Association of Age and Frailty With 30-Day Outcomes Among Patients Undergoing Oral Cavity Cancer Surgery.

OBJECTIVE: To evaluate the impact of age and frailty on 30-day outcomes following surgery for oral squamous cavity carcinoma (OSCC). STUDY DESIGN: Retrospective cross-sectional analysis. SETTING: American College of Surgeons' National Quality Improvement Program (NSQIP) database. METHODS: Patients who underwent OSCC resection were queried via NSQIP (2015-2020). Cases were stratified by age (18-65, 65-75, and older than 75) as well as by modified frailty index scores (mFI 0, mFI 1, and mFI 2+) for comparative analyses. Univariate and multivariable analyses were conducted to examine demographics, perioperative outcomes, and 30-day postoperative adverse events. RESULTS: A total of 3238 patients who underwent OSCC surgery were identified and categorized as nongeriatric ("NGA," age 18-65), younger geriatric ("YGA," age 65-75), and older geriatric ("OGA," age >75) adults. Compared to NGA, geriatric patients had higher the American Society of Anesthesiologists classification, higher modified frailty index scores, and more comorbidities such as hypertension, congestive heart failure, chronic obstructive disease, and diabetes (p < .001). YGAs and OGAs were also less likely to undergo neck dissection (p < .001), composite resection (p = .006), and free flap reconstruction compared to NGAs (p < .001). When controlling for confounders, age was not independently associated with an increased risk of poor outcomes. On the other hand, frailty was found to be independently associated with a higher risk of adverse events (odds ratio: 1.40 [1.15-1.70], p < .001 for mFI 1, odds ratio: 1.45 [1.04-2.02], p = .027 for mFI 2+). CONCLUSION: A higher mFI score, not older age, is associated with an increased risk of 30-day complications following OSCC surgery.

Contemporary Osseous Reconstruction of the Mandible and the Maxilla.

Cancers of the oral cavity and paranasal sinuses often require ablative surgery with adjuvant therapy in most cases. Large, postablative defects of the mandible and the maxilla present several challenges to the reconstructive surgeon. Functional and cosmetically satisfactory restoration requires a thorough understanding of the underlying disease process, a firm grasp of the nuances of head and neck anatomy, and an ability to plan and execute a reconstruction with the most suitable tissue for each particular patient. The authors outline the components of osseous reconstruction of the facial skeleton with a bias toward techniques and approaches that are particularly useful.

Comprehensive approach to functional palatomaxillary reconstruction using regional and free tissue transfer: Report of reconstructive and prosthodontic outcomes of 140 patients.

BACKGROUND: Palatomaxillary defects were historically restored with a prosthetic obturator; however, advances in local and free tissue transfer has provided a viable alternative for appropriately selected patients with palatomaxillary defects. METHODS: A retrospective chart review of patients who underwent palatomaxillary reconstruction by the lead author between 1998 and 2016 was conducted. Patients who were restored with a palatal obturator were excluded. RESULTS: One hundred forty patients were reconstructed with a total of 159 local, regional, and free flaps with a 96.7% success rate. Seventy-four patients (52.8%) underwent prosthodontic rehabilitation, with 183 implants placed and an 86% success rate. CONCLUSION: Palatomaxillary reconstruction applying a systematic approach, using a multitude of techniques, is a safe and effective way to restore patients without compromising the ability to maintain surveillance. Prosthodontic rehabilitation can be achieved in a high percentage of patients using dental implants, leading to optimal aesthetic and functional results.

Predictors of Readmission and Reoperation in Patients Undergoing Parathyroidectomy for Primary Hyperparathyroidism.

