Trends in Maxillomandibular Fixation Technique at a Single Academic Institution.

Study Design: Retrospective chart review. Objective: Restoration of premorbid occlusion is a key goal in the treatment of mandibular fractures. Placement of the patient in maxillomandibular fixation (MMF) is performed during mandibular fracture repair to help establish occlusion. A number of techniques are available to achieve MMF. We sought to examine trends in MMF technique at our institution. Methods: A retrospective chart review was conducted to evaluate patients who underwent surgical treatment of mandibular fractures between January 1, 2011 and March 31, 2021. Data including fracture characteristics, mechanism of injury, patient demographics, complication rates, and MMF technique utilized were collected. Results: One hundred sixty-three patients underwent MMF (132 males). The most common etiology of fracture was assault (34%). There was an increasing preference for rapid MMF techniques over time, as opposed to standard Erich arch bars. No significant difference in obtaining adequate fracture reduction as determined by postoperative imaging or complications were noted between those who underwent MMF with newer rapid techniques vs traditional MMF techniques. Conclusions: Our institution has demonstrated changing trends in the technique utilized for establishing occlusion intraoperatively, more recently favoring rapid MMF techniques, with similar rates of complications and ability to adequately reduce fractures.

A Novel Electronic Record System for Documentation and Efficient Workflow for Community Health Workers: Development and Usability Study.

BACKGROUND: The COVID-19 pandemic added to the decades of evidence that public health institutions are routinely stretched beyond their capacity. Community health workers (CHWs) can be a crucial extension of public health resources to address health inequities, but systems to document CHW efforts are often fragmented and prone to unneeded redundancy, errors, and inefficiency. OBJECTIVE: We sought to develop a more efficient data collection system for recording the wide range of community-based efforts performed by CHWs. METHODS: The Communities Organizing to Promote Equity (COPE) project is an initiative to address health disparities across Kansas, in part, through the deployment of CHWs. Our team iteratively designed and refined the features of a novel data collection system for CHWs. Pilot tests with CHWs occurred over several months to ensure that the functionality supported their daily use. Following implementation of the database, procedures were set to sustain the collection of feedback from CHWs, community partners, and organizations with similar systems to continually modify the database to meet the needs of users. A continuous quality improvement process was conducted monthly to evaluate CHW performance; feedback was exchanged at team and individual levels regarding the continuous quality improvement results and opportunities for improvement. Further, a 15-item feedback survey was distributed to all 33 COPE CHWs and supervisors for assessing the feasibility of database features, accessibility, and overall satisfaction. RESULTS: At launch, the database had 60 active users in 20 counties. Documented client interactions begin with needs assessments (modified versions of the Arizona Self-sufficiency Matrix and PRAPARE [Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences]) and continue with the longitudinal tracking of progress toward goals. A user-specific automated alerts-based dashboard displays clients needing follow-up and upcoming events. The database contains over 55,000 documented encounters across more than 5079 clients. Available resources from over 2500 community organizations have been documented. Survey data indicated that 84% (27/32) of the respondents considered the overall navigation of the database as very easy. The majority of the respondents indicated they were overall very satisfied (14/32, 44%) or satisfied (15/32, 48%) with the database. Open-ended responses indicated the database features, documentation of community organizations and visual confirmation of consent form and data storage on a Health Insurance Portability and Accountability Act-compliant record system, improved client engagement, enrollment processes, and identification of resources. CONCLUSIONS: Our database extends beyond conventional electronic medical records and provides flexibility for ever-changing needs. The COPE database provides real-world data on CHW accomplishments, thereby improving the uniformity of data collection to enhance monitoring and evaluation. This database can serve as a model for community-based documentation systems and be adapted for use in other community settings.

Impact of Adjuvant Radiotherapy Setting on Quality-of-Life in Head and Neck Squamous Cell Carcinoma.

