RESUMO
OBJECTIVE: To describe a case of Burkitt lymphoma (BL) in a child manifesting with acute airway obstruction. To review available literature on the clinical features and characteristic presentation of this disease. METHODS: Case report with literature review. RESULTS: We present the case of an 8-year-old boy with nasopharyngeal BL manifesting initially as sore throat, nasal congestion, and snoring that progressed to dyspnea and, ultimately, acute airway obstruction requiring emergent tracheostomy. The child was treated with intensive chemotherapy and achieved complete response. CONCLUSION: This case highlights the importance of maintaining high clinical suspicion when evaluating common otolaryngologic symptoms and emphasizes the potential for Burkitt lymphoma to cause rapid patient deterioration.
Assuntos
Obstrução das Vias Respiratórias/etiologia , Obstrução das Vias Respiratórias/cirurgia , Linfoma de Burkitt/complicações , Linfoma de Burkitt/tratamento farmacológico , Neoplasias Nasofaríngeas/complicações , Neoplasias Nasofaríngeas/tratamento farmacológico , Traqueostomia/métodos , Doença Aguda , Obstrução das Vias Respiratórias/diagnóstico por imagem , Protocolos de Quimioterapia Combinada Antineoplásica/administração & dosagem , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Linfoma de Burkitt/diagnóstico , Linfoma de Burkitt/diagnóstico por imagem , Criança , Ciclofosfamida/administração & dosagem , Doxorrubicina/administração & dosagem , Dispneia/diagnóstico por imagem , Dispneia/etiologia , Dispneia/cirurgia , Detecção Precoce de Câncer , Emergências , Humanos , Masculino , Metotrexato/administração & dosagem , Neoplasias Nasofaríngeas/diagnóstico , Neoplasias Nasofaríngeas/diagnóstico por imagem , Tomografia por Emissão de Pósitrons , Prednisona/administração & dosagem , Rituximab/administração & dosagem , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Vincristina/administração & dosagemRESUMO
Heart transplantation in children with intellectual disability (ID) is an issue of debate due to the shortage of available donor organs. We sought to perform the first large-scale retrospective cohort study describing the prevalence and outcomes of heart transplantation in this population. The United Network of Organ Sharing database was queried from 2008 to 2015 for pediatric patients (age <19 years) receiving first, isolated heart transplant. Recipients were divided into three subgroups: definite ID, probable ID, and no ID. The chi-square test was used to compare patients' baseline characteristics. Kaplan-Meier and Cox proportional hazard regression analyses were used to estimate the association between ID and death-censored graft failure and patient survival. Over the study period, 565 pediatric patients with definite (131) or probable (434) ID received first heart transplant, accounting for 22.4% of all first pediatric heart transplants (n=2524). Recipients with definite ID did not significantly differ from those without ID in terms of gender, ethnicity, ischemia time, severity of pretransplant condition (waitlist status, mechanical ventilation, inotrope dependence, ECMO, VAD, PVRI, infection prior to transplant), or incidents of acute rejection within the first year. ID was associated with prolonged waitlist time (P<.001). Graft and patient survival at 3 years was equivalent between children with and without ID (P=.811 and .578, respectively). We conclude that intellectual disability is prevalent in children receiving heart transplants, with 22.4% of recipients over the study period having definite or probable ID. ID does not appear to negatively affect transplantation outcomes. Future studies are needed to assess long-term outcomes of transplantation in this population.
Assuntos
Insuficiência Cardíaca/cirurgia , Transplante de Coração/estatística & dados numéricos , Deficiência Intelectual/complicações , Adolescente , Criança , Pré-Escolar , Transtornos Cognitivos , Bases de Dados Factuais , Feminino , Rejeição de Enxerto/epidemiologia , Sobrevivência de Enxerto , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/mortalidade , Transplante de Coração/mortalidade , Humanos , Lactente , Estimativa de Kaplan-Meier , Masculino , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores de Tempo , Doadores de Tecidos , Resultado do TratamentoRESUMO
OBJECTIVE: Simulation may be a valuable tool in training laryngology office procedures on unsedated patients. However, no studies have examined whether existing awake procedure simulators improve trainee performance in laryngology. Our objective was to evaluate the transfer validity of a previously published 3D-printed laryngeal simulator in improving percutaneous injection laryngoplasty (PIL) competency compared with conventional educational materials with a single-blinded randomized controlled trial. METHODS: Otolaryngology residents with fewer than 10 PIL procedures in their case logs were recruited. A pretraining survey was administered to participants to evaluate baseline procedure-specific knowledge and confidence. The participants underwent block randomization by postgraduate year to receive conventional educational materials either with or without additional training with a 3D-printed laryngeal simulator. Participants performed PIL on an anatomically distinct laryngeal model via trans-thyrohyoid and trans-cricothyroid approaches. Endoscopic and external performance recordings were de-identified and evaluated by two blinded laryngologists using an objective structured assessment of technical skill scale and PIL-specific checklist. RESULTS: Twenty residents completed testing. Baseline characteristics demonstrate no significant differences in confidence level or PIL experience between groups. Senior residents receiving simulator training had significantly better respect for tissue during the trans-thyrohyoid approach compared with control (p < 0.0005). There were no significant differences in performance for junior residents. CONCLUSIONS: In this first transfer validity study of a simulator for office awake procedure in laryngology, we found that a previously described low-cost, high-fidelity 3D-printed PIL simulator improved performance of PIL amongst senior otolaryngology residents, suggesting this accessible model may be a valuable educational adjunct for advanced trainees to practice PIL. LEVEL OF EVIDENCE: NA Laryngoscope, 134:318-323, 2024.
