Granuloma Annulare Exhibits Mixed Immune and Macrophage Polarization Profiles with Spatial Transcriptomics.

Granuloma annulare (GA) is an idiopathic condition characterized by granulomatous inflammation in the skin. Prior studies have suggested that GA develops from various triggers, leading to a complex interplay involving innate and adaptive immunity, tissue remodeling, and fibrosis. Macrophages are the major immune cells comprising GA granulomas; however, the molecular drivers and inflammatory signaling cascade behind macrophage activation are poorly understood. Histologically, GA exhibits both palisaded and interstitial patterns on histology; however, the molecular composition of GA at the spatial level remains unexplored. GA is a condition without Food and Drug Administration-approved therapies despite the significant impact of GA on QOL. Spatial transcriptomics is a valuable tool for profiling localized, genome-wide gene expression changes across tissues, with emerging applications in clinical medicine. To improve our understanding of the spatially localized gene expression patterns underlying GA, we profiled the spatial gene expression landscape from 6 patients with GA. Our findings revealed mixed T helper 1 and T helper 2 signals comprising the GA microenvironment and spatially distinct M1 and M2 macrophage polarization characteristics. IFN-γ and TNF signals emerged as important regulators of GA granulomatous inflammation, and IL-32 emerged as a key driver of granulomatous inflammation. Overall, our spatial transcriptomics data indicate that GA exhibits mixed immune and macrophage polarization.

Accuracy of Salivary Circulating Tumor Human Papillomavirus DNA in Detecting Oropharyngeal Cancer: A Systematic Review and Meta-Analysis.

Importance: Circulating tumor human papillomavirus DNA (ctHPV DNA) has shown potential as a biomarker capable of improving outcomes in patients with HPV-related oropharyngeal (OP) cancer. It can be isolated from plasma or saliva, with the latter offering reduced invasiveness and theoretic reduction of lead time. Objective: To perform a systematic review and meta-analysis on the accuracy of salivary ctHPV DNA for detecting HPV-associated OP cancer. Data Sources: Cochrane Library, Embase, PubMed, and Web of Science databases were searched from inception through October 2023. Study Selection: All patients who underwent salivary ctHPV DNA testing at presentation for possible or diagnosed HPV-related OP cancer were included. Non-English and review publications were excluded. Two authors independently voted on article inclusion with a third resolving conflicting votes. Data Extraction and Synthesis: Following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines, multiple authors independently abstracted data and assessed bias of included articles. Bivariate random-effects meta-analysis was performed with I2 to assess for study heterogeneity. Main Outcomes and Measures: Sensitivities, specificities, positive likelihood ratios (PLR), negative likelihood ratios (NLR), and diagnostic odds ratios (DOR) with 95% CIs alongside area under the curve (AUC) of a summary receiver operating characteristic (SROC) curve were calculated. The initial analysis took place throughout December 2023. Results: Of 440 initially identified articles, 6 met inclusion criteria and demonstrated moderate heterogeneity (I2 = 36%) with low risk of bias and low applicability concerns. Overall, 263 total patients were included with a median (range) age of 58 (39-86) years, and 228 (87%) were male patients. Per updated prognostic staging criteria, localized tumors (ie, stages 1 or 2) comprised most cancers at 139 (77%), whereas advanced ones (ie, stages 3 or 4) comprised the remaining 41 (23%). Pooled sensitivity, specificity, PLR, NLR, and DOR values were 64% (95% CI, 36%-85%), 89% (95% CI, 46%-99%), 11.70 (95% CI, 0.37-77.00), 1.21 (95% CI, 0.08-7.00), and 139.00 (95% CI, 0.05-837.00), respectively. The AUC of the SROC curve was 0.80. Conclusions and Relevance: This study supports salivary ctHPV DNA as an acceptably specific test in detecting HPV-associated OP cancer that would benefit from testing in clinical trials prior to real-time implementation.

Quality appraisal of clinical practice guidelines for the evaluation and management of primary hyperparathyroidism.