OBJECTIVE: To determine differences in post-treatment QoL across treatment settings in patients receiving adjuvant radiation therapy for head and neck squamous cell carcinoma (HNSCC). METHODS: This was a prospective observational cohort study of patients with HNSCC initially evaluated in a head and neck surgical oncologic and reconstructive clinic at an academic medical center (AMC). Participants were enrolled prior to treatment in a prospective registry collecting demographic, social, and clinical data. Physical and social-emotional QoL (phys-QoL and soc-QoL, respectively) was measured using the University of Washington-QoL questionnaire at pre-treatment and post-treatment visits. RESULTS: A cohort of 177 patients, primarily male and White with an average age of 61.2 ± 11.2 years, met inclusion criteria. Most patients presented with oral cavity tumors (n = 132, 74.6%), had non-HPV-mediated disease (n = 97, 61.8%), and were classified as Stage IVa (n = 72, 42.8%). After controlling for covariates, patients treated at community medical centers (CMCs) reported a 7.15-point lower phys-QoL compared with those treated at AMCs (95% CI: -13.96 to -0.35, p = 0.040) up to 12 months post-treatment. Additionally, patients who were treated at CMCs had a 5.77-point (-11.86-0.31, p = 0.063) lower soc-QoL score compared with those treated at an AMC, which was not statistically significant. CONCLUSION: This study revealed that HNSCC patients treated with radiation at AMCs reported significantly greater phys-QoL in their first-year post-treatment compared to those treated at CMCs, but soc-QoL did not differ significantly. Further observational studies are needed to explore potential factors, including treatment planning and cancer resource engagement, behind disparities between AMCs and CMCs. LEVEL OF EVIDENCE: Step 3 Laryngoscope, 2024.

Six-week postoperative opioid use and pain following a randomized controlled trial evaluating multimodal analgesia for head and neck free flap patients.

Introduction: Head and neck malignancy treatment often involves invasive surgeries, necessitating effective postoperative pain control. However, chronic reliance on opioid medications remains a challenge for many patients after surgery. Multimodal analgesia (MMA) within enhanced recovery after surgery protocols has shown success in limiting narcotic pain medications for other cancer types. In a prior study, MMA comprising acetaminophen, ketorolac, gabapentin, and a neurogenic block reduced opioid use in the 7-day postoperative period for major head and neck reconstructive surgery. This study investigates the impact of multimodal analgesia on opioid prescription and pain during the 6-week postoperative period for patients undergoing major head and neck oncologic surgeries, aiming to understand the longer-term effects of narcotic use. Methods: The study retrospectively examined participants in a [hybrid type 1 effectiveness-implementation pragmatic trial to assess multimodal analgesia's long-term effectiveness in head and neck free flap surgery. Arm A received scheduled acetaminophen and as-needed opioids, while Arm B received scheduled gabapentin, ketorolac, a regional nerve block at the donor site, scheduled acetaminophen, and as-needed opioids. Retrospective data collection included opioid prescription use and pain scores up to 6 weeks after surgery, gathered from the Kansas prescription drug monitoring program, K-TRACS. Results: Thirty patients participated, 14 in Arm A and 16 in Arm B. The average morphine milligram equivalents per day of filled prescriptions were not significantly different between Arm A and Arm B (7.23 vs. 7.88, p = .845). Additionally, average pain scores at 6 weeks showed no significant difference between the two groups (1.4 vs. 1.9, p = .612). Conclusion: Patients with head and neck cancer treated with multimodal analgesia during the perioperative period did not exhibit significant differences in opioid use and pain within 6 weeks after discharge. To confirm these findings, a re-examination with strict measures of opioid use and scheduled pain assessments in a prospective manner is warranted. Level of Evidence: 4.

Disparities in Olfactory Dysfunction in African Americans.

