than the average of 2.37 publications prior to residency had a significantly higher average number of publications during residency and fellowship compared to those who published below average (p < 0.001). A higher number of publications prior to and during residency were both independently associated with a higher likelihood of academic career placement (p = 0.015 and p = 0.002, respectively). More first-author publications prior to residency were associated with a higher number of publications during residency and fellowship (p = 0.015). In sub-analyses, gender did not impact the average number of publications during residency and fellowship. Similarly, the COVID-19 pandemic did not significantly impact the average number of publications during the fellowship when comparing the classes of 2020-2022 to 2017-2019. CONCLUSION: Research productivity among H&N fellowship graduates has increased in recent years. Research productivity in medical school and residency is associated with scholarly output in later stages of training and academic career placement. LEVEL OF EVIDENCE: NA Laryngoscope, 134:3165-3169, 2024.

Lower odds of COVID-19-related mortality in hospitalised patients with type II diabetes mellitus: A single-centre study.

BACKGROUND: COVID-19 infection in patients with type 2 diabetes mellitus (T2DM) -a chronic illness in Lebanon-is not well described. METHODS: This was a single-centre retrospective observational study of 491 patients, including 152 patients with T2DM, who were hospitalised for COVID-19 between 20 August 2020 and 21 April 2021. Data on clinical characteristics, laboratory and radiological findings and outcomes were collected from the electronic medical records. Clinical characteristics and in-hospital mortality between patients with and without T2DM infected with COVID-19 using multivariate analysis were compared. RESULTS: Patients with T2DM were significantly older than those without T2DM (mean age, 68.7 vs. 60.3 years). Patients with T2DM were more likely to present with a body temperature of <38.3°C (83.9% vs. 69.9%) and less likely to present with chest pain (3.9% vs. 9.1%) and sore throat (2.0% vs. 6.8%). Patients with T2DM were more likely to be hypertensive (76.35% vs. 41%) and dyslipidaemic (58.6% vs. 25.7%) and had more frequent underlying coronary artery disease (33.6% vs. 12.4%). The rates of patients with creatinine levels of ≥1.17 mg/L and troponin T levels of ≥4 ng/dL were higher in the T2DM group than in the non-T2DM group (30.4% vs. 15% and 93.3% vs. 83.1%, respectively). Patients with T2DM were more likely to be admitted to the intensive care unit (ICU) (34.2% vs. 22.1%), require invasive ventilation (18.4% vs. 10.3%) and receive vasopressors (16.4% vs. 10.0%). Increasing age and the use of invasive ventilation and vasopressors were associated with higher odds of mortality (odds ratio (OR), 1.08, 9.95 and 19.83, respectively), whereas longer ICU stay was associated with lower odds of mortality (OR, 0.38). The odds of mortality were lower in the T2DM group than in the non-T2DM group (OR, 0.27). CONCLUSION: Among patients hospitalised for COVID-19, those with T2DM were older, presented with milder symptoms and had more comorbidities and higher troponin T levels compared with those without T2DM. Despite the worse clinical course, the patients with T2DM had lower odds of mortality than those without T2DM.

Cryptococcal meningitis post-covid-19 infection: Immunomodulation, a double-edged sword.

Cryptococcal meningitis is an opportunistic infection associated with altered immunity. Immunomodulatory agent use in severe coronavirus disease 2019 (COVID-19) may predispose such infections. Here, we present a 75-year-old male patient who presented with fever and altered general status after severe COVID-19 infection and developed cryptococcal meningitis. Opportunistic infection may arise from the use of immunomodulation in severe COVID-19, especially in the elderly population. This article describes the case and extensively reviews cryptococcal disease post-COVID-19 literature, highlighting the risk from immunosuppressive treatment.

Characterization and susceptibility of non-albicans Candida isolated from various clinical specimens in Lebanese hospitals.

