Stereotactic body radiotherapy for distant metastases to the head and neck.

PURPOSE: To report clinical outcomes for patients with metastatic disease to the head and neck (HN) treated with stereotactic body radiation therapy (SBRT). METHODS: A retrospective review of patients treated with SBRT to HN sites from 2012 to 2020 was conducted. Treatment indications included the following: oligometastases, oligoprogression, and control a dominant area of progression (DAP). Kaplan-Meier method was used to estimate local control (LC), regional control (RC), overall survival (OS), and progression-free survival (PFS). Univariable (UVA) and multivariable analyses (MVA) were performed. Grade 3-4 acute and late toxicities were reported by the Common Terminology Criteria for Adverse Events v5.0. RESULTS: Fifty-six patients (58 lesions) were analysed with a median follow-up of 16 months. Primary sites included lung (25.0%), kidney (19.6%), breast (19.6%) and other (35.8%). SBRT indications were as follows: oligometastases (42.9%), oligoprogression (19.6%) and local control of a dominant area of progression (37.5%). Most patients received SBRT to a single neck node (n = 47, 81.0%). Median SBRT dose was 40 Gy (range 25-50 Gy) in five fractions, with a median biologically effective dose (BED10) of 72 Gy (range 37.5-100 Gy). One- and 2-year LC and RC rates were 97.6% and 72.7% as well as 100% and 86.7%, respectively. Median OS was 19.2 months (95% [CI] 14.8-69.4), and median PFS was 7.4 months (95% [CI] 5.2-11.9). The 1-year OS and PFS rates for oligometastases, oligoprogression and DAP were 95.8%, 63.6% and 38.1% (p = 0.0039) as well as 56.5%, 27.3% and 19.1% (p = 0.0004), respectively. On MVA, treatment indication and histology were predictive for OS, while indication and prior systemic therapy were predictive for PFS. Cumulative late grade 3 + toxicity rate was 11.3%, without grade 5 events. CONCLUSION: The use of SBRT for metastatic disease to the HN provided excellent LC rates with low rates of regional failure and an acceptable toxicity profile, highlighting its utility in these patients. Patients with oligometastatic disease had better OS and PFS than others.

Differences in both expression and protein activity contribute to the distinct functions of AINTEGUMENTA compared with AINTEGUMENTA-LIKE 5 and AINTEGUMENTA-LIKE 7.

Three members of the Arabidopsis AINTEGUMENTA-LIKE/PLETHORA (AIL/PLT) transcription factor family, AIL5/PLT5, AIL6/PLT3, and AIL7/PLT7, exhibit partially overlapping roles with AINTEGUMENTA (ANT) during flower development. Loss of ANT function alone results in smaller floral organs and female sterility indicating that some ANT functions cannot be provided by these related transcription factors. Previously, we showed that expression of AIL6 at the same levels and spatial pattern as ANT could largely rescue the defects of ant mutants. This suggested that the functional differences between ANT and AIL6 were primarily a consequence of expression differences. Here, we investigated the functional differences between ANT and both AIL5 and AIL7 by expressing these two AILs under the control of the ANT promoter. We found that only ANT:gAIL5 lines with much higher amounts of AIL5 mRNA as compared with ANT could compensate for loss of ANT function. ANT:gAIL7 lines with AIL7 mRNA levels similar to those of ANT were able to rescue some but not all aspects of the ant mutant phenotype. Thus, expression differences alone cannot explain the functional differences between ANT and these two related proteins. Studies in yeast show that AIL5 and AIL7 have lower transcriptional activation activities as compared with ANT and AIL6 when bound to the consensus ANT DNA binding site. Our results suggest that differences in both expression and protein activity contribute to the functional specificity of ANT compared with AIL5 and AIL7.

Understanding compassionate care from the patient perspective: Highlighting the experience of head and neck cancer care.