PURPOSE: Multiple groups have created clinical practice guidelines (CPGs) for the management of primary hyperparathyroidism (PHPT). This report provides a rigorous quality assessment using the Appraisal of Guidelines for Research & Evaluation Instrument (AGREE II) to identify high-performing guidelines and areas for improvement. METHODS: A systematic review was conducted to isolate CPGs addressing the management of PHPT. Guideline data was extracted and quality ratings were assigned by four independent reviewers. Intraclass correlation coefficients (ICC) were calculated to ensure interrater reliability. RESULTS: Twelve guidelines were assessed. The American Association of Endocrine Surgeons (AAES) guideline had the highest mean scaled score across all domains (73.6 ± 31.4%). No other published guideline achieved a "high" quality designation. The highest scoring domain was "clarity of presentation" (mean 60.5 ± 26.5%). The lowest scoring domain was "applicability" (mean 19.8 ± 18.2%). Scoring reliability was excellent, with ICC ≥ 0.89 for all AGREE II 6 domains. CONCLUSION: Although several working groups have developed guidelines to address PHPT management, only those published by the AAES meet all methodologic quality criteria necessary to ensure incorporation of recommendations into clinical practice. Future guidelines would benefit from the development of tools, resources, monitoring criteria that enhance applicability.

SpatialView: an interactive web application for visualization of multiple samples in spatial transcriptomics experiments.

MOTIVATION: Spatial transcriptomics (ST) experiments provide spatially localized measurements of genome-wide gene expression allowing for an unprecedented opportunity to investigate cellular heterogeneity and organization within a tissue. Statistical and computational frameworks exist that implement robust methods for pre-processing and analyzing data in ST experiments. However, the lack of an interactive suite of tools for visualizing ST data and results currently limits the full potential of ST experiments. RESULTS: To fill the gap, we developed SpatialView, an open-source web browser-based interactive application for visualizing data and results from multiple 10× Genomics Visium ST experiments. We anticipate SpatialView will be useful to a broad array of clinical and basic science investigators utilizing ST to study disease. AVAILABILITY AND IMPLEMENTATION: SpatialView is available at https://github.com/kendziorski-lab/SpatialView (and https://doi.org/10.5281/zenodo.10223907); a demo application is available at https://www.biostat.wisc.edu/˜kendzior/spatialviewdemo/.

Metastatic gastric adenocarcinoma to the cutaneous neck and chest wall.

This case describes an atypical cutaneous presentation of metastatic gastric carcinoma in a patient initially presenting with dysphagia and a sclerotic red plaque overlying the anterior neck and chest. Skin biopsy revealed metastatic adenocarcinoma from the upper gastrointestinal tract. Esophagogastroduodenoscopy revealed stage IV metastatic gastric adenocarcinoma. Treatment with chemotherapy was initiated.

Primary Site Surgery in Distantly Metastatic Oropharyngeal Squamous Cell Carcinoma.

OBJECTIVES: Determine if intensive local therapy (i.e., local surgery or radiation) has a survival benefit for patients presenting with distantly metastatic oropharyngeal squamous cell carcinoma (OPSCC). METHODS: Retrospective population-based cohort study of patients in the National Cancer Database presenting with distantly metastatic OPSCC. Overall survival (OS) was compared for patients receiving systemic therapy alone or in combination with local surgery or curative dose radiation, controlling for various clinicodemographic factors. RESULTS: Between 2010 and 2015, 627 patients presented with newly diagnosed, metastatic OPSCC and an initial treatment course including systemic chemotherapy. Multivariable analysis demonstrated that local radiation therapy was independently associated with improved OS (OR 0.64, CI [0.51-0.81]); local surgery was not independently associated with improved OS (OR 0.99, CI [0.65-1.53]). Higher T stages were associated with worse OS (OR 1.69, CI [1.14-2.50] for T3 and OR 1.77, CI [1.22-2.58] for T4 compared to T1). HPV-positive (HPV+) tumors were associated with improved OS compared to HPV- (OR 0.79, CI [0.64-0.97]). Multiagent chemotherapy was associated with improved OS compared to single-agent (OR 0.78, CI [0.62-1.00]). The best survival for the entire cohort and for HPV+ patients was for radiation with systemic therapy and the worst survival for systemic therapy alone. CONCLUSIONS: Curative dose local radiotherapy in addition to systemic therapy is associated with improved OS compared to systemic therapy alone in patients presenting with distantly metastatic OPSCC. There is not a significant survival benefit for local surgery in addition to systemic therapy in this patient population, regardless of HPV status. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:2243-2251, 2024.