OBJECTIVES: To examine olfactory performance in African Americans (AA) and Whites by comparing individual scent scores on objective olfactory tests to assess potential racial-ethnic differences of scent detection. METHODS: Cross-sectional study of healthy participants, age 18+ years, and without sinonasal inflammatory disease from June 2021 to April 2022. Included participants self-identified as AA or White. Patients were recruited from outpatient clinics at University of Kansas Medical Center, and the local community. Two smelling tests were employed: Affordable Rapid Olfactory Measurement Array (AROMA) and Sniffin' Sticks (SST-12). Sino-Nasal Outcome Test (SNOT-22) was used for self-reported olfactory function . Pearson correlation and chi-square tests were used to detect statistical significance. RESULTS: Our sample included 102 (46 AA and 56 Whites) participants. AROMA and SST-12 scores were significantly correlated in AA (P < .01, Pearson's Rho = .642) and Whites (P < .05, Pearson's Rho = .297). Mean scores on AROMA were significantly lower for AAs: 64.2 and Whites: 75.5 (P < .01). On AROMA, AA less accurately identified the scents of Licorice, Orange, Lavender, Cinnamon, Clove, and Rosemary (P < .05). Similarly, SST-12 mean scores for AAs: 84.2 were also lower than Whites: 89.9 (P < .01). On SST-12, AA less accurately identified the scent of pineapple Based on SST-12 scoring criteria, 60.9% of AA and 30.4% of Whites were classified as hyposmic (P < .05). SNOT-22 Smell scores were equivalent for both groups. CONCLUSION: On both tests of olfaction, AA performed worse than Whites and a greater proportion of AA were considered hyposmic compared to Whites. This is a discrepancy with self-reported olfaction, which showed no difference between Whites and AA. AA performed significantly worse than their White counterparts on several scents, with possible implications regarding cultural appropriateness of scents used in olfactory testing.

Forecasting Rural and Urban Otolaryngologists, Radiation Oncologists, and Oropharyngeal Carcinoma.

OBJECTIVE: To forecast oropharyngeal carcinoma (OPC) incidence with otolaryngologist and radiation oncologist numbers per population by rural and urban counties through 2030. METHODS: Incident OPC cases were abstracted from the Surveillance, Epidemiology, and End Results 19 database, and otolaryngologists and radiation oncologists from the Area Health Resources File by county from 2000 to 2018. Variables were analyzed by metropolitan counties with over 1,000,000 people (large metros), rural counties adjacent to a metro (rural adjacent), and rural counties not adjacent to a metro (rural not adjacent). Data were forecasted via an unobserved components model with regression slope comparisons. RESULTS: Per 100,000 population, forecasted OPC incidence increased from 2000 to 2030 (large metro: 3.6 to 10.6 cases; rural adjacent: 4.2 to 11.9; rural not adjacent: 4.3 to 10.1). Otolaryngologists remained stable for large metros (2.9 to 2.9) but declined in rural adjacent (0.7 to 0.2) and rural not adjacent (0.8 to 0.7). Radiation oncologists increased from 1.0 to 1.3 in large metros, while rural adjacent remained similar (0.2 to 0.2) and rural not adjacent increased (0.2 to 0.6). Compared to large metros, regression slope comparisons indicated similar forecasted OPC incidence for rural not adjacent (p = 0.58), but greater for rural adjacent (p < 0.001, r = 0.96). Otolaryngologists declined for rural regions (p < 0.001 and p < 0.001, r = -0.56, and r = -0.58 for rural adjacent and not adjacent, respectively). Radiation oncologists declined in rural adjacent (p < 0.001, r = -0.61), while increasing at a lesser rate for rural not adjacent (p = 0.002, r = 0.96). CONCLUSIONS: Rural OPC incidence disparities will grow while the relevant, rural health care workforce declines. LEVEL OF EVIDENCE: NA Laryngoscope, 134:136-142, 2024.

Disentangling Social Determinants of Health and Rurality in Head and Neck Cancer 2-Year Mortality.

Social determinants of health (SDoH) and rurality are known factors that may influence outcomes in head and neck squamous cell carcinoma (HNSCC). Patients residing in remote locations or those with multiple SDoH may encounter barriers to initial diagnosis, adherence to multidisciplinary treatments, and posttreatment surveillance, which may impact their overall survival. However, previous studies have shown mixed results associated with rural residence. The aim of this study is to identify the impact of rurality and SDoH on 2-year survival in HNSCC. The study was conducted using a Head and Neck Cancer Registry at a single institution from June 2018 through July 2022. Rurality, defined by US census scores, and individual measures of SDoH were used. Our results indicate that each additional adverse SDoH factor results in 1.5 times the odds of mortality at 2 years. Individualized measures of SDoH, rather than rurality alone, better reflect patient prognosis in HNSCC.

Association of Social-Ecological Factors With Delay in Time to Initiation of Postoperative Radiation Therapy: A Prospective Cohort Study.