Objectives: To address the knowledge gap in the practice of compassionate healthcare by elucidating patient perspectives on compassion, empathy, and sympathy. Methods: Semi-structured telephone interviews were conducted at two time points with patients undergoing head and neck cancer treatment. Questions explored participants' understanding of compassion, sympathy, and empathy, as they relate to each other and to healthcare. Interviewers manually recorded responses. Qualitative exploratory methods were used to analyze data; inductive line-by-line coding was conducted to develop primary codes. Themes emerged through categorization of codes. Results: Ninety-five interviews conducted with 63 participants across two time points revealed four major themes - Compassion-vs-Empathy-vs-Sympathy, Coping Methods, Showing Care, and Nature of Interaction - encompassing seven categories, with a total of 24 codes. Codes were consistent across time points, except for two new codes, "positivity" and "personalized" emerging during follow-up interviews. Conclusions: Patient narrative from this study supported the concept that compassion is multidimensional and enabled several dimensions to be identified, highlighting the importance of patient perspectives in improving the provision of compassionate healthcare. Findings should be considered in future training and practice.

Patient satisfaction with different types of craniofacial prostheses.

STATEMENT OF PROBLEM: A maxillofacial prosthesis represents an effective method of giving maxillofacial defects a positive esthetic appearance with minimal risk. However, studies of complications among prosthesis wearers are lacking. PURPOSE: The purpose of this cross-sectional study was to determine levels of patient satisfaction with various maxillofacial prostheses and retention types, as measured through a survey questionnaire package. MATERIAL AND METHODS: Patients treated at the Sunnybrook Health Sciences Center Craniofacial Prosthetics Unit (CPU) since 2015 were included. They had been treated according to a standardized protocol and answered a survey questionnaire package with the following sections: demographics, frequency of prosthesis usage, and the Toronto Outcome Measure for Craniofacial Prosthetics (TOMCP-27) survey addressing patient satisfaction. To be eligible for this study, patients must have been more than 18 years of age, in possession of a maxillofacial prosthesis, and received treatment at the Sunnybrook Health Sciences Center CPU since 2015. RESULTS: A total of 157 patients were eligible and contacted, of whom 51 agreed to participate in the survey. The study population was overall extremely satisfied with their maxillofacial prostheses. In 77.8% of the TOMCP-27 questions, the largest group of patients chose the answer demonstrating the highest level of satisfaction. Of all prosthesis types surveyed, patients with auricular prostheses reported the greatest rates of satisfaction, with the entire group having selected answers corresponding to the highest levels of overall satisfaction. However, patients with orbital prostheses were more likely to experience varying degrees of dissatisfaction, with 72% of the highest reported levels of dissatisfaction being from this prosthesis group. In addition, patients with osseointegrated implant-retained prostheses reported higher satisfaction levels with other retention methods, with the bar clasp group outperforming the magnetic coupling retention group. CONCLUSIONS: Patients experienced an excellent overall rate of satisfaction with their maxillofacial prostheses. Future development should focus on the continued development of osseointegrated methods, improved magnetic coupling, and improved prosthesis technology, especially for orbital prostheses.

Surgical Tray Optimization: a Quality Improvement Initiative that Reduces Operating Room Costs.

Surgical trays contain unused instruments which generate wasted resources from unnecessary reprocessing/replacement costs. We implemented a quality improvement initiative to optimize surgical trays for common otolaryngology procedures, and examined the impact on costs, operating room (OR) efficiency, and patient safety.We studied five common otolaryngology procedures over a 10-month period at a single community hospital. We compared pre- and post-intervention outcome measures including instrument utilization, tray set up time, tray rebuilding time, and balancing measures (operative time, instrument recall, patient safety). We estimated cost-savings from an institutional perspective over 1- and 10-year time horizons. Costs were expressed in 2017 Canadian dollars and modeled as a function of surgical volume, labor costs, instrument depreciation, and indirect costs.A total of 238 procedures by six surgeons were observed. At baseline, only 35% of instruments were utilized. We achieved an average instrument reduction of 26%, yielding 1-year cost savings of $9,010 CDN and 10-year cost savings of $69,576 CDN. Tray optimization reduced average OR tray setup time by 2.5 ± 0.4 min (p = 0.03) and average tray rebuilding time by 1.4 ± 0.2 min (p = 0.06). There was minimal impact on balancing measures such as OR time, stakeholder perception of patient safety and trainee education, and only a single case of instrument recall.Surgical tray optimization is a simple, effective, and scalable strategy for reducing costs and improving OR efficiency without compromising patient safety.