Postoperative mometasone irrigations improve quality of life in skull base tumor patients.

Objectives: The use of topical corticosteroids to manage postoperative sinonasal symptoms after endoscopic skull base surgery (ESBS) has not been well studied. We quantified long-term impact of postoperative steroid irrigations (SIs) on quality of life of patients after ESBS. Methods: Retrospective review of patients at the University of Pennsylvania undergoing ESBS from 2010 to 2019. Data on patient demographics and postoperative treatment with nasal saline irrigation twice daily with and without dissolved steroids (mometasone or budesonide) was collected. Preoperative, and 1-, 3-, 6-, 12-, 18-, and 24-month postoperative Sino-Nasal Outcome Test (SNOT-22) scores were assessed. Results: A total of 727 patients were assessed (53.4% males), with 479 patients in the no SI group and 248 patients in the SI group. Preoperative SNOT-22 scores did not differ significantly (P = 0.19). 1-, 3-, 6-, 12-, 18-, and 24-month post-op SNOT-22 scores did not significantly differ between groups. However, mometasone irrigations resulted in significantly lower postoperative 2-year SNOT-22 scores compared to budesonide (P < 0.01) and saline (P = 0.03). Conclusions: Though corticosteroid irrigations are routine in managing inflammatory sinus disease, their role in postoperative management after ESBS for tumors is unclear. Our findings suggest that mometasone irrigation may be effective at improving postoperative quality of life in patients after ESBS.

Nodal Metastasis in Surgically Treated Oral Cavity Squamous Cell Carcinoma.

INTRODUCTION: Management of the neck in oral cavity squamous cell carcinoma (OCSCC) is essential to oncologic control and survival. The rates of lymph node metastasis (LNM) vary based on oral cavity tumor site and stage and influence treatment decisions. The aim of this paper was to describe clinical LNM for different tumor subsites and stages of surgically managed OCSCC. METHODS: We conducted a retrospective analysis of 25,846 surgically managed OCSCC patients from the National Cancer Database (NCDB) stratified by tumor subsite and clinical T-stage. For cN + patients, rates of pathologic LNM and absence of pathologic LNM were determined. For cN0 patients, outcomes included the rates of elective neck dissection (END) and occult LNM and predictors of occult LNM determined by a multivariable logistic regression model. RESULTS: A total of 25,846 patients (59.1% male, mean age 61.9 years) met inclusion criteria with primary tumor sites including oral tongue (50.8%), floor of mouth (21.2%), lower alveolus (7.6%), buccal mucosa (6.7%), retromolar area (4.9%), upper alveolus (3.6%), hard palate (2.7%), and mucosal lip (2.5%). Among all sites, clinical N+ rates increased with T-stage (8.9% T1, 28.0% T2, 51.6% T3, 52.5% T4); these trends were preserved across subsites. Among patients with cN + disease, the overall rate of concordant positive pathologic LNM was 80.1% and the rate of discordant negative pathologic LNM was 19.6%, which varied based on tumor site and stage. In the overall cohort of cN0 patients, 59.9% received END, and the percentage of patients receiving END increased with higher tumor stage. Occult LNM among those cN0 was found in 25.1% of END cases, with the highest rates in retromolar (28.8%) and oral tongue (27.5%) tumors. Multivariable regression demonstrated significantly increased rates of occult LNM for higher T stage (T2 OR: 2.1 [1.9-2.4]; T3 OR: 3.0 [2.5-3.7]; T4 OR: 2.7 [2.2-3.2]), positive margins (OR: 1.4 [1.2-1.7]), and positive lymphovascular invasion (OR: 5.1 [4.4-5.8]). CONCLUSIONS: Management of the neck in OCSCC should be tailored based on primary tumor factors and considered for early-stage tumors.

