Facility Volume and Changing Facilities for Postoperative Radiotherapy in Salivary Gland Cancer.

OBJECTIVES: Changing location of postoperative radiotherapy (PORT) after treatment at a high-volume facility (HVF) is associated with worse survival in various head and neck cancers. Our study investigates this relationship in salivary gland cancer (SGC). METHODS: The 2004-2016 National Cancer Database was queried for all cases of adult SGC treated with surgery and PORT with or without adjuvant chemotherapy. Patients with multiple cancer diagnoses, metastatic disease, or unknown PORT facility were excluded. Reporting facilities with >95th percentile annual case volume were classified as HVFs, the remainder were classified low-volume facilities (LVFs). RESULTS: A total of 7885 patients met inclusion criteria, of which 418 (5.3%) were treated at an HVF. Patients treated at an HVF had higher rates clinical nodal positivity (18.2% vs. 14.0%, p < 0.001) and clinical T3/T4 (27.3% vs. 20.7%, p = 0.001) disease. Patients at HVFs changed facility for PORT at lower rates (18.9% vs. 24.5%, p = 0.009). Patients treated at an HVF had higher 5-year overall survival (5-OS) than those treated at an LVF (79.0% vs. 72.0%, p = 0.042). Patients treated at an HVF that changed PORT facility had worse 5-OS (60.8% vs. 83.2%, p < 0.001). Radiation facility change was an independent predictor of worse survival in patients treated at an HVF (HR: 8.99 [3.15-25.67], p < 0.001) but not for patients treated at a LVF (HR: 1.11 [0.98-1.25], p = 0.109). CONCLUSIONS: Patients treated at an HVF changing facility for PORT for SGC experience worse survival. Our data suggest patients treated surgically at an HVF should be counseled to continue their PORT at the same institution. LEVEL OF EVIDENCE: 3 Laryngoscope, 2024.

Systematic Review of Literature Citing the ISCHEMIA Trial.

PURPOSE OF REVIEW: Optimal therapy for patients with chronic coronary artery disease (CCD) has long been a topic under investigation and a subject of debate. Seeking to clarify appropriate management, the International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial compared medical management versus coronary angiography for patients with stable ischemic heart disease. Its reception in the medical community has been met with both acclaim and criticism. In light of such disparate views of this trial, a systematic review of the literature citing the ISCHEMIA trial was performed. RECENT FINDINGS: All articles citing the ISCHEMIA trial on PubMed as of July 21, 2023, were compiled and underwent qualitative analysis. A total of 430 articles were evaluated; 109 (25.3%) did not offer substantial commentary on ISCHEMIA and cite it as background evidence for further study. Of the commentary articles, the majority (224, 52.1%) gave balanced, honest appraisals of the ISCHEMIA trial. A total of 46 (10.7%) strongly praised the trial while another 39 (9.1%) were strongly critical of the results. Almost three-quarters of the literature citing the ISCHEMIA trial was commentary in nature, with roughly equal distribution across the spectrum of praise and criticism. Despite being one of the largest studies on CCD and coronary revascularization ever conducted, the impact of ISCHEMIA on the cardiology community appears to be mixed.

Chronic invasive fungal rhinosinusitis and granulomatous invasive fungal sinusitis: A systematic review of symptomatology and outcomes.