Importance: Timely initiation of postoperative radiation therapy (PORT) is associated with reduced recurrence rates and improved overall survival in patients with head and neck squamous cell carcinoma (HNSCC). Measurement of the association of social-ecological variables with PORT delays is lacking. Objective: To assess individual and community-level factors associated with PORT delay among patients with HNSCC. Design, Setting, and Participants: This prospective cohort study carried out between September 2018 and June 2022 included adults with untreated HNSCC who were enrolled in a prospective registry at a single academic tertiary medical center. Demographic information and validated self-reported measures of health literacy were obtained at baseline visits. Clinical data were recorded, and participant addresses were used to calculate the area deprivation index (ADI), a measure of community-level social vulnerability. Participants receiving primary surgery and PORT were analyzed. Univariable and multivariable regression analysis was performed to identify risk factors for PORT delays. Exposures: Surgical treatment and PORT. Main Outcomes and Measures: The primary outcome was PORT initiation delay (>42 days from surgery). Risk of PORT initiation delay was evaluated using individual-level (demographic, health literacy, and clinical data) and community-level information (ADI and rural-urban continuum codes). Results: Of 171 patients, 104 patients (60.8%) had PORT delays. Mean (SD) age of participants was 61.0 (11.2) years, 161 were White (94.2%), and 105 were men (61.4%). Insurance was employer-based or public among 65 (38.5%) and 75 (44.4%) participants, respectively. Mean (SD) ADI (national percentile) was 60.2 (24.4), and 71 (41.8%) resided in rural communities. Tumor sites were most commonly oral cavity (123 [71.9%]), with 108 (63.5%) classified as stage 4 at presentation. On multivariable analysis, a model incorporating individual-level factors with health literacy in addition to community-level factors was most predictive of PORT delay (AOC= 0.78; R2, 0.18). Conclusions and Relevance: This cohort study provides a more comprehensive assessment of predictors of PORT delays that include health literacy and community-level measures. Predictive models that incorporate multilevel measures outperform models with individual-level factors alone and may guide precise interventions to decrease PORT delay for at-risk patients with HNSCC.

Quantifying Faculty Perception of Diversity, Equity, and Inclusion Within Academic Otolaryngology-Head and Neck Surgery Departments.

OBJECTIVE: Investigating faculty perceptions of diversity, equity, and inclusion (DEI) among academic otolaryngology programs. STUDY DESIGN: Quantitative survey. SETTING: Academic otolaryngology departments. METHODS: The DEI Inventory was developed by a multi-institutional health equity consortium and disseminated within 16 academic otolaryngology programs. The inventory consisted of 25 items graded on a 5-point Likert scale (strongly disagree to strongly agree), 2 yes/no questions, and 5 items reflecting overall DEI, stress, and burnout among academic otolaryngologists. Validated imposter phenomenon and personality trait measures were also included. RESULTS: The inventory received 158 (31.0%) partial and 111 (21.8%) full responses. No significant differences were identified in DEI scores by race. Compared to males, females reported lower scores on the overall DEI Inventory (3.6 vs 4.3, p < .001). Female respondents also reported greater levels of imposter phenomenon than their male counterparts (53.2 vs 47.5, p = .049). CONCLUSION: Preliminary responses to our DEI Inventory suggest that faculty perception of DEI is not impacted by race. Female faculty report considerably lower perceptions of DEI than their male counterparts and experience greater levels of imposter phenomenon. The results of the DEI Inventory can help departments design meaningful interventions to improve levels of DEI among faculty.

Integrating HPV Vaccination Within PrEP care Delivery for Underserved Populations: A Mixed Methods Feasibility Study.