Assuntos
Internato e Residência , Laringoplastia , Laringe , Otolaringologia , Treinamento por Simulação , Humanos , Competência Clínica , Endoscopia , Laringe/cirurgia , Otolaringologia/educação , Impressão Tridimensional , Treinamento por Simulação/métodosRESUMO
OBJECTIVE: To analyze the factors and costs associated with 30-day readmissions for patients undergoing radical nephrectomy. MATERIALS AND METHODS: We used the 2014 Nationwide Readmission Database to identify adults who underwent radical nephrectomy for renal cancer, stratified by surgical approach. We determined patient factors associated with readmission rates, diagnoses, and costs using multivariate logistic regression. RESULTS: Among 19,523 individuals, the 30-day readmission rate was 7.7% (n = 1,506). On multivariate regression, odds of readmission were significantly increased with age ≥75 in those who underwent open nephrectomy (OR: 1.35; 95%CI: 1.03-1.78). Subjects with a Charlson comorbidity score ≥3 had significantly higher rates of readmission regardless of surgical approach (Open RN - OR: 1.85; 95%CI: 1.33-2.56; Lap RN - OR: 1.99; 95%CI 1.10-3.59; Robotic RN - OR: 2.18; 95%CI: 1.23-3.86). Common reasons for readmission were gastrointestinal, cardiovascular, urinary tract infections, and wound complications across all surgical approaches. The mean cost per readmission was as high as 126% ($20,357) of the mean index admission cost. CONCLUSION: One in 13 adults undergoing radical nephrectomy is readmitted within 30 days of discharge. Associated readmission cost is up to 1.26 times the cost of index admission. Our findings may inform efforts aiming to reduce hospital readmissions and curtail healthcare costs.
Assuntos
Readmissão do Paciente , Robótica , Adulto , Humanos , Estados Unidos , Complicações Pós-Operatórias/etiologia , Hospitalização , Nefrectomia/efeitos adversos , Fatores de Risco , Estudos Retrospectivos , Bases de Dados FactuaisRESUMO
OBJECTIVES/HYPOTHESIS: To determine the rate and predictors of receiving multiple tympanostomy tube (TT) placements in children. STUDY DESIGN: Systematic review and meta-analysis. METHODS: PubMed, EMBASE, and Cochrane Library databases were searched for studies reporting the risk factors for receiving repeat TT (r-TT) placements in children with chronic otitis media with effusion or recurrent acute otitis media. These articles were systematically reviewed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) recommendations. Data were pooled using a random-effects model. RESULTS: Twenty-one studies involving a total of 290,897 children were included. Among all patients, 24.1% (95% confidence interval (CI), 18.2%-29.9%) underwent ≥2 TT placements and 7.5% (95% CI, 5.7%-9.4%) underwent ≥3 TT placements. Craniofacial disease (odds ratio (OR) 5.13, 95% CI, 1.57-16.74) was the strongest predictor of r-TT. Younger age at initial TT placement and shorter TT retention time were also significantly associated with r-TT. Receipt of primary adenoidectomy with initial TT placement was associated with decreased odds of r-TT (OR, 0.46; 95% CI, 0.39-0.55). Long-term tubes also significantly reduced the odds of r-TT (OR, 0.27; 95% CI, 0.17-0.44). CONCLUSIONS: About 1 in 4 children receiving TT will receive at least one repeat set of TT and about 1 in 14 will receive multiple repeat sets. Concurrent adenoidectomy and long-term tubes reduced the incidence of r-TT. Younger patients and those with earlier extrusion of the initial set are at increased risk for repeat surgery. The identification of these risk factors may improve parental counseling and identify patients who might benefit from closer follow-up. LEVEL OF EVIDENCE: NA Laryngoscope, 131:E2363-E2370, 2021.