INTRODUCTION: Chronic invasive fungal rhinosinusitis (CIFRS) and granulomatous invasive fungal sinusitis are two uncommon diseases differentiated primarily by the pathologic finding of non-caseating granulomas in GIFRS. Both share many similarities in presentation. We aim to characterize the symptomatology and outcomes of these diseases. METHODS: A comprehensive search strategy was designed to identify studies in the Cochrane, EMBASE and PubMed databases from database inception to January 2022. Inclusion criteria included all patients with a diagnosis of either CIFRS or GIFRS. All studies were screened by two reviewers. Chi-square analyses were used where appropriate. RESULTS: 51 studies were included totaling 513 patients. The majority were diagnosed with CIFRS (389, 75.8 %) compared to GIFRS (124, 24.4 %). CIFRS was more common in immunocompromised or diabetic patients (p < 0.0001; p = 0.02). Patients with CIFRS were more likely to exhibit nasal symptoms including discharge (p = 0.0001), obstruction (p = 0.03) and congestion (p = 0.001) as well as systemic symptoms including fever, which no GIFRS patient exhibited, facial pain (p = 0.007), headache (p = 0.004). Aspergillus was the most common organism identified in both groups with a slight predominance among GIFRS patients (p = 0.01). GIFRS patients were also more likely to present with no identifiable organisms (p = 0.0006). CIFRS patients were more likely to die of disease (p = 0.0008). CONCLUSIONS: CIFRS generally presents with more symptoms and is associated with poorer outcomes primarily occurring in an immunocompromised population. GIFRS likely follows a more insidious course in immunocompetent patients. Understanding the key differences in symptomatology and outcomes for these two populations is critical for appropriate diagnosis and prognostication.

Aortic Valve Replacement: A Case of Aortic Valve Insufficiency Secondary to Infective Endocarditis.

Acute aortic valve insufficiency (AAVI) is a pathologic medical condition that has a presentation on a spectrum of severity and is attributable to numerous etiologies. Most often, it is caused by infective endocarditis, which depending on the patient's clinical status may require treatment with either surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR). This case presents a patient with acute aortic valve insufficiency secondary to infective endocarditis, requiring intervention. Further, it also provides real-time use of the general guidelines used in the determination of SAVR vs. TAVR candidacy. This case will further help providers in the cardiology realm to identify this presentation and increase comfort in referring to existing guidelines, as well as highlight where the current guidelines appear limited.

SMAD signaling pathway is disrupted by BPA via the AMH receptor in bovine granulosa cells†.

Significant events that determine oocyte competence occur during follicular growth and oocyte maturation. The anti-Mullerian hormone, a positive predictor of fertility, has been shown to be affected by exposure to endocrine disrupting compounds, such as bisphenol A and S. However, the interaction between bisphenols and SMAD proteins, mediators of the anti-Mullerian hormone pathway, has not yet been elucidated. AMH receptor (AMHRII) and downstream SMAD expression was investigated in bovine granulosa cells treated with bisphenol A, bisphenol S, and then competitively with the anti-Mullerian hormone. Here, we show that 24-h bisphenol A exposure in granulosa cells significantly increased SMAD1, SMAD4, and SMAD5 mRNA expression. No significant changes were observed in AMHRII or SMADs protein expression after 24-h treatment. Following 12-h treatments with bisphenol A (alone or with the anti-Mullerian hormone), a significant increase in SMAD1 and SMAD4 mRNA expression was observed, while a significant decrease in SMAD1 and phosphorylated SMAD1 was detected at the protein level. To establish a functional link between bisphenols and the anti-Mullerian hormone signaling pathway, antisense oligonucleotides were utilized to suppress AMHRII expression with or without bisphenol exposure. Initially, transfection conditions were optimized and validated with a 70% knockdown achieved. Our findings show that bisphenol S exerts its effects independently of the anti-Mullerian hormone receptor, while bisphenol A may act directly through the anti-Mullerian hormone signaling pathway providing a potential mechanism by which bisphenols may exert their actions to disrupt follicular development and decrease oocyte competence.

Unique Variant of Zieve Syndrome With a Normal Reticulocyte Count.

Zieve syndrome is a rare diagnosis seen in patients with chronic alcohol use which consists of a distinct clinical triad of hyperlipidemia, hemolytic anemia, and jaundice. Patients typically have an elevated reticulocyte count due to the hemolytic nature of the anemia. We present the case of a 44-year-old female who was discovered to have an unusual variant of Zieve syndrome with a normal reticulocyte count, which was believed to be due to suppression of bone marrow from excessive alcohol consumption. She was treated with steroids and complete alcohol cessation, with remarkable improvement on subsequent follow-up. An exhaustive literature review of 31 documented cases of Zieve syndrome was conducted to better understand the clinical presentation and overall prognosis of these patients. This case report and literature review aimed to improve patient outcomes through increased recognition of this underrecognized syndrome.