National treatment trends in human papillomavirus-positive oropharyngeal squamous cell carcinoma.

BACKGROUND: Human papillomavirus (HPV)-mediated oropharyngeal cancer (OPC) is associated with dramatically improved survival in comparison with HPV-negative OPC and can be successfully treated with surgical and nonsurgical approaches. National treatment trends for OPC were investigated with the National Cancer Data Base (NCDB). METHODS: The NCDB was reviewed for primary HPV-mediated OPC in 2010-2014. Multivariable regression was used to identify predictors of both nonsurgical therapy and receipt of adjuvant chemoradiation (CRT). RESULTS: There were 13,363 patients identified with a median age at diagnosis of 58 years. The incidence of triple-modality treatment (surgery with adjuvant chemotherapy) decreased from 23.7% in 2010 to 16.9% in 2014 (R2  = 0.96), whereas the incidence of nonsurgical treatment increased from 63.9% to 68.7% (R2  = 0.89). Hospitals in the top treatment volume quartile (quartile 1 [Q1]; n = 29) had a lower rate of positive margins (16.3%) than bottom-quartile centers (n = 741; rate of positive margins, 36.4%; P < .001); Q1 hospitals used surgical therapy significantly more. Independent predictors of nonsurgical therapy included older age, advanced disease, lower hospital volume, and living closer to the hospital or outside the Pacific United States. In surgically treated patients, younger age, lower hospital volume, nodal disease, positive surgical margins, and extranodal extension (ENE) also predicted more adjuvant CRT use. CONCLUSIONS: The use of upfront surgical treatment decreased from 2010 to 2014. Hospital volume shows a strong, inverse correlation with the rate of positive surgical margins. The upfront treatment strategy is predicted not only by staging but also by patient-, geographic-, and hospital-specific factors. Lower hospital volume remains independently associated with increased triple-modality therapy after adjustments for positive margins, ENE, and pathologic staging.

Development and validation of a Surgical Prioritization and Ranking Tool and Navigation Aid for Head and Neck Cancer (SPARTAN-HN) in a scarce resource setting: Response to the COVID-19 pandemic.

BACKGROUND: In the wake of the coronavirus disease 2019 (COVID-19) pandemic, access to surgical care for patients with head and neck cancer (HNC) is limited and unpredictable. Determining which patients should be prioritized is inherently subjective and difficult to assess. The authors have proposed an algorithm to fairly and consistently triage patients and mitigate the risk of adverse outcomes. METHODS: Two separate expert panels, a consensus panel (11 participants) and a validation panel (15 participants), were constructed among international HNC surgeons. Using a modified Delphi process and RAND Corporation/University of California at Los Angeles methodology with 4 consensus rounds and 2 meetings, groupings of high-priority, intermediate-priority, and low-priority indications for surgery were established and subdivided. A point-based scoring algorithm was developed, the Surgical Prioritization and Ranking Tool and Navigation Aid for Head and Neck Cancer (SPARTAN-HN). Agreement was measured during consensus and for algorithm scoring using the Krippendorff alpha. Rankings from the algorithm were compared with expert rankings of 12 case vignettes using the Spearman rank correlation coefficient. RESULTS: A total of 62 indications for surgical priority were rated. Weights for each indication ranged from -4 to +4 (scale range; -17 to 20). The response rate for the validation exercise was 100%. The SPARTAN-HN demonstrated excellent agreement and correlation with expert rankings (Krippendorff alpha, .91 [95% CI, 0.88-0.93]; and rho, 0.81 [95% CI, 0.45-0.95]). CONCLUSIONS: The SPARTAN-HN surgical prioritization algorithm consistently stratifies patients requiring HNC surgical care in the COVID-19 era. Formal evaluation and implementation are required. LAY SUMMARY: Many countries have enacted strict rules regarding the use of hospital resources during the coronavirus disease 2019 (COVID-19) pandemic. Facing delays in surgery, patients may experience worse functional outcomes, stage migration, and eventual inoperability. Treatment prioritization tools have shown benefit in helping to triage patients equitably with minimal provider cognitive burden. The current study sought to develop what to the authors' knowledge is the first cancer-specific surgical prioritization tool for use in the COVID-19 era, the Surgical Prioritization and Ranking Tool and Navigation Aid for Head and Neck Cancer (SPARTAN-HN). This algorithm consistently stratifies patients requiring head and neck cancer surgery in the COVID-19 era and provides evidence for the initial uptake of the SPARTAN-HN.