Human Papillomavirus (HPV) vaccination is effective at preventing anal cancer, which disproportionally impacts gay/bisexual men (GBM) and transgender women (TGW). Vaccine coverage among GBM/TGW is insufficient to reduce anal cancer disparities. Federally qualified health centers (FQHCs) can increase reach and uptake of HPV vaccination by integrating and promoting HPV vaccination in ongoing HIV preventive care (e.g., Pre-exposure Prophylaxis [PrEP]). The purpose of the current study was to assess the feasibility and potential impact of integrating HPV vaccination with PrEP care. We conducted a mixed methods study of PrEP providers and staff (qualitative interviews, N = 9) and PrEP patients (quantitative survey, N = 88) at an FQHC in Philadelphia, Pennsylvania. Qualitative thematic analysis of PrEP provider/staff interviews was informed by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to identify and describe barriers and facilitators to HPV vaccination implementation. Quantitative analysis of PrEP patient survey was informed by the Information-Motivation-Behavioral Skills Model. Quantitative interviews resulted in 16 themes related to characteristics of the inner and outer clinic context. Barriers among providers included lack of focus on HPV in PrEP management guidelines, in metrics mandated by funding agencies, and in electronic medical record templates. Lack of anal cancer specific knowledge and motivation was identified in both PrEP patients and providers/staff. Providing HPV vaccination during routine PrEP visits was highly acceptable to both patients and providers. Based on these findings, we recommend several multi-level strategies to increase HPV vaccine uptake among PrEP patients.

Assessing the Risk of Adjuvant Radiotherapy Initiation Delays With Social Support Surveys.

OBJECTIVE: In patients with head and neck squamous cell carcinoma (HNSCC), initiating postoperative radiotherapy (PORT) greater than 42 days after surgery is associated with a higher risk of poor survival outcomes. Social support has been shown to modulate behaviors related to care-seeking and treatment adherence. In this study, we sought to determine the relationship between social support metrics and PORT delays. STUDY DESIGN: Prospective cohort study. SETTING: Single tertiary medical center. METHODS: Patients with HNSCC who underwent primary surgical excision requiring PORT were prospectively enrolled. Patient-perceived social support metrics were assessed using the Medical Outcomes Study Social Support Survey (MOS-SSS) at initial presurgical evaluation. Associations with PORT delays were evaluated via univariable and multivariable logistic regression analysis. RESULTS: A total of 111 patients met the inclusion criteria for the study. An additional 28 patients were recommended to receive PORT but did not initiate treatment and were included for secondary analysis. All four subscales of the MOS-SSS (positive social interaction, affectionate support, tangible support, and emotional/informational support) were significantly associated with PORT initiation delays on univariable analysis. On multivariable analysis, the overall MOS-SSS score (odds ratio [OR] 2.08, 1.15-4.35, p = .028) was significantly associated with PORT initiation delays. On secondary analysis, lower tangible support was associated with a lack of PORT initiation (OR 1.63, 1.05-2.54, p = .028). CONCLUSION: Social support metrics were significantly associated with PORT delays, which may help promote tighter scheduling and closer monitoring of high-risk patients.

Long-term trends in body mass index throughout upper airway stimulation treatment: does body mass index matter?

STUDY OBJECTIVES: Upper airway stimulation is a surgical option for patients with obstructive sleep apnea who fail other forms of noninvasive treatment. Current guidelines recommend a baseline body mass index (BMI) below 32 kg/m2 for eligibility. In this study, we identify trends in BMI before and after upper airway stimulation to characterize the influence of BMI on treatment success. METHODS: Patients underwent upper airway stimulation implantation between 2016 and 2021. Sleep study data were collected from preoperative and most recent postoperative sleep study. BMI data were collected and compared across the following time points: preoperative sleep study (BMI-1), initial surgeon consultation (BMI-2), surgery (BMI-3), titration polysomnogram (BMI-4), and second postoperative sleep study (BMI-5). Patients were categorized into groups (BMI ≥32 [BMI32], 25 ≤ BMI <32 [BMI25], BMI <25 [BMI18]) based BMI-1, and clinical outcomes were compared. RESULTS: 253 patients were included. The BMI32 group showed a significant decrease in BMI between BMI-1 and BMI-3 (33.9 vs 32.2; P < .001) and a significant increase in BMI between BMI-3 and BMI-5 (32.2 vs 33.0; P = .047). Apnea-hypopnea index improvement and treatment success rate were not significantly different between groups. On univariate and multivariable logistic regression, a lower BMI-5 was significantly predictive of treatment success (odds ratio: 0.88; 95% confidence interval: 0.79-0.97; P = .016). BMI-5 was also significantly associated with improvement in apnea-hypopnea index (P = .002). Other BMI time points were not associated with measures of treatment success. CONCLUSIONS: Reduced BMI after upper airway stimulation implantation, as opposed to baseline BMI, predicted treatment success. These findings may guide patient counseling, with implications for long-term adherence and therapy success. CITATION: Renslo B, Virgen CG, Sawaf T, et al. Long-term trends in body mass index throughout upper airway stimulation treatment: does body mass index matter? J Clin Sleep Med. 2023;19(6):1061-1071.