When blood pressure refuses to budge: exploring the complexity of resistant hypertension.

Resistant hypertension, defined as blood pressure that remains above goal despite using three or more antihypertensive medications, including a diuretic, affects a significant proportion of the hypertensive population and is associated with increased cardiovascular morbidity and mortality. Despite the availability of a wide range of pharmacological therapies, achieving optimal blood pressure control in patients with resistant hypertension remains a significant challenge. However, recent advances in the field have identified several promising treatment options, including spironolactone, mineralocorticoid receptor antagonists, and renal denervation. In addition, personalized management approaches based on genetic and other biomarkers may offer new opportunities to tailor therapy and improve outcomes. This review aims to provide an overview of the current state of knowledge regarding managing resistant hypertension, including the epidemiology, pathophysiology, and clinical implications of the condition, as well as the latest developments in therapeutic strategies and future prospects.

Assessing the Association Between Time to Surgery and Survival in Sinonasal Squamous Cell Carcinoma.

INTRODUCTION: To assess the association between time to surgery (TTS) and survival in sinonasal squamous cell carcinoma patients (SSCC). METHODS: We queried the 2004-2016 National Cancer Database for all cases of adult SSCC undergoing primary surgical treatment. Patients with missing TTS information were excluded. We conducted a multivariate analysis of patient demographic and clinicopathological characteristics' effect on overall survival (OS) using a Cox proportional hazards model enhanced with cubic spline non-linear approximation. Bootstrapping methods were utilized to detect the aggregate risk of TTS delay on patient OS. RESULTS: A total of 2,881 patients met the inclusion criteria. The majority of patients were male (63.5%), White (86.3%), and over the age of 60 (58.4%). Parametric cubic spline approximation Cox hazard model detected a non-linear association between patient OS and TTS below 30 days with the lowest risk occurring at 18 days and steadily increasing subsequently. To analyze the aggregate risk and identify the optimal TTS cut-off after 30 days of surgical delay, the cohort sample was bootstrapped and dichotomized. The largest increase in aggregated risk was identified at 59 days (Hazards Ratio [HR] = 1.006 [0.839-1.084], p = 0.003). 60 days were used as the optimal TTS cut-off for analyzing the survival rate using the Cox proportional hazard model. Undergoing surgery within 60 days translated to a 14.6% decreased chance of death (HR: 0.854 [0.83-0.96]). CONCLUSIONS: Increasing TTS is associated with worse overall survival in patients with SSCC. Our study suggests that surgery should be done within 60 days to achieve optimal survival results. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:3389-3395, 2023.

Opioid prescription trends among American Head and Neck Society fellowship graduates.

BACKGROUND: Opioids are commonly used to manage the pain of head and neck (HN) cancer patients. METHODS: Retrospective cohort of graduates from American Head and Neck Society accredited fellowships from 1997 to 2018. The Center for Medicare and Medicaid Services Part D Provider Utilization and Payment database 2014-2019 was cross-referenced with provider names to identify opioid prescription trends. RESULTS: From 2014 to 2019, there was no significant difference in the average number of opioid beneficiaries per provider (18.02 vs. 18.10, p = 0.586) or opioid claims per provider (28.06 vs. 26.73, p = 0.708). The average total opioid day supply per beneficiary declined from 11.09 to 7.05 days from 2014 to 2019 (p < 0.001). In 2019, providers in the Northeast had the lowest prescribed opioid day supply (3.67 days) compared to those from the South who had the highest (10.32 days). CONCLUSIONS: Opioid prescription length has significantly declined among HN surgeons, with variations across geographic regions.

Endoscopic Management of Rhinolithiasis: A Systematic Review.