Metastasis to gastrostomy sites from upper aerodigestive tract malignancies: a systematic review and meta-analysis.

BACKGROUND AND AIMS: Metastasis to the gastrostomy site in patients with upper aerodigestive tract (UADT) malignancies is a rare but devastating adverse event that has been poorly described. Our aim was to determine the overall incidence and clinicopathologic characteristics observed with development of gastrostomy site metastasis in patients with UADT cancers. METHODS: This was a systematic review and meta-analysis of 6138 studies retrieved from Medline, EMBASE, CINAHL, and the Cochrane Register after being queried for studies including gastrostomy site metastasis in patients with UADT malignancies. RESULTS: The final analysis included 121 studies. Pooled analysis showed an overall event rate gastrostomy site metastasis of .5% (95% confidence interval [CI], .4%-.7%). Subgroup analysis showed an event rate of .56% (95% CI, .40%-.79%) with the pull technique and .29% (95% CI, .15%-.55%) with the push technique. Clinicopathologic characteristics observed with gastrostomy site metastasis were late-stage disease (T3/T4) (57.8%), positive lymph node status (51.2%), and no evidence of systemic disease (M0) (62.8%) at initial presentation. The average time from gastrostomy placement to diagnosis of metastasis was 7.78 ± 4.9 months, average tumor size on detection was 4.65 cm (standard deviation, 2.02), and average length of survival was 7.26 months (standard deviation, 6.23). CONCLUSIONS: Gastrostomy site metastasis is a rare but serious adverse event that occurs at an overall rate of .5%, particularly in patients with advanced-stage disease, and is observed with a very poor prognosis. These findings emphasize a need for clinical practice guidelines to include a regular assessment of the PEG site and highlight the importance of detection and management of gastrostomy site metastasis by the multidisciplinary care oncology team.

Early squamous cell carcinoma of the oral tongue with histologically benign lymph nodes: A model predicting local control and vetting of the eighth edition of the American Joint Committee on Cancer pathologic T stage.

BACKGROUND: The eighth edition of the American Joint Committee on Cancer staging manual (AJCC8) added depth of invasion to the definition of pathologic T stage (pT). In the current study, the authors assess pT stage migration and the prognostic performance of the updated pT stage and compare it with other clinicopathologic variables in patients with early squamous cell carcinoma of the oral tongue (OTSCC; tumors measuring ≤4 cm) with histologically benign lymph nodes (pN0). METHODS: A multi-institutional cohort of patients with early OTSCC was restaged as per AJCC8. Primary endpoints were local recurrence (LR) and locoregional recurrence (LRR). Influential variables were identified and an LR/LRR prediction model was developed. RESULTS: There were a total of 494 patients, with 49 LR and 73 LRR. AJCC8 pT criteria resulted in upstaging of 37.9% of patients (187 of 494 patients), including 34.5% (64 of 185 patients) from pT2 to pT3, without improving the prognostication for LR or LRR. Both LR and LRR were found to be similar for patients with AJCC8 pT2 and pT3 disease. On multivariate analysis, LR was only found to be associated with distance to the closest margin (hazard ratio, 0.36; 95% CI, 0.20-0.64 [P = .0007]) and perineural invasion (hazard ratio, 1.92; 95% CI, 1.10-0.64 [P = .046]). Based on these 2 predictors, a final proportional hazards regression model (which may be used similar to a nomogram) was developed. The proposed model appeared to be superior to AJCC pT stage for estimating the probability of LR and LRR for individual patients with early OTSCC. CONCLUSIONS: AJCC8 pT criteria resulted in pT upstaging of patients with pN0 disease without improved LR or LRR prognostication. The proposed model based on distance to the closest margin and perineural invasion, status outperformed pT as a predictor of LR and LRR in patients with early OTSCC.