Cutaneous mantle cell lymphoma presenting as a diffuse morbilliform rash: A case report.

This case describes a patient with known mantle cell lymphoma without cutaneous involvement presenting with a diffuse morbilliform rash during an inpatient admission for bacterial pneumonia. The patient was thought to have a hypersensitivity to antibiotics but failed to improve after the offending agents were stopped. A skin biopsy revealed metastatic cutaneous mantle cell lymphoma. Treatment with high-dose corticosteroids and chemotherapy was initiated resulting in the resolution of the rash.

Luminescence Studies on Dy3+ Doped Calcium Aluminum Borosilicate (CABS) Glasses for White Light Emission and Applications in w-LEDs.

Dy3+ doped calcium aluminum borosilicate (CABS) glasses have been synthesized via quick melt quench technique. CABS: xDy3+ glasses (x = 0.1, 0.5, 1, 1.5 and 2 mol%) were subjected to various morphological and photoluminescence studies. X-ray diffraction (XRD) and Fourier transform infrared (FT-IR) spectroscopy were conducted to study the structural and bonding nature of the undoped glass. The excitation spectra of Dy3+ doped CABS glasses under 574 nm emission show many sharp peaks amongst which the transition from 6H15/2 → 6P7/2 (351 nm) had the highest intensity. Under 351 nm excitation, glasses exhibit sharp peaks in the blue, yellow and red regions corresponding to the transitions 4F9/2 → 6H15/2, 6H13/2, 6H11/2 and 6H9/2 respectively. The dipole-dipole nature of the interaction between the Dy3+ ions is confirmed via Dexter theory and Inokuti-Hirayama (I-H) model. CIE coordinates estimated from the emission profiles of these glasses under 351 nm excitation fall in the white region. Considering that these glasses exhibit sharp visible emission under UV excitation, have stable yellow to blue (Y/B) ratios and fast decays with intense energy transfers, we propose to utilise these glasses for white light generation and other white light LED (w-LED) and solid-state lighting (SSL) applications.

Nodal metastasis in surgically treated laryngeal squamous cell carcinoma.

BACKGROUND: Management of the neck in laryngeal squamous cell carcinoma (LSCC) is essential to oncologic control and survival. We aim to describe patterns and rates of clinical/pathologic lymph node disease, elective neck dissection (END), and occult lymph node metastasis (LNM) in patients with surgically-managed LSCC. METHODS: Retrospective cohort study of patients in the National Cancer Database (NCDB) diagnosed with LSCC between January 2004 and December 2016 who underwent primary surgery. RESULTS: Seven thousand eight hundred and seventy-six patients met inclusion criteria. For cN0 patients, the rates of END and occult LNM both increased with tumor stage and were highest for supraglottic tumors. Predictors of occult LNM included supraglottic site, pathologic T3 and T4 stage, positive margins, and presence of lymphovascular invasion (p < 0.05). CONCLUSIONS: The propensity for cervical LNM in surgically-managed LSCC varies based on primary tumor site and stage, and a variety of disease factors increase risk of occult LNM.

Structural, optical, and luminescence properties of Dy3+ -activated potassium calcium silicate phosphor for white light-emitting diodes.