Assuntos
Adenoidectomia/estatística & dados numéricos , Remoção de Dispositivo/estatística & dados numéricos , Ventilação da Orelha Média/estatística & dados numéricos , Otite Média/cirurgia , Reoperação/estatística & dados numéricos , Assistência ao Convalescente , Criança , Doença Crônica/terapia , Humanos , Ventilação da Orelha Média/instrumentação , Fatores de Proteção , Recidiva , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVES: To evaluate the incidence, causes, risk factors, and costs associated with 30-day readmissions in parotidectomy patients utilizing the Nationwide Readmissions Database (NRD). STUDY DESIGN: Retrospective cohort study. METHODS: We examined the NRD for patients who underwent parotidectomy between 2010 and 2014. Rates, causes, and costs of 30-day readmissions were determined. Multivariate logistic regression was used to identify risk factors for readmission. RESULTS: Among 15,102 included patients, 594 (3.9%) were readmitted within 30 days. The average cost per readmission was $12,502. Infectious (22.7%) and wound (11.2%) complications were the two most common causes of readmission. After controlling for other covariates, significant predictors of readmission included advanced comorbidity (odds ratio [OR], 1.61; 95% confidence interval [CI], 1.09-2.37), a malignant parotid tumor (OR, 2.37; 95% CI, 1.63-3.43), length of stay ≥2 days (OR, 1.54; 95% CI, 1.09-2.18), and nonroutine discharge destinations (home with care [OR, 1.88; 95% CI, 1.27-2.78] and nursing facility [OR, 2.69; 95% CI, 1.55-4.67]). CONCLUSION: In this nationwide database analysis, we found that nearly 4% of all patients undergoing parotidectomy are readmitted within 30 days. Readmissions are commonly due to infections and wound complications. Quality improvement proposals targeting avoidable readmissions should focus on early recognition and prevention of infection and wound complications. Risk factors contributing to readmission include advanced comorbidity, malignant parotid tumor, prolonged index hospitalization, and nonroutine discharge destinations. LEVEL OF EVIDENCE: NA Laryngoscope, 130:1212-1217, 2020.
Assuntos
Custos e Análise de Custo , Doenças Parotídeas/cirurgia , Glândula Parótida/cirurgia , Readmissão do Paciente/economia , Readmissão do Paciente/estatística & dados numéricos , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Estados UnidosRESUMO
OBJECTIVE: To characterize treatment delays in sinonasal cancer managed with surgery and adjuvant radiation and determine the associated impact on survival. STUDY DESIGN: Retrospective cohort study. METHODS: We identified adults in the National Cancer Database treated for sinonasal squamous cell carcinoma with definitive surgery followed by adjuvant radiation from 2004 to 2014. We then examined intervals of diagnosis to surgery (DTS), surgery to radiation (SRT), and radiation duration (RTD). Next, we performed recursive partitioning analysis (RPA) to identify thresholds for these treatment intervals that estimated the greatest differences in survival. We determined the association of treatment delay with overall survival using Cox proportional hazards regression. RESULTS: Among 2,267 patients included, median durations of DTS, SRT, and RTD were 32, 49, and 47 days, respectively. Predictors of treatment delay included care transitions, black race, and Medicare insurance. We identified thresholds of 26, 64, and 51 days for DTS, SRT, and RTD, respectively, as estimating the largest survival differences. Delays in SRT (hazard ratio [HR] 1.20; 95% confidence interval [CI], 1.03-1.40), and RTD (HR, 1.27; 95% CI, 1.10-1.46) beyond these thresholds independently predicted mortality. Delay in DTS beyond the RPA-derived threshold was not significantly associated with mortality after adjusting for other covariates. CONCLUSION: Delays in SRT and RTD intervals are associated with decreased overall survival. Median durations may serve as national benchmarks. Treatment delays could be considered quality indicators for sinonasal cancer treated with surgery and adjuvant radiation. LEVEL OF EVIDENCE: NA Laryngoscope, 130:2-11, 2020.
Assuntos
Carcinoma de Células Escamosas/mortalidade , Carcinoma de Células Escamosas/cirurgia , Neoplasias dos Seios Paranasais/mortalidade , Neoplasias dos Seios Paranasais/cirurgia , Tempo para o Tratamento , Idoso , Carcinoma de Células Escamosas/radioterapia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias dos Seios Paranasais/radioterapia , Radioterapia Adjuvante , Estudos Retrospectivos , Taxa de Sobrevida , Estados UnidosRESUMO
OBJECTIVES/HYPOTHESIS: Frailty is a measure of decreased physiologic reserve that has been associated with adverse outcomes in older surgical patients. We aimed to measure the association of preoperative frailty with outcomes in patients undergoing sinonasal cancer surgery. STUDY DESIGN: Retrospective cohort study. METHODS: We identified 5,346 patients in the Nationwide Readmissions Database undergoing sinonasal cancer surgery from 2010 to 2014. Frailty was defined using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnoses indicator. Multivariate regression was used to analyze the association of frailty with postoperative outcomes. RESULTS: Frailty was present in 7.4% of patients. Frailty was a significant independent predictor of intensive care unit-level complications (odds ratio [OR]: 4.83; 95% confidence interval [CI]: 2.95-7.93; P < .001) and nonhome discharge (OR: 3.07; 95% CI: 1.68-5.60; P < .001). Compared to nonfrail patients, frail patients had threefold longer median length of stay (12 days vs. 4 days; P < .001) and more than twofold higher median hospital costs ($44,408 vs. $18,660; P < .001). Frailty outperformed advanced comorbidity (defined as Charlson-Deyo score ≥3), age ≥80 years, and markers of surgical complexity (e.g., skull base/orbit involvement, flap reconstruction, neck dissection) in predicting serious complications, nonhome discharge, length of stay, and hospital costs. CONCLUSIONS: Frailty appears to have a stronger and more consistent association with adverse outcomes and increased resource utilization after sinonasal cancer surgery than age or comorbidity index. This information may be used in surgical risk stratification and can guide strategies to prevent or mitigate adverse events in this high-risk group. LEVEL OF EVIDENCE: NA Laryngoscope, 130:290-296, 2020.