The immune microenvironment and expression of PD-L1, PD-1, PRAME and MHC I in salivary duct carcinoma.

AIMS: Salivary duct carcinoma (SDC) is an aggressive salivary malignancy that results in high mortality rates and is often resistant to chemotherapy. Anti-programmed death-1 (PD-1)/programmed death ligand-1 (PD-L1) checkpoint inhibitors have led to dramatic improvements in patients with various cancers. Other immunotherapeutic approaches, e.g. cancer vaccines, have shown promising results. Cancer testis antigens, e.g. preferentially expressed antigen in melanoma (PRAME), are regarded as promising vaccine targets because of their tumour-specific expression pattern. METHODS AND RESULTS: We analysed the immunoexpression of PD-L1, PD-1, major histocompatibility complex class I (MHC I) and PRAME in 53 SDCs. The immunoexpression levels of PD-L1 in tumour cells (TCs) and immune cells (ICs), PD-1 in ICs, PRAME in TCs and MHC I in TCs were analysed, and were correlated with outcome. PRAME expression was seen in 83% of SDCs. No PRAME staining was present in normal salivary gland tissue. With the three established diagnostic algorithms proposed for head and neck squamous cell carcinoma, the criteria being a combined positive score of ≥1, TC% ≥1%, and TC% ≥25%, 35 (66%), 17 (32%) and three cases (6%), respectively, were deemed to be positive for PD-L1. PD-1-positive ICs were seen in 35 (66%) cases. MHC I down-regulation was seen in 82% of SDCs. There was a significant correlation among PD-L1 expression in ICs, PD-1 expression in ICs, and PRAME expression in TCs. PD-L1 expression in TCs and lack of PD-1 expression in ICs were associated with decreased disease-specific survival in SDC patients. CONCLUSIONS: Alterations of the tumour immune microenvironment are common in SDCs, including expression of PD-1/PD-L1 and PRAME, which opens the way to potential novel immune therapies, such as cancer vaccination and PD-1/PD-L1 blockade, in these tumours.

Follow-up of Benign Thyroid Nodules-Can We Do Less?

OBJECTIVE: To determine the incidence of malignancy, follow-up ultrasound (US), and repeat fine needle aspiration (FNA) in thyroid nodules that have been previously biopsied as benign. METHODS: This is a retrospective, descriptive study of benign thyroid nodules evaluated by US between 2010-2011. We determined the frequency of follow-up ultrasounds and FNAs, mean years of follow-up, interval between follow-up US, change in nodule size, reasons for repeat FNA (rFNA), frequency of thyroidectomy, and thyroid malignancy during 5 years of follow-up. RESULTS: A total of 733 benign thyroid nodules were reviewed in 615 patients. Mean years of US follow-up was 3.47 ± 1.65 years; 275 (37.5%) had no follow-up US; 109 (14.9%) had 1 follow-up US; 93 (12.7%) had 2 follow-up US; and 256 (34.9%) had 3 or more follow-up US. Assessment of thyroid nodule size showed that 215 (28.8%) nodules decreased in size, 145 (19.4%) increased in size by less than 50%, and 91 (12.1%) increased in size by more than 50%. Of the 733 nodules, 17 nodules (2.3%) underwent thyroidectomy for which the pathology result of 9 (1.2%) showed malignancy, and 65 (8.9%) thyroid nodules underwent rFNA. When applying the 2015 recommendations for repeat FNA, 35% were done unnecessarily. CONCLUSION: In our sample of initially benign thyroid nodules, only 9 patients (1.2%) had pathology-proven malignancy after a mean follow-up of 3.5 years. Over 30% of patients had more than 3 rUSs. Decreased interval and frequency of rUS should be considered in future guidelines for thyroid management.