Investigation of a Novel Activity-Based Checks (ABC) Functional Pain Scale in the Post-Operative Urologic Surgery Patient.

Introduction: The authors investigated a novel functional pain scale, the Activity-Based Checks (ABCs) of Pain, following open urologic surgery. The primary objectives were to establish the strength of the correlation between the ABCs and the numeric rating scale (NRS) and determine the impact of functional pain on the patient's opioid requirements. We hypothesized that ABC score would correlate strongly with NRS and that the ABC score during hospitalization would be more closely correlated with the number of opioids prescribed and used. Methods: This prospective study included patients at a tertiary academic hospital undergoing nephrectomy and cystectomy. The NRS and ABCs were collected pre-operatively, during the inpatient stay, and at the one-week follow-up. Milligrams of morphine equivalents (MMEs) prescribed at discharge and the MME reportedly taken during the first post-operative week were recorded. Spearman's Rho was used to assess the correlation between scale variables. Results: Fifty-seven patients were enrolled. The ABCs correlated strongly with the NRS at baseline and post-operative appointments (r = 0.716, p < 0.001 and 0.643, p < 0.001). Neither the NRS nor the composite ABCs score was predictive of outpatient MME requirements; the ABCs function, "Walking outside the room" significantly correlated to MMEs taken after discharge (r = 0.471, p = 0.011). The greatest predictor of MMEs taken was the number of MMEs prescribed (0.493, p = 0.001). Conclusions: This study highlighted the importance of post-operative pain assessment that takes functional pain into consideration to evaluate pain, inform management decisions, and reduce opiate reliance. It also emphasized the strong relationship between opioids prescribed and opioids consumed.

Factors affecting adherence to intranasal treatment for allergic rhinitis: A qualitative study.

Objective: To determine the facilitators of and barriers to adherence to use of intranasal pharmacotherapy (daily intranasal corticosteroids and/or antihistamine, and nasal saline irrigation [NSI]), for allergic rhinitis (AR). Methods: Patients were recruited from an academic tertiary care rhinology and allergy clinic. Semi-structured interviews were conducted after the initial visit and/or 4-6 weeks following treatment. Transcribed interviews were analyzed using a grounded theory, inductive approach to elucidate themes regarding patient adherence to AR treatment. Results: A total of 32 patients (12 male, 20 female; age 22-78) participated (seven at initial visit, seven at follow-up visit, and 18 at both). Memory triggers, such as linking nasal routine to existing daily activities or medications, were identified by patients as the most helpful strategy for adherence at initial and follow-up visits. Logistical obstacles related to NSI (messy, takes time, etc.) was the most common concept discussed at follow-up. Patients modified the regimen based on side effects experienced or perceived efficacy. Conclusions: Memory triggers help patients adhere to nasal routines. Logistical obstacles related to NSI can deter from use. Health care providers should address both concepts during patient counseling. Nudge-based interventions that incorporate these concepts may help improve adherence to AR treatment. Level of Evidence: 2.

Pilot randomized, controlled, preoperative intervention for nutrition trial in head and neck cancer.

BACKGROUND: Several prospective studies report improved outcomes with pretreatment nutrition interventions prior to radiation therapy for head and neck cancer (HNC), but none have assessed similar interventions before surgery for HNC. METHODS: POINT, a pilot randomized controlled trial, was conducted to evaluate a multimodal nutrition intervention. Patients undergoing primary surgery with free flap reconstruction for HNC were randomly assigned to the control arm or a preoperative multimodal nutrition intervention. RESULTS: POINT included 49 patients. Nutrition risk scores did not change significantly for either the intervention or control group. Control patients had a significant decrease in body weight in the preoperative period (p < 0.001). Conversely, weight among intervention patients did not significantly decrease (p = 0.680). The intervention mitigated weight loss in patients with dysphagia (p = 0.001). CONCLUSIONS: Preoperative nutrition optimization shows potential to reduce weight loss normally experienced by patients with head and neck cancer prior to surgical extirpation, especially among those with subjective dysphagia.