A dysprosium (Dy3+ )-activated potassium calcium silicate (K4 CaSi3 O9 ) phosphor was prepared using a solid-state synthesis route. The phosphor had a cubic structure with the space group Pa 3 ¯ as confirmed using X-ray diffraction (XRD) measurements. Details of surface morphology and elemental composition of the as-synthesized undoped KCS phosphor was obtained using scanning electron microscopy (SEM) and energy-dispersive X-ray (EDX) spectroscopy. The chemical structure as well as the vibrational modes present in the as-prepared KCS phosphor was analyzed using Fourier transform infrared (FT-IR) spectroscopy. Diffuse reflectance spectra (DRS) were used to determine the optical bandgap of the phosphors and were found to be in the optical range 3.52-3.71 eV. Photoluminescence (PL) spectra showed intense yellow emission corresponding to the 4 F9/2 →6 H13/2 transition under 350 nm excitation. Commission International de l'Eclairage colour chromaticity coordinates were evaluated using the PL spectral data lie within the white region. Dexter theory and the Inokuti-Hirayama (I-H) model were applied to study the nature of the energy transfer mechanism in the as-prepared phosphors. The relatively high activation energy of the phosphors was evaluated using temperature-dependent PL (TDPL) data and confirmed the high thermal stability of the titled phosphor. The abovementioned results indicated that the as-prepared KCS:Dy3+ phosphor was a promising candidate for n-UV-based white light-emitting diodes.

Determinants of Patient Refusal of Postoperative Radiation Therapy in Sinonasal Squamous Cell Carcinoma.

Objectives Although adjuvant radiotherapy may be indicated in patients with sinonasal squamous cell carcinoma (SNSCC) following primary surgery, some patients choose to forgo recommended postoperative radiation therapy (PORT). This study aimed to elucidate factors associated with patient refusal of recommended PORT in SNSCC and examine overall survival. Methods Retrospective analysis of patients with SNSCC treated with primary surgery from the National Cancer Database diagnosed between 2004 and 2016. A multivariable logistic regression model was created to determine the association between clinical or demographic covariates and likelihood of PORT refusal. Unadjusted Kaplan-Meier estimates, log-rank tests, and a multivariable Cox proportional hazard model were used to assess overall survival. Results A total of 2,231 patients were included in the final analysis, of which 1,456 (65.3%) were males and 73 (3.3%) refused recommended PORT. Patients older than 74 years old were more likely to refuse PORT than those younger than 54 (odds ratio [OR] 3.43, 95% confidence interval [CI]: 1.84-6.62). Median survival among the entire cohort, those who received recommended PORT, and those who refused PORT was 83.0 months (95% CI: 74.6-97.1), 83.0 months (95% CI: 74.9-98.2), and 63.6 months (95% CI: 37.3-101.4), respectively. Refusal of PORT was not associated with overall survival (hazard ratio: 0.99, 95% CI: 0.69-1.42). Conclusions PORT refusal in patients with SNSCC is rare and was found to be associated with several patient factors. The decision to forgo PORT is not independently associated with overall survival in this cohort. Further study is required to determine the clinical implications of these findings as the treatment decisions are complex.

Clinical practice guidelines for management of head and neck squamous cell carcinoma of unknown primary: an AGREE II appraisal.

IMPORTANCE: Squamous cell carcinoma without a known primary is an uncommon form of head and neck cancer that requires multidisciplinary collaboration for effective management. OBJECTIVE: To evaluate the quality of clinical practice guidelines (CPG) using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. DESIGN: A systematic literature search was performed to identify CPGs pertaining to the diagnosis and treatment of head and neck squamous cell carcinoma of unknown primary (HNSCCUP). Data were abstracted from guidelines meeting inclusion criteria and appraised by four independent reviewers in the six domains of quality defined by the AGREE II. SETTING: Online database. PARTICIPANTS: None. EXPOSURE: None. MAIN OUTCOME(S) AND MEASURE(S): Quality domain scores and intraclass correlation coefficients (ICC) were calculated across domains to qualify inter-rater reliability. RESULTS: Seven guidelines met inclusion criteria. Two guidelines achieved a score of > 60% in five or more AGREE II quality domains to gain designation as 'high'-quality content. One "average-quality" guideline authored by the ENT UK Head and Neck Society Council achieved a score of > 60% in three quality domains. The remaining four CPGs demonstrated low-quality content, with deficits most pronounced in domains 3 and 5, suggesting a lack of rigorously developed and clinically applicable information. CONCLUSIONS AND RELEVANCE: As the diagnosis and treatment of head and neck cancer continues to evolve, identification of high-quality guidelines will become increasingly important. The authors recommend consulting HNSCCUP guidelines from the National Institute for Health and Care Excellence (NICE) or the American Society of Clinical Oncology (ASCO). TRIAL REGISTRATION: None.