Retrospective Application of the 2015 American Thyroid Association Guidelines for Ultrasound Classification, Biopsy Indications, and Follow-up Imaging of Thyroid Nodules: Can Improved Reporting Decrease Testing?

INTRODUCTION: Thyroid ultrasound has been widely used to determine which nodules need further investigation. The goal of this study is to determine if using an ultrasonographic features checklist based on 2015 American Thyroid Association (ATA) guidelines can improve reporting and decrease unnecessary further testing. METHODS: In this retrospective study, ultrasonographic images of all nodules biopsied at our institution in 2014 and 2015 were reviewed by radiologists blinded to fine needle aspiration (FNA) biopsy result using a checklist. The checklist was prepared based on 2015 ATA guidelines. The ultrasonographic characteristics of thyroid nodules were compared with the result of biopsy to determine positive predictive value (PPV), negative predictive value (NPV), sensitivity, and specificity for predicting malignancy. Radiologists also made an overall recommendation on need for FNA. RESULTS: A total of 425 thyroid nodule ultrasound scans were reviewed by radiologists. Biopsy results of 31 nodules were malignant and 394 were non-malignant. Malignant nodules showed higher frequency of solid composition, hypoechoechogenicity, and cervical lymph node involvement compared to benign nodules. Solid nodule composition had the highest PPV (13%) and NPV (94.7%). Extra-thyroid extension had the highest specificity (90.1%). Lesion vascularity had the highest sensitivity (83.8%), followed by hypoechogenicity (65.6%). Overall, the checklist had a positive predictive value of 9%, negative predictive value of 97.5%, sensitivity of 96.8%, and specificity of 11.14%. Radiologists determined that 10% of the nodules were very low-risk and did not require FNA. CONCLUSION: Using a checklist based on 2015 ATA guideline thyroid nodule ultrasonographic features is a sensitive tool with high NPV to predict benign thyroid nodule, thereby preventing unnecessary FNAs.

Compressed supercontinuum probe for transient absorption microscopy.

Here, we combine three optical advancements to transient absorption microscopy in order to access the photodynamics in systems requiring stringent spatial and temporal resolution criteria. First, a broadband visible probe is generated by a commercial photonic crystal fiber. Second, a spatial light modulator-based pulse shaper is incorporated to reduce the pulse dispersion and improve temporal resolution. Third, 1.4 numerical aperture objectives for excitation and light collection provide optimal spatial resolution. The result of these improvements is a probe beam that spans 115 nm across the visible region yet maintains a ∼100 fs instrument response at the sample position. We demonstrate the capabilities of this microscope by imaging polystyrene beads in a solution of IR-144 dye, revealing aggregated species at the bead surfaces.

Radiologic Differences between Human Papillomavirus-Related and Human Papillomavirus-Unrelated Oropharyngeal Carcinoma on Diffusion-Weighted Imaging.

BACKGROUND AND PURPOSE: Human papilloma virus-related oropharyngeal carcinoma (HPV+ OPC) is a unique entity compared to HPV-unrelated (HPV-) OPC. Previous studies were inconclusive regarding the differences between HPV+ and HPV- OPCs on diffusion-weighted imaging (DWI). This study sought to determine if there is an association between HPV status and apparent diffusion coefficient (ADC) values as an imaging biomarker in OPCs. MATERIALS AND METHODS: OPC patients with pretreatment MRI including DWI were retrospectively reviewed and analyzed as a blinded, controlled cohort. HPV status was biopsy-ascertained with p16 staining. ADC values were determined by placing the largest possible circular region of interest in solid portions of primary tumors and/or metastatic lymph nodes. Necrotic and cystic portions were excluded. RESULTS: Twenty-eight HPV+ and 12 HPV- patients were included. Adjusted for age and sex, ADC values were significantly lower in HPV+ OPC primary tumors (p = 0.013) and lymph node metastases (p = 0.013). The area under the curve (AUC) was 0.85 and 0.90, respectively. A model with a linear combination of the 2 variables yielded an AUC of 0.92. CONCLUSION: ADC values were significantly lower in both the primary tumors and lymph node metastases in HPV+ OPCs compared to HPV- OPCs. These results confirm the results of prior studies.