Assuntos
Utilização de Instalações e Serviços/estatística & dados numéricos , Fragilidade/complicações , Neoplasias dos Seios Paranasais/cirurgia , Complicações Pós-Operatórias/etiologia , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Recursos em Saúde/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
OBJECTIVE: To characterize the epidemiology and clinicopathologic determinants of survival following the diagnosis of clear cell adenocarcinoma in the head and neck region. STUDY DESIGN: Retrospective cohort study. SETTING: The Surveillance, Epidemiology, and End Results registry (1994 to 2014). SUBJECTS AND METHODS: A total of 173 cases were identified. Study variables included age, sex, race, tumor subsite, tumor stage, tumor grade, surgical excision, and regional and distant metastases. Survival measures included overall survival (OS) and disease-specific survival (DSS). RESULTS: Median age at diagnosis was 63 years, 48% were female, and 80.2% were white. Fourteen percent of patients presented with regional lymph node metastases, while 3.3% of patients presented with distant metastases. Most of the tumors presented in the oral cavity, salivary glands, and pharynx. Kaplan-Meier analysis demonstrated OS and DSS of 77.2% and 83.7% at 5 years, respectively. Median OS after diagnosis was 153 months. Bivariate analysis showed that surgical excision was associated with 5-fold increased OS and DSS, whereas advanced age, high tumor grade, advanced stage, larger tumor size, nodal disease, and distant metastases were all significant predictors of decreased OS and DSS. CONCLUSIONS: Clear cell adenocarcinoma is a rare neoplasm that typically affects white individuals in their early 60s, with a generally favorable prognosis. It most commonly arises in the oral cavity, major salivary glands, and pharynx. Surgical excision is associated with 5-fold survival benefit, whereas advanced age, high tumor grade, advanced stage, nodal disease, and distant metastases are independently associated with worse OS and DSS.
Assuntos
Adenocarcinoma de Células Claras , Neoplasias de Cabeça e Pescoço , Adenocarcinoma de Células Claras/diagnóstico , Adenocarcinoma de Células Claras/mortalidade , Adenocarcinoma de Células Claras/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Neoplasias de Cabeça e Pescoço/diagnóstico , Neoplasias de Cabeça e Pescoço/mortalidade , Neoplasias de Cabeça e Pescoço/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Taxa de SobrevidaRESUMO
IMPORTANCE: Thirty-day hospital readmissions have substantial direct costs and are increasingly used as a measure of quality care. However, data regarding the risk factors and reasons for readmissions in head and neck cancer surgery reconstruction are lacking. OBJECTIVE: To describe the rate, risk factors, and causes of 30-day readmission in patients with head and neck cancer following free or pedicled flap reconstruction. DESIGN, SETTING, AND PARTICIPANTS: This retrospective, population-based cohort study analyzed medical records from the Nationwide Readmissions Database of 9487 patients undergoing pedicled or free flap reconstruction of head and neck oncologic defects between January 1, 2010, and December 31, 2014. Data analysis was performed in October 2017. EXPOSURES: Pedicled or free flap reconstruction of an oncologic head and neck defect. MAIN OUTCOMES AND MEASURES: The primary outcome was 30-day all-cause readmissions. Secondary outcomes included risk factors, causes, and costs of readmission. Multivariate regression analyses were conducted to determine factors independently associated with 30-day readmissions. RESULTS: Among 9487 patients included in the study (6798 male; 71.7%), the median age was 63 years (interquartile range, 55-71 years), and the 30-day readmission rate was 19.4% (n = 1839), with a mean cost per readmission of $15â¯916 (standard error of the mean, $785). The most common indication for readmission was wound complication (26.5%, n = 487). On multivariate regression, significant risk factors for 30-day readmission were median household income in the lowest quartile (vs highest quartile: odds ratio [OR], 1.58; 95% CI, 1.18-2.11), congestive heart failure (OR, 1.68; 95% CI, 1.14-2.47), liver disease (OR, 2.02; 95% CI, 1.22- 3.33), total laryngectomy (OR, 1.40; 95% CI, 1.12-1.75), pharyngectomy (OR, 1.47; 95% CI, 1.08-2.01), blood transfusion (OR, 1.30; 95% CI, 1.04-1.64), discharge to home with home health care (vs routine: OR, 1.32; 95% CI, 1.04-1.67), and discharge to a nursing facility (vs routine: OR, 1.77; 95% CI, 1.30-2.40). CONCLUSIONS AND RELEVANCE: Using the Nationwide Readmissions Database, we demonstrate that approximately 1 in 5 patients undergoing head and neck cancer surgery reconstruction is readmitted within 30 days of surgery. Readmissions are most commonly associated with wound complications. Socioeconomic status, complex ablative procedures, and patient comorbidities are independent risk factors for readmission. These findings may be useful to clinicians in developing perioperative interventions aimed to reduce hospital readmissions and improve quality of patient care.