Objective Identify risk factors for 30-day reoperation and readmission after parathyroidectomy for primary hyperparathyroidism. Study Design Retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2012 through 2014. Subjects and Methods Patients undergoing parathyroidectomy and parathyroid reexploration for primary hyperparathyroidism. Univariate and multivariate analyses were conducted to determine risk factors for reoperation and readmission. Results Of the 9439 patients who underwent parathyroidectomy, 72 patients underwent 1 reoperation in the first 30 days after surgery, and 8 patients underwent 2 reoperations. The most common reasons were hematoma (25%) and persistent hyperparathyroidism (15.9%). Risk factors included smoking (odds ratio [OR], 1.86; 95% confidence interval [CI], 0.97-3.31), insulin-dependent diabetes (OR, 2.38; 95% CI, 1.02-4.86), and history of bleeding disorder (OR, 3.95; 95% CI, 1.48-8.79). In total, 182 (1.9%) patients were readmitted within 30 days of surgery; the most common cause was hypocalcemia (17.0%). Risk factors included operative time (hours) (OR, 1.3; 95% CI, 1.1-1.5), insulin-dependent diabetes mellitus (OR, 2.01; 95% CI, 1.2-3.3), dyspnea with moderate exertion (OR, 5.77; 95% CI, 0.86-14.67), and age (decade) (OR, 1.16; 95% CI, 1.02-1.32). Patients undergoing outpatient surgery were less likely to be readmitted (OR, 0.49; 95% CI, 0.35-0.69) or undergo reoperation (OR, 0.44; 95% CI, 0.27-0.73). Conclusions Thirty-day reoperation rate after parathyroidectomy was low and most commonly occurred due to hematoma. Risk factors for readmission were multifactorial and associated with perioperative factors, patient factors, and medical comorbidities. Preoperative counseling for patients at increased risk of readmission and reoperation may decrease these rates.

Treatment and survival vary by race/ethnicity in patients with anaplastic thyroid cancer.

BACKGROUND: Anaplastic thyroid cancer (ATC) is the rarest type of thyroid cancer and has the lowest overall survival. To the authors' knowledge, the impact of socioeconomic status and race/ethnicity has not yet been described. METHODS: Data regarding 719 patients diagnosed with their first primary malignant ATC from January 1, 1998 to December 31, 2011 in the Surveillance, Epidemiology, and End Results program registries were examined. Differences in receipt of thyroidectomy, radiotherapy, and lymph node examination were examined by race/ethnicity. Survival also was examined by race/ethnicity. RESULTS: Nearly 70% of patients were non-Hispanic white, and 55.4% of patients received treatment. Tumor size (P = .13), lymph node involvement (P = .60), and residence in high poverty neighborhoods (P = .08) did not vary by race/ethnicity. Nonwhite patients were more likely to receive no treatment (adjusted odds ratio, 0.29; 95% confidence interval [95% CI], 0.16-0.54). When receipt of radiotherapy was adjusted for, nonwhite patients had a higher risk of overall death (adjusted hazards ratio [aHR], 1.24; 95% CI, 1.01-1.54), although not disease-specific death (aHR, 1.14; 95% CI, 0.92-1.42). Patients living in areas of high poverty had lower overall survival (aHR, 1.54; 95% CI, 1.09-2.18) and disease-specific survival (aHR, 1.68; 95% CI, 1.19-2.36). CONCLUSIONS: In this population-based study of patients with ATC, nonwhite patients were found to be less likely to receive treatment. Furthermore, nonwhite patients had poorer overall survival, and patients living in areas of high poverty had both worse overall and disease-specific survival. Racial/ethnic and socioeconomic disparities appear to exist in the treatment and survival of patients with ATC. Cancer 2018;124:1780-90. © 2018 American Cancer Society.

The folded postauricular flap: A novel approach to reconstruction of large full thickness defects of the conchal bowl.

Extensive subtotal full-thickness auriculectomy defects pose a challenge for the reconstructive surgeon. The posterior island flap (PIF), based on the posterior auricular artery, has been described as a reconstructive option for auricular defects, with reports describing a "pull-through" or "revolving door" technique to reconstruct subtotal partial thickness and full thickness auricular defects. These techniques may result in posterior "pinning" of the auricle. This patient is an 87-year-old male who presented after Mohs excision of squamous cell carcinoma of the conchal bowl, which resulted in a 4x4cm subtotal auriculectomy defect. A folded PIF was used to reconstruct the large full thickness defect, in a multistage manor. Post-operatively, the patient had a reconstructed auricle that was suitable for wearing hearing aids and glasses. We describe a novel technique of the folded PIF for an extensive full-thickness auricular defect, which utilizes a single, well camouflaged donor site, provides well-vascularized local tissue with excellent color match, and allows for the restoration of the post-auricular sulcus.

Total lower lip and chin reconstruction with radial forearm free flap: A novel approach.