OBJECTIVE: This study reviews the presentation, management, and outcomes of patients with rhinolithiasis. DATA SOURCES: An electronic database search of PubMed, SCOPUS, CINAHL, and the Cochrane Library was performed in accordance with the PRISMA 2020 updated guidelines for reporting systematic reviews. REVIEW METHODS: Case reports and case series published from 2004 to 2020 were included. Data collected included patient demographics, clinical symptoms at presentation, diagnosis, treatment, complications, and follow-up. Relevant descriptive statistics were computed using Microsoft Excel 2013 (Microsoft Corp). RESULTS: Fifty-five case reports and five case series were included (n = 122). The majority were female (60.7%). The mean age was 29.4 years (range, 4-80 years). The most common symptoms were rhinorrhea (81.1%), nasal obstruction (79.5%), nasal malodor (38.5%), and headache (27.9%). Computed tomography imaging was obtained in 109 (91.5%) cases. Concurrent rhinosinusitis (35.2%) and deviated nasal septum (28.7%) were commonly identified. Rhinoliths were commonly found in the right nostril (52.5%) and in between the inferior turbinate and nasal septum (26.9%). All rhinoliths were fully excised using endoscopic sinonasal surgery, accompanied by a septoplasty (9.2%). The nidus was identified in 27 (22.2%) patients. There were no recurrences or complications over an average follow-up of 8.5 months (range, 0.25-36 months). CONCLUSION: Rhinolithiasis is an uncommon entity of the nasal cavity and should be suspected in patients with long-standing unilateral nasal obstruction, rhinorrhea, and nasal malodor. Rigid nasal endoscopy and endoscopic sinonasal surgery are the most important methods for diagnosis and treatment, respectively.

An Unusual Presentation of Juvenile Polymyositis in an Adolescent Girl.

Juvenile idiopathic inflammatory myopathies (JIIMs) are a group of diverse, systemic autoimmune diseases that manifest in childhood and are characterized by weakness and chronic inflammation of skeletal muscles. One of the relatively rare variants of JIIMs is juvenile polymyositis (JPM). JPM patients present with proximal and distal muscle weakness, gait instability with falls, muscle pain and tenderness, and high levels of creatine kinase (CK) during adolescence. There are currently few people being diagnosed with JPM, which raises the question of whether or not it is a distinct disease. We discuss the case of a 13-year-old girl who presented to the hospital with generalized body swelling and difficulty swallowing solid food. She also had drooling of saliva during the presentation and a history of difficulty climbing up and down the stairs for three months. Her extensive laboratory workup showed a positive antinuclear antibody (ANA) test and increased muscle enzyme. A muscle biopsy was ordered, and she was diagnosed with JPM. Such a unique presentation has rarely been reported in the pediatric literature. This case report outlines an unusual JPM presentation that could help clinicians identify the condition and start treatment as soon as possible to minimize complications.

Facility volume and survival: Human papilloma virus positive oropharyngeal squamous cell carcinoma.

BACKGROUND: To analyze the impact of facility volume on survival for human papilloma virus positive oropharyngeal squamous cell carcinoma (HPV+ OPSCC) patients. METHODS: Patients treated for HPV+ OPSCC from 2010 to 2017 were queried from the National Cancer Database. Facilities of average annual case volume <50th percentile were categorized as low-volume (LV) and >95th percentile as high-volume (HV). RESULTS: 11,546 were included, with 10,305 patients (89.3 %) treated at LV and 1241 (10.7 %) at HV facilities. A greater proportion of cases involving resection of base of tongue and lingual tonsil were treated at HV (30.3 %) compared to LV (22.3 %) facilities (p < 0.001). Patients treated at a HV facility had greater percentage of clinical T4 (11.2 % vs. 8.6 %, p = 0.001) and N+ disease (90.5 % vs. 85.7 %, p < 0.001) patients. Survival analysis showed no statistically significant difference between five-year overall survival rates by facility volume (p = 0.388) for all patients. On multivariable analysis, facility volume was not associated with survival (HR: 0.968 [0.758-1.235], p = 0.791). These trends were found for both patients undergoing primary surgery or chemoradiotherapy. CONCLUSION: Our data indicates that patients with HPV+ OPSCC do not experience a survival benefit with treatment at HV facility, suggesting these patients may be adequately treated at LV centers.

Extent of Surgery for Follicular Thyroid Carcinoma.