Assuntos
Neoplasias de Cabeça e Pescoço/cirurgia , Custos Hospitalares/estatística & dados numéricos , Readmissão do Paciente/economia , Procedimentos de Cirurgia Plástica/economia , Complicações Pós-Operatórias/economia , Retalhos Cirúrgicos , Idoso , Comorbidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Classe SocialRESUMO
OBJECTIVE: To evaluate the impact of frailty on adverse perioperative outcomes in patients treated with radical cystectomy for bladder cancer. MATERIAL AND METHODS: We identified 9459 adults (age ≥18) in the Nationwide Readmission Database who underwent radical cystectomy in 2014 for bladder cancer. We defined patients' frailty status using Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator and compared in-hospital mortality, ICU-level complications, 30-day readmissions, nonhome discharge, length of hospitalization, and hospital-related costs between frail and nonfrail patients using χ2 tests. We used multivariate logistic regression to identify predictors of the primary outcomes of interest. RESULTS: Of 9459 patients undergoing radical cystectomy, 7.1% (nâ¯=â¯673) met criteria. Frail patients were more likely than nonfrail patients to have comorbid conditions (68.2% vs 59.7%; P= .005), in-hospital mortality (4.2% vs 1.5%; P= .04), ICU-level complications (52.9% vs 18.6%; P<.001), nonhome discharge (33.9% vs 11.6%; P <.001), longer length of stay (median 15 vs 7 days; P<.001), and higher median cost of the index admission ($39,665 vs $27,307). Frailty was the strongest independent predictor of ICU-level complications, nonhome discharge, increased length of stay, and hospital-related costs of any covariate. CONCLUSION: Frail patients receiving radical cystectomy were more likely than nonfrail patients to have adverse perioperative outcomes and higher odds of in-hospital mortality, ICU-level complications, nonhome discharge, increased length of stay, and hospital-related costs. Preoperative consideration of frailty may be useful in clinical guidance and shared decision-making.
Assuntos
Cistectomia , Fragilidade/complicações , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Neoplasias da Bexiga Urinária/cirurgia , Idoso , Estudos de Coortes , Cistectomia/métodos , Feminino , Humanos , Masculino , Prognóstico , Estudos Retrospectivos , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVES/HYPOTHESIS: Determine the rate, diagnoses, and risk factors associated with 30-day nonelective readmissions for patients undergoing surgery for oropharyngeal cancer. STUDY DESIGN: Retrospective cohort study. METHODS: We analyzed the Nationwide Readmissions Database for patients who underwent oropharyngeal cancer surgery between 2010 and 2014. Rates and causes of 30-day readmissions were determined. Multivariate logistic regression was used to identify risk factors for readmission. RESULTS: Among 16,902 identified cases, the 30-day, nonelective readmission rate was 10.2%, with an average cost per readmission of $14,170. The most common readmission diagnoses were postoperative bleeding (14.1%) and wound complications (12.6%) (surgical site infection [8.6%], dehiscence [2.3%], and fistula [1.7%]). On multivariate regression, significant risk factors for readmission were major ablative surgery (which included total glossectomy, pharyngectomy, and mandibulectomy) (odds ratio [OR]: 1.29, 95% confidence interval [CI]: 1.06-1.60), advanced Charlson/Deyo comorbidity (OR: 2.00, 95% CI: 1.43-2.79), history of radiation (OR: 1.58, 95% CI: 1.15-2.17), Medicare (OR: 1.34, 95% CI: 1.06-1.69) or Medicaid (OR: 1.82, 95% CI: 1.32-2.50) payer status, index admission from the emergency department (OR: 1.19, 95% CI: 1.02-1.40), and length of stay ≥6 days (OR: 1.57, 95% CI: 1.19-2.08). CONCLUSIONS: In this large database analysis, we found that approximately one in 10 patients undergoing surgery for oropharyngeal cancer is readmitted within 30 days. Procedural complexity, insurance status, and advanced comorbidity are independent risk factors, whereas postoperative bleeding and wound complications are the most common reasons for readmission. LEVEL OF EVIDENCE: 4. Laryngoscope, 129:910-918, 2019.