BACKGROUND: The management of large chin and lower lip defects is challenging due to this facial subunit's tremendous functional and aesthetic importance. Specific methods for total lower lip and mentum reconstruction are not well chronicled. Aesthetic and functional goals of this reconstruction include restoration of oral competence by maintaining lower lip height, vermilion reestablishment, color-matched skin introduction to the chin, sensation restoration, and ideally restoration of dynamic activity to the lower lip. METHODS: Literature review performed. RESULTS: Presentation of novel, two-stage technique for lower lip and chin reconstruction with a submental flap and a radial forearm free flap, suspension of the lower lip and chin with a tensor fascia lata graft, and vermilion reconstruction with a buccal mucosal flap. CONCLUSIONS: This procedure meets all goals of total lower lip reconstruction with the exception of the introduction of dynamic tissue and represents a novel solution to a challenging reconstructive problem.

Association of Socioeconomic Status and Race/Ethnicity With Treatment and Survival in Patients With Medullary Thyroid Cancer.

IMPORTANCE: Medullary thyroid cancer (MTC) is a relatively rare neoplasm of the thyroid but accounts for 14% of thyroid cancer-related deaths. Female sex, young age, and stage at presentation have been found to predict survival and treatment. However, patterns of survival and treatment by socioeconomic status and race/ethnicity have not been fully described. OBJECTIVE: To determine whether socioeconomic status and race/ethnicity are associated with survival and treatment in patients with MTC. DESIGN, SETTING, AND PARTICIPANTS: Data for 1647 patients with MTC from January 1, 1998, to December 31, 2011, in the Surveillance, Epidemiology, and End Results (SEER) Program registry were examined. Data analysis was conducted from June 1, 2013, to July 31, 2014. MAIN OUTCOMES AND MEASURES: Differences in receipt of thyroidectomy and lymph node examination by race/ethnicity were examined using logistic regression models. Overall and disease-specific survival were examined by race/ethnicity using Kaplan-Meier survival curves and adjusted Cox proportional hazards regression models. RESULTS: Of the 1647 patients with MTC were 1192 white (72.4%), 139 black (8.4%), 222 Hispanic (13.5%), and 94 other races/ethnicities (5.7%). Of these, 1539 (93.4%) underwent surgical treatment. There were no differences in receipt of thyroidectomy by race/ethnicity; however, black patients (adjusted odds ratio, 0.61; 95% CI, 0.39-0.93) and female patients (adjusted odds ratio, 0.76; 95% CI, 0.59-0.99) were less likely to undergo lymph node examination compared with non-Hispanic white and male patients. Black patients had lower overall (adjusted hazard ratio, 2.40; 95% CI, 1.45-3.98) and disease-specific survival (adjusted hazard ratio, 2.9; 95% CI, 1.64-5.14) compared with non-Hispanic white patients. CONCLUSIONS AND REVELANCE: In this population-based study of patients with MTC, black patients were less likely to have lymph node examination following surgery. Furthermore, Hispanic and black patients had poorer overall and disease-specific survival compared with non-Hispanic white patients after accounting for clinical factors. Racial/ethnic disparities exist in the type of treatment as well as outcomes in patients with MTC.

Subcutaneous immunotherapy.

BACKGROUND: Allergic rhinitis, asthma, and Hymenoptera sensitivity affect approximately 20%, 9%, and 0.66% to 3.3% of adults in the United States, respectively. Various environmental control measures and pharmacologic options are available for symptomatic treatment of allergic rhinitis and allergic asthma. However, allergen-specific immunotherapy is the only form of treatment that alters the natural history of allergic disease. METHODS: A literature review was performed. Information from systematic reviews, meta-analyses, and practice parameters were closely examined and summarized, and they are included in this primer. RESULTS: There is evidence that supports the use of subcutaneous immunotherapy (SCIT) for the treatment of perennial and seasonal allergic rhinitis, asthma, and Hymenoptera sensitivity. Efficacy of SCIT has been established in the adult and pediatric populations. Adverse reactions occur in up to 71% of patients. However, the rate of serious or fatal side effects is very rare. CONCLUSION: SCIT is safe and effective in the treatment of allergic rhinitis, allergic asthma, and Hymenoptera sensitivity. Adverse reactions occur but, in general, SCIT is well tolerated, and the vast majority of reactions are mild and very rarely fatal.

Pharmacotherapy of child and adolescent depression.