The Use of Dissemination and Implementation to Improve Multimodal Analgesia in Head and Neck Surgery.

OBJECTIVES: To optimize the delivery of multimodal analgesia to patients undergoing major head and neck oncologic surgeries. METHODS: Pilot study included patients enrolled to receive either scheduled acetaminophen and as-needed opioids (control group) or scheduled acetaminophen, gabapentin, ketorolac, and as-needed opioids (experimental group). RCT, a hybrid type 1 effectiveness-implementation pragmatic trial, was designed to test the effectiveness of the intervention. Arm A received scheduled acetaminophen and as-needed opioids. Arm B received scheduled gabapentin, ketorolac, a regional nerve block at the free tissue donor site, scheduled acetaminophen and as-needed opioids. RESULTS: Pilot: Thirty-one patients undergoing major head and neck surgery were enrolled. Mean MMEs administered in control group (n = 15) was 251.60 mg (SD = 224.57 mg); mean MMEs in Experimental group (n = 16) was 195.78 mg (SD = 131.08 mg), p = 0.401. LOS was 8.0 days in control versus 7.0 days in experimental group (p = 0.054). RCT: Interim analysis for safety and futility was planned during trial's design after 30 patients (n = 14 Arm A, and n = 16 Arm B). Mean MMEs administered were 135.1 mg in Arm A, (SD = 86.0 mg) versus mean MME of 51.3 mg in Arm B (SD = 43.3 mg, (p < 0.05)). Given clear superiority results, the trial was prematurely terminated. Functional pain scores, LOS, and complications were similar between the arms (p > 0.05). Variability of mean MME was compared before and after implementation of the management protocols: SD in RCT#1 was 181.46 mg versus 124.6 mg in RCT#2. CONCLUSION: Multimodal analgesia significantly reduced the need for opioids in patients undergoing major head and neck surgery. LEVEL OF EVIDENCE: 1, Randomized Clinical Trial Laryngoscope, 133:S1-S11, 2023.

Perioperative Outcomes in Patients Who Underwent Fibula, Osteocutaneous Radial Forearm, and Scapula Free Flaps: A Multicenter Study.

Importance: Studies comparing perioperative outcomes of fibula free flaps (FFFs), osteocutaneous radial forearm free flaps (OCRFFFs), and scapula free flaps (SFFs) have been limited by insufficient sample size. Objective: To compare the perioperative outcomes of patients who underwent FFFs, OCRFFFs, and SFFs. Design, Setting, and Participants: This cohort study assessed the outcomes of 1022 patients who underwent FFFs, OCRFFFs, or SFFs for head and neck reconstruction performed at 1 of 6 academic medical centers between January 2005 and December 2019. Data were analyzed from September 17, 2021, to June 9, 2022. Main Outcomes and Measures: Patients were stratified based on the flap performed. Evaluated perioperative outcomes included complications (overall acute wound complications, acute surgical site infection [SSI], fistula, hematoma, and flap failure), 30-day readmissions, operative time, and prolonged hospital length of stay (75th percentile, >13 days). Patients were excluded if data on flap type or clinical demographic characteristics were missing. Associations between flap type and perioperative outcomes were analyzed using logistic regression, after controlling for other clinically relevant variables. Adjusted odds ratios (aORs) with 95% CIs were generated. Results: Perioperative outcomes of 1022 patients (mean [SD] age, 60.7 [14.5] years; 676 [66.1%] men) who underwent major osseous head and neck reconstruction were analyzed; 510 FFFs (49.9%), 376 OCRFFFs (36.8%), and 136 SFFs (13.3%) were performed. Median (IQR) operative time differed among flap types (OCRFFF, 527 [467-591] minutes; FFF, 592 [507-714] minutes; SFF, 691 [610-816] minutes). When controlling for SSI, FFFs (aOR, 2.47; 95% CI, 1.36-4.51) and SFFs (aOR, 2.95; 95% CI, 1.37-6.34) were associated with a higher risk of flap loss than OCRFFFs. Compared with OCRFFFs, FFFs (aOR, 1.77; 95% CI, 1.07-2.91) were associated with a greater risk of fistula after controlling for the number of bone segments and SSI. Both FFFs (aOR, 1.77; 95% CI, 1.27-2.46) and SFFs (aOR, 1.68; 95% CI, 1.05-2.69) were associated with an increased risk of 30-day readmission compared with OCRFFFs after controlling for Charlson-Deyo comorbidity score and acute wound complications. Compared with OCRFFFs, FFFs (aOR, 1.78; 95% CI, 1.25-2.54) and SFFs (aOR, 1.96; 95% CI, 1.22-3.13) were associated with a higher risk of prolonged hospital length of stay after controlling for age and flap loss. Conclusions and Relevance: Findings of this cohort study suggest that perioperative outcomes associated with OCRFFFs compare favorably with those of FFFs and SFFs, with shorter operative times and lower rates of flap loss, 30-day readmissions, and prolonged hospital length of stay. However, patients undergoing SFFs represented a more medically and surgically complex population than those undergoing OCRFFFs or FFFs.