OBJECTIVES: To examine the association between the extent of surgery and overall survival in follicular thyroid cancer (FTC) patients. STUDY DESIGN: Retrospective analysis of the National Cancer Database (NCDB). METHODS: Patients who underwent surgical intervention for FTC from 2004 to 2015 were selected. Patients were >18 years old, with tumor size 1-4 cm, no other malignancies, and >0 follow up time. Patients were divided into two cohorts based on extent of surgery: lobectomy (≥1 lobe resected) and thyroidectomy (total or near total resection). Pearson's chi-squared analysis was used to compare cohorts. Kaplan-Meier survival and Cox hazards models were utilized to determine overall survival between two cohorts with p < 0.05 used for significance. RESULTS: A total of 6871 patients were identified with FTC, of which 1507 patients underwent lobectomy and 5364 patients underwent total thyroidectomy. There were no significant differences in patient demographics, comorbidity index, local spread, or tumor grade. Patients undergoing lobectomy had mean survival of 12.94 versus 12.71 years for those undergoing thyroidectomy. Extent of surgery was not associated with a significant difference in survival (5 years OS = 96% in lobectomy and 95.5% in total thyroidectomy, p = 0.08). Stratification by tumor grade resulted in no significant difference in survival between lobectomy and thyroidectomy. CONCLUSION: Survival time was not significantly different in patients with more extensive resection of FTC. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:993-999, 2023.

Utility of Preoperative Laboratory Testing for Ambulatory Endoscopic Sinonasal Surgery in Low-Risk Patients.

BACKGROUND: Preoperative laboratory tests (PLTs) are often obtained prior to outpatient surgical procedures. The objective of this study is to examine the current practice of routine PLT in low-risk patients undergoing ambulatory endoscopic sinonasal surgery (ESS) and to assess whether such testing impacts surgical outcomes. METHODS: Patients undergoing ambulatory ESS were identified from the 2011 to 2018 NSQIP database. Low-risk patients were defined as American Society of Anesthesiologist class 1 or 2. PLTs were grouped into hematologic, chemistry, coagulation, and liver function tests. Chi-square analyses and independent samples t-tests were conducted to compare categoric and continuous variables, respectively. RESULTS: A total of 664 cases met the inclusion criteria, of which 419 (62.1%) underwent at least one PLT. Of these, the most frequent PLT obtained was a complete blood cell count (92.4%). Major complications occurred in 1.5% of patients. There were no statistically significant differences in overall postoperative complications between those with and without PLT (P = .264). Specifically, no significant difference was seen in the incidence of postoperative bleeding (P = .184), urinary tract infection (P = .444), pulmonary embolism (P = .444), or wound infection (P = .701). On multivariable analyses, PLT status was not significantly associated with any complication (P = .097) or unplanned readmission (P = .898). CONCLUSIONS: Our analysis did not reveal an association between the use of PLT and postoperative morbidity or unplanned readmission in low-risk patients undergoing outpatient ESS.

Length of Stay in Patients Undergoing Tracheoplasty: A NSQIP Study.

BACKGROUND: Prolonged length of stay (LOS) has been associated with increased morbidity and resource utilization in various surgical procedures. We aim to determine factors associated with increased hospital stay in patient undergoing tracheoplasty. METHODS: The 2012-2018 National Surgical Quality Improvement Program (NSQIP) database was queried for patients undergoing tracheoplasty. Patient LOS was the primary clinical outcome. A LOS >75th percentile was considered as prolonged and was utilized for bivariate analysis of demographic, comorbidity, and operative characteristics. LOS was utilized as a continuous variable for multivariate linear regression analysis. RESULTS: A total of 252 patients were queried. The majority of patients were female (67.5%), white (82.4%), and over the age of 65 (77.0%). Patients had a median LOS of 7 days with the 75th percentile cutoff being defined at 10 days. On bivariate analysis of associated comorbidities, patients with prolonged LOS were more commonly obese (72.4% vs. 53.1%, p = 0.009), diabetic (37.9% vs. 16.5%, p < 0.001), dyspneic (58.6% vs. 40.7%, p = 0.016), and had chronic steroid use (25.9% vs. 12.9%, p = 0.018). Multivariable logistic regression analysis demonstrated significant associations between prolonged LOS and both chronic obstructive pulmonary disorder (COPD) (OR: 3.43, p = 0.020) and chronic steroid use (OR: 3.81, p = 0.018). CONCLUSIONS: This study elucidates factors associated with prolonged LOS in patients undergoing tracheoplasty. Patients with COPD and chronic steroid use were significantly associated with prolonged LOS. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:1938-1942, 2023.