Assuntos
Neoplasias Orofaríngeas/cirurgia , Procedimentos Cirúrgicos Otorrinolaringológicos/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Adulto , Idoso , Comorbidade , Bases de Dados Factuais , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Período Pós-Operatório , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: The impact of treatment delays on survival in oropharyngeal cancer and whether the effect varies by human papillomavirus (HPV) status have yet to be defined. METHODS: Retrospective analysis of the survival impact of time from diagnosis to surgery (DTS), surgery to radiation (SRT), and duration of radiation (RTD) for patients in the National Cancer Database with resected oropharyngeal cancer who underwent adjuvant radiation from 2010 to 2014. RESULTS: We identified optimal thresholds of 30, 40, and 51 days for DTS, SRT, and RTD, respectively, with treatment times exceeding these thresholds associated with significantly worse overall survival. Prolonged SRT and RTD were associated with mortality regardless of HPV status, although rising DTS was only predictive among patients with HPV-negative tumors. CONCLUSIONS: Treatment delays significantly impact survival in oropharyngeal cancer. The consequences of prolonged DTS may be stronger in HPV-negative than HPV-positive disease. These data serve as a foundation for future research and clinical management.
Assuntos
Carcinoma de Células Escamosas/mortalidade , Carcinoma de Células Escamosas/cirurgia , Neoplasias Orofaríngeas/mortalidade , Neoplasias Orofaríngeas/cirurgia , Infecções por Papillomavirus/complicações , Tempo para o Tratamento , Idoso , Carcinoma de Células Escamosas/microbiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias Orofaríngeas/microbiologia , Papillomaviridae , Infecções por Papillomavirus/diagnóstico , Infecções por Papillomavirus/mortalidade , Estudos Retrospectivos , Fatores Socioeconômicos , Taxa de SobrevidaRESUMO
OBJECTIVES: Delays in the initiation of postoperative radiation have been associated with worse outcomes; however, the effect of the overall treatment package time (interval from surgery through the completion of radiation) remains undefined. The purpose of this study was to determine the impact of package time on survival and to evaluate this effect among different subgroups of head and neck cancer patients. PATIENTS AND METHODS: In this observational cohort study, the National Cancer Database was used to identify 35,167 patients with resected nonmetastatic head and neck cancer who underwent adjuvant radiation from 2004 to 2014. Kaplan-Meier survival estimates and multivariate Cox regression analyses were performed to determine the effect of treatment package time on overall survival. RESULTS: Median package time was 96â¯days (interquartile range, 85-112â¯days). After adjusting for covariates, package times of 11â¯weeks or less were associated with improved survival (adjusted hazard ratio (aHR), 0.90; 95% confidence interval, 0.83-0.97) compared to an interval of 12-13â¯weeks, whereas package times of more than 14â¯weeks were associated with worse survival (aHR, 1.14, 1.14, and 1.22 for 14-15, 15-17, and >17â¯weeks, respectively). A significant interaction was identified between package time and disease site, nodal status, and stage. Specifically, patients with oropharyngeal tumors, advanced stage (III or IV) disease, or nodal involvement experienced more pronounced increases in mortality risk with delays in treatment time. CONCLUSIONS: Treatment package time independently impacts survival. This effect may be strongest for patients with oropharyngeal tumors or advanced stage disease.
Assuntos
Carcinoma de Células Escamosas/radioterapia , Carcinoma de Células Escamosas/cirurgia , Neoplasias Orofaríngeas/radioterapia , Neoplasias Orofaríngeas/cirurgia , Tempo para o Tratamento , Idoso , Carcinoma de Células Escamosas/tratamento farmacológico , Carcinoma de Células Escamosas/patologia , Feminino , Seguimentos , Humanos , Estimativa de Kaplan-Meier , Perda de Seguimento , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante , Estadiamento de Neoplasias , Neoplasias Orofaríngeas/tratamento farmacológico , Neoplasias Orofaríngeas/patologia , Cuidados Pós-Operatórios , Modelos de Riscos Proporcionais , Radioterapia Adjuvante , Taxa de Sobrevida , Resultado do Tratamento , Estados UnidosRESUMO
BACKGROUND: Survival outcomes for adjuvant chemoradiotherapy (aCRT) and adjuvant radiotherapy (aRT) were compared in patients with oropharyngeal squamous cell carcinoma (OPSCC) with intermediate-risk features. METHODS: We identified 2164 patients with OPSCC in the National Cancer Database without positive margins or extracapsular extension and with at least one intermediate-risk feature: pT3-T4 disease, ≥two positive lymph nodes, level IV/V nodal disease, and/or lymphovascular invasion. We assessed predictors of aCRT use and covariables impacting overall survival. RESULTS: aCRT was commonly used for both human papillomavirus (HPV)-positive (62.0%) and HPV-negative (64.3%) patients with OPSCC. Higher N stage, level IV/V neck disease, and younger age strongly predicted aCRT utilization. There was no significant survival benefit associated with aCRT vs aRT in HPV-positive (hazard ratio [HR], 0.93; 95% confidence interval [CI], 0.62-1.38; P = .71) or HPV-negative (HR, 0.75; 95% CI, 0.51-1.10; P = .15) disease. CONCLUSIONS: Despite high rates of utilization, aCRT is not associated with better survival vs aRT for OPSCC with intermediate-risk features, including HPV-negative tumors.