Postoperative Radiation Therapy Refusal in Major Salivary Gland Cancers.

OBJECTIVE: Major salivary gland cancers (MSGCs) are often treated with primary surgery followed by adjuvant therapy for high-risk pathology. Patients with these cancers may opt out of recommended postoperative radiation therapy (PORT) for many reasons and consequently may suffer worse outcomes. STUDY DESIGN: Retrospective cohort study. SETTING: National Cancer Database. METHODS: Patients diagnosed with MSGC from 2004 to 2016 were identified, and overall survival and risk factors for refusal of recommended PORT were analyzed based on demographic, socioeconomic, and clinical factors. Multivariable logistic regression and a Cox model were used to conduct the analysis. RESULTS: 211 out of 4704 qualifying patients (4.5%) refused recommended PORT. Multivariable analysis demonstrated increased PORT refusal for age >74 years (odds ratio OR 4.34, confidence interval [CI] [2.43-7.85]), Asian race (OR 2.25, CI [1.10-4.23]), and certain facility types (comprehensive cancer center, OR 2.39, CI [1.08-6.34]; academic research program, OR 3.29, CI [1.49-8.74]; and integrated network cancer program, OR 2.75, CI [1.14-7.7]). N2 stage was associated with decreased PORT refusal (OR 0.67, CI [0.45-0.98]). The 5-year overall survival for patients who received and refused PORT were significantly different at 65.8% and 53.8%, respectively (p < .001). When controlling for several factors, PORT refusal was independently associated with significantly lower overall survival (HR 1.54, CI [1.21-1.98]). CONCLUSION: Patient refusal of recommended PORT in MSGC is rare, associated with various disease and socioeconomic factors, and may decrease overall survival. Our findings can assist clinicians in counseling patients and identifying those who may be more likely to opt out of recommended PORT.

Thermally stable Sm3+ -doped alkali zinc alumino borosilicate (AZABS) glass for warm white light generation and w-LED applications.

Samarium ion (Sm3+ )-doped alkali zinc alumino borosilicate (AZABS) glass was synthesized via quick melt quench technique. Various spectroscopic studies like optical absorption, photoluminescence (PL) emission, PL excitation, temperature-dependent PL and PL decay kinetics were performed on the as prepared glass system. Under 402 nm excitation, three sharp bands at wavelengths 563, 599 and 645 nm corresponding to transitions 4 G5/2 → 6 H5/2 , 6 H7/2 and 6 H9/2 , respectively, can be seen in the PL emission spectra. The 0.25 mol% Sm3+ glass has the highest intensity for these emissions. The lanthanide interaction in the glass matrix is dipole-dipole in nature as was proven from Dexter's analysis. The direct bandgap of 0.25 mol% Sm3+ -doped AZABS glass was calculated to be 2.88 eV. The lifetimes of the as prepared glass range from 1.93 ms for the lowest concentration of Sm3+ to 0.75 ms for the highest. From temperature dependent PL studies, the activation energy for 0.25 mol% Sm3+ -doped AZABS glass was found to be 0.19 eV which shows high thermal stability of this glass. We propose to utilize these Sm3+ -doped AZABS glasses for white-light emitting diodes (w-LEDs) and solid-state lighting (SSL) applications.

Enhanced Recovery After Surgery for Pediatric Cleft Repair: A Systematic Review and Meta-Analysis.