Assessment of conditions leading to lost-to-follow-up of head and neck cancer patients.

PURPOSE: Head and neck cancer patients require close clinical follow up to monitor and address sequelae of treatment and for adequate cancer surveillance. The goal of this study is to determine barriers and risk factors for head and neck cancer patients who are lost-to-follow-up. MATERIALS AND METHODS: A chart review of the Head and Neck Cancer Registry was performed to identify patients who were lost-to-follow-up (LTF). LTF was defined as missing two consecutive appointments as recommended by their oncologic surgeon. Those identified as LTF were contacted via email and phone to complete a 16-question survey addressing possible barriers to follow up. RESULTS: Of the 353 patients reviewed, 53 met the criteria for LTF (15%). Forty-eight participants were contacted, and 23 surveys were completed (48%). Of the 23 patients that responded, 22% reported difficulty scheduling an appointment, 30% had transportation barriers, 22% had personal or work obligations that prevented follow up, 17% did not follow up because they "felt better," and 39% were following up with an otolaryngologist or oncologist closer to home. Only three participants (13%) were aware of the recommended 5-year surveillance period. CONCLUSION: Head and neck cancer patients have a variety of reasons they are lost to follow-up. Understanding these barriers is critical to creating a patient-centered model that balances both clinical surveillance needs and reasonable expectations for patients. Improvements can be made to educate patients on the recommended length of follow-up and its importance.

PrEP patient attitudes, beliefs and perceived barriers surrounding HPV vaccination: a qualitative study of semistructured interviews with PrEP patients in primary care clinics in Kansas and Missouri.

OBJECTIVES: Men who have sex with men who use pre-exposure prophylaxis (PrEP) have not traditionally been targets for human papillomavirus (HPV) vaccine programmes, despite their high risk for HPV-related cancers and HPV vaccine being approved by the U.S. Food and Drug Administration (FDA) for people up to age 45. The objective of this study was to assess attitudes and barriers towards HPV vaccine for adult PrEP users in the primary care context. METHODS: Semistructured phone interviews of 16 primary care patients taking PrEP in the Kansas City metropolitan area were conducted, with interviews assessing HPV vaccination status, and attitudes, beliefs and perceived barriers surrounding HPV vaccine. Interview notes were open-coded by student authors, and themes were generated through code review and consensus. Data were then analysed using thematic analysis. RESULTS: The results showed that most patients believed that preventative health was important and felt the HPV vaccine was important. Most patients were open to vaccination if recommended by their primary care physician and covered by insurance. Most participants believed HPV infection to be far worse in women, and there were gaps in knowledge surrounding HPV and its effects in men. CONCLUSIONS: While more research is needed to better understand facilitators of a linkage between PrEP and HPV vaccine in clinical settings for groups at high risk for HPV-related cancers, getting primary care providers involved in educating high-risk patients about the importance of HPV vaccination and actively recommending the vaccine to those patients has the potential to prevent HPV-related cancers.