Background: Invasive fungal infections have presented a challenge in treatment. In the past, it was known that the frontrunner in such infections is Candida albicans with little emphasis placed on non-albicans Candida species (NAC). Studies worldwide have shown a rise in fungal infections attributed to non-albicans Candida species. The aim of this study is to describe the epidemiology of NAC infections along with an overview of resistance in Lebanese hospitals. Methods: This is a two-year observational multi-central descriptive study. Between September 2016 and May of 2018, a total of 1000 isolates were collected from 10 different hospitals distributed all over the country. For the culture, Sabouraud Dextrose Agar was used. Antifungal Susceptibility was evaluated by determining the Minimum Inhibitory Concentration (MIC) in broth (microdilution) of the different antifungal treatments. Results: Out of the 1000 collected isolates, Candida glabrata, being the most isolated species (40.8%), followed by Candida tropicalis: 231(23.1%), Candida parapsilosis: 103(10.3%), and other NAC species at lower percentage. Most of these isolates (88.67%) were susceptible to posaconazole, 98.22% were susceptible to micafungin, and 10% were susceptible to caspofungin. Conclusion: The change of etiology of fungal infections involving a significant increase in NAC cases is alarming due to the different antifungal susceptibility patterns and the lack of local guidelines to guide the treatment. In this context, proper identification of such organisms is of utmost importance. The data presented here can help in establishing guidelines for the treatment of candida infections to decrease morbidity and mortality. Future surveillance data are needed.

Citations and Author Characteristics in Open-Access and Subscription-Based Otolaryngology Journals.

OBJECTIVE: To describe the academic impact and author characteristics of open-access journals in otolaryngology. METHODS: Original articles from three open-access (OTO Open, Laryngoscope Investigative Otolaryngology, and World Journal of Otorhinolaryngology) and three conventional subscription-based otolaryngology specific journals (Otolaryngology - Head & Neck Surgery, The Laryngoscope, JAMA Otolaryngology - Head & Neck Surgery) were assessed. Publication dates of articles from January 2017 to July 2020 were included. Google Scholar and Web of Science citation counts were recorded. H-indexes of first and last authors were included according to Google Scholar and Web of Science and analyzed. RESULTS: This analysis included 3284 articles. Articles published in open-access otolaryngology-specific journals had significantly fewer citations on average (6.8) than articles published in subscription-based journals (12.4, p < 0.0001). The last authors of articles published in subscription-based journals had significantly higher h-indexes (23.50) compared with the last authors of articles published in open-access journals (19.53, p < 0.0001). The first authors of articles published in open-access journals had similar h-indexes (10.26) as the first authors of articles published in subscription-based journals (10.33). CONCLUSIONS: Articles published in open-access journals in otolaryngology were cited significantly less than those published in subscription-based journals. The h-index of the last authors was significantly lower in open-access journals; however, the h-index of the first authors was similar between open-access and subscription-based journals. As measured by citations, open-access publications do not yet appear to have the impact of subscription-based publications. LEVEL OF EVIDENCE: NA Laryngoscope, 133:79-82, 2023.

Hearing restoration and the stria vascularis: evidence for the role of the immune system in hearing restoration.

PURPOSE OF REVIEW: This article reviews the current literature regarding the pathogenesis of immune-mediated sensorineural hearing loss, utilizes previously published single-nucleus transcriptional profiles to characterize cytokine and cytokine receptor expression in the adult stria vascularis cell types to support immune system interaction with the stria vascularis and reviews the current literature on immunomodulatory agents currently being used for hearing-restoration treatment. RECENT FINDINGS: The literature review highlights recent studies that elucidate many cytokines and immune markers, which have been linked to various immune-mediated disease processes that have been observed with sensorineural hearing loss within the stria vascularis and highlights recent publications studying therapeutic targets for these pathways. SUMMARY: This review highlights the current literature regarding the pathogenesis of immune-mediated hearing loss. The role of cochlear structures in human temporal bones from patients with immune-mediated sensorineural hearing loss are highlighted, and we review cytokine signalling pathways relevant to immune-mediated sensorineural hearing loss and localize genes encoding both cytokine and cytokine receptors involved in these pathways. Finally, we review immunomodulatory therapeutics in light of these findings and point to opportunities for the application of novel therapeutics by targeting these signalling pathways.

Timing for Step-Down Therapy of Candidemia in Non-Neutropenic Patients: An International Multi-Center Study.