OBJECTIVE: Perform a systematic review assessing the efficacy of enhanced recovery after surgery (ERAS) protocols for cleft palate repair. Primary outcomes included hospital length of stay, readmission rates, and postoperative narcotic use. Secondary outcomes included complications, time to initial postoperative oral intake, and pain scores. DATA SOURCES: Cohort and randomized studies of ERAS protocols pertaining to cleft palate repair were identified by systematic review of Medline, Scopus, Embase, and grey literature. REVIEW METHODS: Data extracted included patient demographics, clinical care protocols, complication rates, postoperative narcotic use, time to initial postoperative oral intake, hospital length of stay, family satisfaction, and 30-day readmission. Meta-analysis was used to compare outcomes between patients enrolled in ERAS protocols versus those in conventional care pathways. RESULTS: Eight hundred sixty-five articles were screened, and 5 studies met full inclusion criteria. A total of 425 patients were included. Patients in ERAS protocols saw a mean reduction of - 23.96 hours in length of stay compared to controls (95% confidence interval [CI]: - 26.4, - 20.6). Patients in ERAS protocols also had decreased total morphine consumption (mean difference [MD]: - 3.88 mg; CI: - 4.31, - 3.45), and decreased time to first initial feed compared to controls (MD: - 3.88 hours; CI: - 4.3, - 3.5). There was no difference in readmission rates or complication rates between ERAS and control groups. CONCLUSIONS: ERAS protocols have seen limited use in pediatric patients. The present study sought to assess the impact of ERAS protocols following primary palatoplasty. Our results indicate decreased hospital length of stay, postoperative opioid consumption, and time to feeding, without increasing readmission rates or complication rates.

Reconstruction with Mucosal Graft Reduces Recurrence After Endoscopic Surgery of Rathke Cleft Cyst.

OBJECTIVES: Rathke cleft cysts (RCCs) arise from the development of the Rathke pouch. Recurrence is common after either drainage or cyst removal. The endoscopic endonasal approach (EEA) is increasingly utilized for the management of RCC. Various techniques have been described to try to reduce the rates of recurrence. We studied the effect of fenestration with a nasoseptal flap (NSF) on recurrence rates by comparing a cohort of patients undergoing this technique to a cohort of patients undergoing conventional drainage. METHODS: Patients who underwent EEA for RCC between 2011 and 2020 were identified and divided into 2 cohorts: conventional fenestration versus fenestration with NSF. Surgical approach, reconstructive method, and recurrences were recorded. Primary end point was symptomatic or radiographic recurrence. RESULTS: 21 patients were identified undergoing EEA. An NSF was used to line the cyst cavity in 11 cases. Conventional fenestration without mucosal reconstruction was performed in the remaining 10 cases. In the cases without NSF, 5 (50%) developed recurrence requiring revision surgery, while there was only one recurrence in the NSF group (P < 0.05). In patients requiring revision, all had an NSF placed and none had a second recurrence of their RCC. CONCLUSIONS: NSF placement into a fenestrated RCC is useful to prevent cyst reaccumulation and reoperation. Typical fenestration carries an unacceptably high rate of recurrence.

Critical review of clinical practice guidelines for evaluation of neck mass in adults / Revisão crítica das diretrizes de prática clínica para avaliação de massas cervicais em adultos

Abstract Objective: Several clinical practice guidelines have been produced and disseminated for the evaluation of a neck mass. However, to date, the quality and methodologic rigor of these clinical practice guidelines have not been appraised. Therefore, this study set out to identify and assess the methodologic quality of national and international guidelines for the evaluation and management of neck masses in adults. Methods: We conducted a comprehensive search of EMBASE, MEDLINE/PubMed, SCOPUS and grey literature sources until September 2020. The quality of these guidelines was assessed by four reviewers using the Appraisal of Guidelines for Research and Evaluation, 2nd edition (AGREE II). Domain scores were considered acceptable quality if they scored >60%, and Intraclass Correlation Coefficients (ICC) were calculated to assess agreement among the appraisers. Results: Seven guidelines were assessed for evaluation. Among these, only the American Academy of Otolaryngology (AAO), Cancer Care Manitoba (CCMB), and the American Society of Clinical Oncology (ASCO) achieved an overall rating of ‟high". The remaining four guidelines achieved ratings of either ‟average" or ‟low". The ‟Scope and Purpose" domain achieved the highest mean score (94.4%±5.0%), and lowest was ‟Applicability" (51.5%±29.2%). ICC analysis showed substantial to very good agreement across all domains (0.75-0.98). Conclusion: These findings highlight the variability in methodologic quality of guidelines for the evaluation and management of adult neck mass. The results from this analysis highlight the need to improve guidelines development process for this topic and may guide the selection and use of these guidelines in clinical practice.