Pediatric depression is a prevalent and recurrent condition that persists into adulthood and carries significant impairment, morbidity, and risk of mortality. Although there has been a surge of pediatric antidepressant studies in recent years, depression remains largely understudied, unrecognized, and untreated in children and adolescents. Few antidepressant trials have yielded positive results in pediatric depression. Regulatory agencies recently issued warnings against the use of selective serotonin reuptake inhibitors and newer antidepressants in depressed children and adolescents because of a possible link between their use and the appearance or worsening of suicidal ideation or attempts. The authors review data on efficacy and safety of antidepressants for the treatment of pediatric depression to provide treating clinicians with a basis on which to guide their treatment recommendations.

Impulsive-aggressive traits and suicidal adolescents and young adults with alcoholism.

Suicidal behavior and alcohol use disorders among adolescents and young adults are serious public health problems. In the study of suicidal behavior among young people with alcoholism, it has been shown that aggression and impulsivity are higher among those who attempted suicide. Impulsivity has been related to suicidal and self-destructive behaviors within different psychiatric conditions, i.e. alcohol and substance use disorders, mood disorders, conduct disorder, impulse control disorders, antisocial personality disorder, and borderline personality disorder. The term impulsivity has been used to define different constructs such as (1) personality trait or cognitive style in which disinhibition is the core characteristic, (2) a tendency to act immediately in response to external or internal stimuli, and (3) a group of psychiatric disorders with behavioral dyscontrol. Among adolescents suicidal behavior is transmitted in families independently of psychiatric conditions, but not independently of impulsivity/aggression. Two causal links between impulsiveness and alcoholism have been proposed: (1) adolescents who develop alcoholism possess higher premorbid levels of impulsiveness than those who do not develop alcoholism, and (2) levels of impulsiveness differentiate both populations only after the development of alcoholism, with higher levels of impulsiveness among those adolescents who developed alcoholism. Cognitive behavioral techniques have shown promising results in the treatment of adolescents with alcohol and substance use disorder and suicidality. The relative frequency of suicidal behavior among adolescents and young adults suffering from alcoholism and its subsequent devastating effects on individuals, families and society merits further research and development of prevention strategies.

Demographic and clinical features of adolescents and young adults with alcohol-related disorders admitted to the psychiatric emergency room.

OBJECTIVES: To determine the incidence of alcohol related problems (ARP) among adolescents admitted to the Psychiatric Emergency Room (PER) and to describe the demographic and clinical characteristics. METHODS: The study was a retrospective review of admissions to the PER, where we reviewed the psychiatric records of all of the 14-30 year olds admitted to the PER during the three-month period between April 1st, 2003 and June 30th, 2003. Demographic and clinical data of subjects with and without ARP were compared. RESULTS: During the three-month time period, 108 patients between the age of 14 and 30 were admitted to the PER. 14 (13.2%) of these had ARP, and ARP tended to occur more in males (chi2 = 3.81; df=l; p = 0.05). The number of psychiatric diagnoses among those who had ARP was significantly higher than among those who did not have ARP (t = -3.12; df=104; p = 0.002). ARP were found to be associated with personality disorder and misuse of other substances. 37.5% of those adolescents and young adults with ARP had a personality disorder, while 13% of those without ARP had a personality disorder (chi2 = 4.64; df=1; p = 0.03). 50% of those with ARP consumed (an)other substance/s, while 12.0% of those patients without ARP consumed (an)other substance/s (chi2 = l2.48; df=1; p < 0.001). Of the female adolescents and young adults with ARP, 50% were admitted to PER after an episode of self-poisoning. CONCLUSION: ARP in young adults admitted to the PER for acute psychiatric care are associated with greater psychiatric comorbidity, especially personality disorders. In females, ARP may be associated with an increased risk for self-poisoning. Adequate detection of ARP in the PER could promote earlier specific interventions specifically tailored to ARP among adolescents and young adults.

Suicide in early childhood: a brief review.

The rate of suicide in the United States among prepubertal children and young adolescents had increased by 120% from 1980 to 1992. From 1992 to the present the rate has decreased slightly by 33%. We address a brief review of the most relevant findings in literature that are related to the risk of suicide. Although the most reported findings were child mood disorder, any type of family distress and family history of suicide attempts, the severity of those does not seem to increase the risk of suicide. However, there were other environmental factors that may influence the risk of suicide, such as the access to firearms. It is critical to detect risk factors and triggers in prepubertal populations in order to reduce the incidence of suicide in this age group and older age groups.