Assuntos
Carcinoma de Células Escamosas/terapia , Quimiorradioterapia Adjuvante , Neoplasias Orofaríngeas/terapia , Radioterapia Adjuvante , Idoso , Carcinoma de Células Escamosas/mortalidade , Carcinoma de Células Escamosas/cirurgia , Feminino , Humanos , Estimativa de Kaplan-Meier , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Neoplasias Orofaríngeas/mortalidade , Neoplasias Orofaríngeas/cirurgia , Pontuação de Propensão , Sistema de Registros , Fatores de RiscoRESUMO
OBJECTIVES:: Cell therapies using mesenchymal stromal cells (MSCs) have been proposed as a promising new tool for the treatment of vocal fold scarring. However, the mechanisms by which MSCs promote healing as well as their duration of survival within the host vocal fold have yet to be defined. The aim of this work was to assess the persistence of embedded MSCs within a tissue-engineered vocal fold mucosal replacement in a rabbit model of vocal fold injury. METHODS:: Male rabbit adipose-derived MSCs were embedded within a 3-dimensional fibrin gel, forming the cell-based outer vocal fold replacement. Four female rabbits underwent unilateral resection of vocal fold epithelium and lamina propria and reconstruction with cell-based outer vocal fold replacement implantation. Polymerase chain reaction and fluorescent in situ hybridization for the sex-determining region of the Y chromosome (SRY-II) in the sex-mismatched donor-recipient pairs sought persistent cells after 4 weeks. RESULTS:: A subset of implanted male cells was detected in the implant site at 4 weeks. Many SRY-II-negative cells were also detected at the implant site, presumably representing native female cells that migrated to the area. No SRY-II signal was detected in contralateral control vocal folds. CONCLUSIONS:: The emergent tissue after implantation of a tissue-engineered outer vocal fold replacement is derived both from initially embedded adipose-derived stromal cells and infiltrating native cells. Our results suggest this tissue-engineering approach can provide a well-integrated tissue graft with prolonged cell activity for repair of severe vocal fold scars.
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Cicatriz/terapia , Células-Tronco Mesenquimais/fisiologia , Engenharia Tecidual/métodos , Transplante de Tecidos/métodos , Disfunção da Prega Vocal/terapia , Prega Vocal , Animais , Cicatriz/patologia , Cicatriz/fisiopatologia , Coelhos , Regeneração/fisiologia , Resultado do Tratamento , Disfunção da Prega Vocal/etiologia , Disfunção da Prega Vocal/fisiopatologia , Prega Vocal/patologia , Prega Vocal/fisiologia , Prega Vocal/transplanteRESUMO
BACKGROUND: Tongue fibrosis resulting from head and neck cancer, surgery, radiation, chemotherapy, or a combination thereof devastates one's quality of life. Therapeutic options are limited. Here we investigate human bone marrow-derived multipotent stromal cells (MSC) as a novel injectable treatment for post-injury tongue fibrosis. METHODS: MSCs were grown in culture. Eighteen athymic rats underwent unilateral partial glossectomy. After two weeks for scar formation, a single injection was performed in the tongue scar. Three treatment groups were studied: low and high concentration MSC, and control media injection. Tongues were harvested for evaluation at three weeks post-treatment. RESULTS: Dense fibrosis was achieved in control animals at five weeks. High concentration MSC reduced cross sectional scar burden (P = .007) and pathologic score for inflammation and fibrosis. CONCLUSION: This study establishes the feasibility of a novel rodent tongue fibrosis model, and begins to assess the utility of human MSCs to reduce scar burden. LEVEL OF EVIDENCE: N/a.