Malnutrition and Postoperative Outcomes Following Transcervical Zenker Diverticulectomy.

OBJECTIVES: Hypoalbuminemia has been used as a proxy for poor nutrition, and has been associated with poor postoperative outcomes in varying surgical procedures. This study investigates the association between albumin status and complications following transcervical Zenker diverticulectomy. STUDY DESIGN: Retrospective database review. METHODS: The National Surgical Quality Improvement Program database was queried for patients who underwent transcervical Zenker diverticulectomy between 2005 and 2018. Univariate and multivariable analyses were conducted to determine associations between albumin status and postoperative complications. RESULTS: 318 patients undergoing transcervical Zenker diverticulectomy with available albumin values were queried. The mean serum albumin was 3.90 g/dL (SD = 0.56). Univariate analysis showed that hypoalbuminemia was associated with increased age (77.68 vs. 70.03 years) and female gender (54.4% vs. 45.6%), as well as sepsis (p = 0.045), reintubation (p = 0.040), urinary tract infection (p = 0.017), any medical complication (p < 0.001), any life-threatening complication (p = 0.017), and mortality (p = 0.012). Multivariable analyses found no associations between hypoalbuminemia and mortality (OR 33.136, 95% CI N/A, p = 1.000), any medical complication (OR 1.154, 95% CI 0.326-4.079, p = 0.824), any life-threatening complication (OR 0.604, 95% CI 0.079-4.586, p = 0.604), and length of stay (p = 0.249). CONCLUSIONS: This study suggests no association between hypoalbuminemia and postoperative complications in transcervical Zenker diverticulectomy. Hypoalbuminemia and malnutrition may not be a contraindication for surgery correcting Zenker diverticulectomy. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:1402-1408, 2023.

Exploring the Prognostic Significance of the C-reactive Protein/Albumin Ratio in Assessing the Severity of Acute Pancreatitis: A Prospective Observational Study in the Indian Population.

Background The present study aimed to evaluate the predictive utility of the C-reactive protein (CRP)/albumin (CRP/Alb) ratio in predicting outcomes of acute pancreatitis in Indian patients. Methods This prospective observational study included 150 patients admitted within 24 hours of symptom onset. Serum CRP and albumin levels were measured to calculate the CRP/Alb ratio. Atlanta criteria classified severity as mild, moderate, or severe. The primary outcome was persistent organ failure. Results The mean age was 45±15 years, and 63% were males. The median C-reactive protein was 120 mg/L, Alb 3.2 g/dL, and CRP/Alb ratio 0.28. Severe acute pancreatitis patients (n = 50) had higher CRP/Alb ratios than mild cases (0.45 vs. 0.20, p<0.001). At a cut-off of 0.25, the CRP/Alb ratio demonstrated 85% sensitivity, 80% specificity, and an AUROC of 0.82 for predicting organ failure. This was significantly higher than the CRP (area under the receiver operating characteristic (AUROC) curve 0.72, p = 0.03) and Ranson score (AUROC 0.76, p = 0.04). On multivariate regression, CRP/Alb ratio >0.25 independently predicted severe acute pancreatitis after adjusting for age, gender, and CT severity index (adjusted OR 5.2, 95% CI 2.8-9.6). Conclusion The CRP/Alb ratio calculated within 24 hours reliably predicts persistent organ dysfunction in Indian acute pancreatitis patients. Incorporating this inexpensive biomarker into clinical prediction tools could significantly improve early risk stratification and streamline healthcare delivery in resource-limited settings.