Resumo Introdução: Várias diretrizes de práticas clínicas foram produzidas e divulgadas para a avaliação de massa cervical. Porém, até o momento, a qualidade e o rigor metodológico dessas diretrizes de práticas clínicas não foram avaliados. Objetivo: Identificar e avaliar a qualidade metodológica das diretrizes nacionais e internacionais para a avaliação e tratamento de massas cervicais em adultos. Método: Fizemos uma pesquisa abrangente das fontes de dados Embase, Medline/PubMed, Scopus e literatura cinza até setembro de 2020. A qualidade dessas diretrizes foi avaliada por quatro revisores com a 2a edição do Appraisal of Guidelines for Research and Evaluation (AGREE II). Os escores dos domínios foram considerados de qualidade aceitável se pontuassem >60% e os coeficientes de correlação intraclasse (Intraclass correlation coefficient - ICC) foram calculados para avaliar a concordância entre os avaliadores. Resultados: Sete diretrizes foram investigadas para avaliação. Entre elas, apenas a American Academy of Otolaryngology (AAO), o Cancer Care Manitoba (CCMB) e a American Society of Clinical Oncology (ASCO) obtiveram uma classificação geral ‟alta". As quatro diretrizes restantes obtiveram classificações ‟media" ou ‟baixa". O domínio ‟Escopo e objetivo'" obteve o maior escore médio (94,4% ± 5,0%) e o domínio ‟Aplicabilidade" obteve o menor escore (51,5%±29,2%). A análise ICC mostrou concordância substancial a muito boa em todos os domínios (0,75-0,98). Conclusão: Esses achados destacam a variabilidade na qualidade metodológica das diretrizes para avaliação e tratamento de massa cervical em adultos. Os resultados dessa análise destacam a necessidade de melhorar o processo de desenvolvimento de diretrizes para esse tópico e podem orientar a seleção e o uso dessas diretrizes na prática clínica.

Implementation of an enhanced recovery after surgery protocol for head and neck cancer patients: Considerations and best practices.

Enhanced recovery after surgery (ERAS) protocols have been developed in numerous surgical specialties as a means of systematically improving patient recovery, functional outcomes, cost savings, and resource utilization. Such multidisciplinary initiatives seek to minimize variability in several aspects of perioperative patient care, helping to reduce inpatient length of hospital stay, complications, and the overall resource and financial burden of surgical care. Head and neck oncology patients stand to benefit from the implementation of comprehensive ERAS protocols, as these patients have complex medical needs that may dramatically impact multiple aspects of their recovery, including breathing, eating, nutrition, pain, speech, swallowing, and communication. Implementing ERAS protocols for head and neck cancer patients may present unique challenges, and require significant interdisciplinary coordination and collaboration. We therefore sought to provide a comprehensive guide to the planning and institution of such ERAS systems at institutions undertaking care of head and neck cancer patients. Key elements to consider in the implementation of successful ERAS protocols for this population include organizing a team consisting of frontline leaders such as nursing staff, medical specialists, and associated health professionals; designing interventions based on systematically evaluated, high-quality literature; and instituting a clear methodology for regularly updating protocols and auditing the success or potential limitations of a given intervention. Potential obstacles to the success of ERAS interventions for head and neck cancer patients include challenges in systematically tracking progress of the protocol, as well as resource limitations in a given health system.