RESUMO
Objective We sought to describe the patient, tumor, and survival characteristics of minor salivary gland carcinoma (MSGC) of the oropharynx using a large, population-based database. Study Design Cross-sectional analysis of the National Cancer Institute's SEER database (Surveillance, Epidemiology. and End Results). Subjects and Methods We reviewed the SEER database for all cases of MSGC of the oropharynx from 1988 to 2013. Relevant demographic, clinicopathologic, and survival variables were extracted and analyzed. Cox multivariate regression was performed to identify prognostic factors. Results We identified 1426 cases of MSGC of the oropharynx (mean age, 58 years; 51% female). The soft palate (39.2%) and base of tongue (38.6%) were the most commonly involved sites. The most common histologic subtypes were mucoepidermoid carcinoma (32.1%), adenocarcinoma (25.9%), and adenoid cystic carcinoma (23.3%). Five- and 10-year rates of disease-specific survival were 75.1% and 61.6%, respectively. Independent prognostic factors included tumor grade, T stage, N stage, and age >70 years. Conclusions This study represents the largest multivariate survival analysis of MSGC of the oropharynx to date. Independent prognosticators include tumor grade, T stage, N stage, and age.
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Neoplasias Orofaríngeas/patologia , Neoplasias das Glândulas Salivares/patologia , Glândulas Salivares Menores/patologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Estudos Transversais , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Gradação de Tumores , Estadiamento de Neoplasias , Neoplasias Orofaríngeas/epidemiologia , Prognóstico , Fatores de Risco , Programa de SEER , Neoplasias das Glândulas Salivares/epidemiologia , Taxa de Sobrevida , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Hospital readmissions are an increasingly scrutinized marker of surgical care delivery and quality. There is a paucity of information in the literature regarding the rate, risk factors, and common causes of readmission after surgery for sinonasal cancer. METHODS: We analyzed the Nationwide Readmissions Database for patients who underwent surgery for a diagnosis of sinonasal cancer between 2010 and 2014. Rates, causes, and patient-, procedure-, and hospital-level risk factors for 30-day readmission were determined. Multivariate logistic regression was used to identify predictors of 30-day readmission. RESULTS: Among the 4173 cases, the 30-day readmission rate was 11.6%, with an average cost per readmission of $18,403. The most common readmission diagnoses were wound complications (15.3%) and infections (13.4%). On multivariate regression, significant risk factors for readmission were chronic renal failure (odds ratio [OR], 2.95; 95% confidence interval [CI], 1.41-6.17), involvement of the skull base or orbit (OR, 1.67; 95% CI, 1.11-2.51), nonelective initial surgical admission (OR, 2.35; 95% CI, 1.42-3.89), and length of stay ≥7 days (OR, 1.87; 95% CI, 1.14-3.05). CONCLUSION: Through the use of a large national database, we found that approximately 1 in 9 patients undergoing surgery for sinonasal cancer was readmitted within 30 days. Readmissions were most commonly associated with wound complications and infections. Factors related to procedural complexity were more important predictors of readmission than patients' demographics or comorbidities.
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Neoplasias dos Seios Paranasais/cirurgia , Readmissão do Paciente/economia , Readmissão do Paciente/estatística & dados numéricos , Distribuição por Idade , Bases de Dados Factuais , Feminino , Custos Hospitalares/estatística & dados numéricos , Humanos , Modelos Logísticos , Masculino , Neoplasias Nasais/cirurgia , Razão de Chances , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Fatores de Risco , Estados Unidos/epidemiologiaRESUMO
Objective To characterize patterns of secondary complications after inpatient head and neck surgery. Study Design Retrospective cohort study. Setting National Surgical Quality Improvement Program (2005-2015). Subjects and Methods We identified 18,584 patients who underwent inpatient otolaryngologic surgery. Four index complications were studied: pneumonia, bleeding or transfusion event (BTE), deep/organ space surgical site infection (SSI), and myocardial infarction (MI). Each patient with an index complication was matched to a control patient based on propensity for the index event and event-free days. Rates of 30-day secondary complications and mortality were compared. Results Index pneumonia (n = 254) was associated with several complications, including reintubation (odds ratio [OR], 11.7; 95% confidence interval [CI], 5.2-26.4), sepsis (OR, 8.8; 95% CI, 4.5-17.2), and death (OR, 5.3; 95% CI, 1.9-14.9). Index MI (n = 50) was associated with increased odds of reintubation (OR, 17.2; 95% CI, 3.5-84.1), ventilatory failure (OR, 5.8; 95% CI, 1.8-19.1), and death (OR, 24.8; 95% CI, 2.9-211.4). Index deep/organ space SSI (n = 271) was associated with dehiscence (OR, 7.2; 95% CI, 3.6-14.2) and sepsis (OR, 38.3; 95% CI, 11.6-126.4). Index BTE (n = 1009) increased the odds of cardiac arrest (OR, 3.9; 95% CI, 1.8-8.5) and death (OR, 2.9; 95% CI, 1.6-5.1). Conclusions Our study is the first to quantify the effect of index complications on the risk of specific secondary complications following inpatient head and neck surgery. These associations may be used to identify patients most at risk postoperatively and target specific interventions aimed to prevent or interrupt further complications.