BACKGROUND: Candida bloodstream infection (BSI) remains one of the leading causes of BSI in critically ill and immunosuppressed cancer patients. In light of the changing epidemiology and rising resistant species, duration of treatment and appropriate timing of stepdown therapy from intravenous (IV) to oral antifungal agents are crucial for utmost disease control and overall survival. METHOD: We performed a multicenter retrospective study, with 119 non-neutropenic patients enrolled from four different medical institutions in Brazil, Lebanon, Spain and the United States, to assess the duration of IV therapy and appropriate time to step-down to oral therapy in adult patients, 14 years of age and older, with documented candidemia. The analysis was done using the statistical program R and SAS v9.4. Descriptive statistics are presented as frequencies and tables and the Fisher exact test was used to test the association between the categorical variables: organism, cancer, country, antifungal drug and duration of therapy, and time of step-down. RESULTS: Candida albicans contributed to 45% of bloodstream infection versus 55% of infection caused by Candida non-albicans. The three most common Candida non-albicans are: Candida glabrata 24%, Candida parapsilosis 13% and Candida tropicalis 8%. Most (57%) of the patients were admitted to ICU, whereas 52% had underlying malignancy. Multivariate analysis showed that a stay at ICU or an underlying cancer requiring chemotherapy were independently associated with failure and death (p <0.001). The average total duration of therapy was 14 days in all patients and 16 days in those who responded and survived. Forty-five patients were stepped down to either fluconazole and/or voriconazole in association with clinical and microbiologic resolution of the candidemia. The average (and median) day of step-down was 5 days. Patients who had a stepdown had more favorable outcomes (78% survival) as compared to those with no stepdown (56% survival) (P = 0.022). However, the 20 patients who received 1-4 days of first IV treatment before a stepdown to oral azoles had a comparable outcome (20% mortality) to the 25 patients who received >5 days of treatment (24% mortality - p = 0.75). CONCLUSION: Our data support the IDSA guidelines in that the total duration of treatment for candidemia should be at least 14 days after a negative blood culture. However, in non-neutropenic cancer patients with candidemia, a step-down to oral azole therapy can safely take place early (within 4 days of initiating IV therapy) as long as the patient had clinical and microbiologic resolution of the bloodstream infections.

The effect of temporary closure and enhanced terminal disinfection using aerosolized hydrogen peroxide of an open-bay intensive care unit on the acquisition of extensively drug-resistant Acinetobacter baumannii.

BACKGROUND: At Makassed Hospital's open-bay intensive care unit (ICU), enhanced terminal disinfection (ETD) using hydrogen peroxide (H2O2) was performed without a predefined schedule in extensively-drug-resistant Acinetobacter baumannii (XDR-AB) outbreaks. In this study, we aimed to check for the value of the temporary closure of the ICU and the use of ETD with aerosolized H2O2 and Ag+ on minimizing the rate of XDR-AB acquisition in patients admitted to the ICU of our facility, which might consequently help us determine the optimal schedule for such procedure in this unit. METHODS: This is a retrospective medical file review of patients admitted to the ICU between January 2016 and May 2018. We divided this period into numerical weeks (NW) after each closure and ETD episode. Risk factors of acquisition (RFA) were determined by comparing the characteristics of patients who acquired XDR-AB to those who didn't. The proportion of patients residing in each NW was included in the RFA analysis. RESULTS: Out of 335 patients, 13% acquired XDR-AB. The overall incidence of XDR-AB acquisition was 14.6 cases/1000 patient days. RFA were XDR-AB contact pressure ≥ 3 days [Odds Ratio (OR) = 9.86, 95% Confidence Interval (CI) (3.65-26.64), P < 0.0001)], mechanical ventilation [OR = 4.99, 95%CI (1.76-14.15), P = 0.002)], and having a wound [OR = 3.72, 95%CI (0.99-13.96), P = 0.05)]. Patients who stayed during NW 7,11 and 14 were at risk of acquisition where the odds significantly increased by 6.5, 9.7 and 14.4 folds respectively (P = 0.03,0.01, and 0.01, respectively). We considered NW 7 as the most suitable time for temporary closure of the ICU and ETD with aerosolized H2O2. CONCLUSION: Contact pressure, mechanical ventilation, and presence of a wound were RFA of XDR-AB. Temporary closure of the ICU with ETD using aerosolized H2O2 decreased the rate of XDR-AB acquisition, yet this effect fades away with time. The ETD was shown to be most efficiently done when repeated every 7 calendar weeks in our open-bay ICU as part of a prevention bundle.