Stereotactic body radiotherapy for head and neck cancer: an addition to the armamentarium against head and neck cancer.

In the recent years, stereotactic body radiation therapy (SBRT) has emerged as a potential therapy for head and neck malignancies. Although early results appear to be promising, serious acute and late effects have been observed, mainly in patients who have had prior external beam radiotherapy. This review will discuss the radiobiology of SBRT, clinical rationale and outcomes for SBRT in head and neck cancers and focus on the benefits and potential limitations in both de novo and re-irradiation settings.

Randomised clinical trial to compare total contact casts, healing sandals and a shear-reducing removable boot to heal diabetic foot ulcers.

The objective of this study was to evaluate the efficacy of three off-loading techniques to heal diabetic foot wounds: total contact casts (TCCs), healing sandals (HSs) and a removable boot with a shear-reducing foot bed (SRB). This was a 12-week, single-blinded randomised clinical trial with three parallel treatment groups of adults with diabetes and a foot ulcer (n = 73). Ulcer healing was defined as full reepithelialisation with no drainage. Diabetic patients with grade UT1A or UT2A forefoot ulcers on the sole of the foot were enrolled. Patients with malignancy, immune-compromising diseases, severe peripheral vascular disease (ankle-brachial index < 0·60 or transcutaneous oxygen < 25 mm/Hg), alcohol or substance abuse within 6 months, untreated osteomyelitis or Charcot arthropathy with residual deformity that would not fit the HS or boot were excluded. In the intent-to-treat analysis, significantly higher proportion of patients were healed in the TCC group (69·6%) compared to those treated with the SRB (22·2%, P < 0·05). There was no difference in the rate of healed ulcers in the HS (44·5%) and TCC groups. Ulcers in the TCC group healed faster than those in the HS group (5·4 ± 2·9 versus 8·9 ± 3·5 weeks, P < 0·02). However, there was no difference in the time to healing in the TCC and SRB groups (6·7 ± 4·3 weeks, P = 0·28). Patients who used HS were significantly more active (4022 ± 4652 steps per day, P < 0·05) than those treated with TCCs (1447 ± 1310) or SRB (1404 ± 1234). It is concluded that patients treated with TCCs had the highest proportion of healed wounds and fastest healing time. The novel shear-reducing walker had the lowest healing and highest rate of attrition during the study.

Intraoperative Ultrasound for Removal of a Fishbone Foreign Body Embedded in the Tongue.

Background: Ultrasound (U/S) is a dynamic imaging modality with many applications in medicine. In Otolaryngology, U/S is used routinely in the clinic with several evolving applications intraoperatively. Case Report. A 53-year-old male presented to the emergency department with dysphagia, odynophagia, hoarseness, and sensation of foreign body after ingesting fish. A CT scan identified an approximately 2 cm horizontally-oriented foreign body consistent with a fishbone embedded in the left posterolateral tongue. Intraoperative U/S was used to localize and remove the fishbone without complications. Results: The patient recovered well after surgery and was discharged home on postoperative day 2. No residual foreign body was found on the repeat CT scan. Conclusion: Our case demonstrates the effectiveness of intraoperative U/S for removal of fishbone foreign bodies from the tongue and serves to inspire future applications of this modality in Otolaryngology.

Oropharyngeal Cancer Staging Health Record Extraction Using Artificial Intelligence.

Importance: Accurate, timely, and cost-effective methods for staging oropharyngeal cancers are crucial for patient prognosis and treatment decisions, but staging documentation is often inaccurate or incomplete. With the emergence of artificial intelligence in medicine, data abstraction may be associated with reduced costs but increased efficiency and accuracy of cancer staging. Objective: To evaluate an algorithm using an artificial intelligence engine capable of extracting essential information from medical records of patients with oropharyngeal cancer and assigning tumor, nodal, and metastatic stages according to American Joint Committee on Cancer eighth edition guidelines. Design, Setting, and Participants: This retrospective diagnostic study was conducted among a convenience sample of 806 patients with oropharyngeal squamous cell carcinoma. Medical records of patients with staged oropharyngeal squamous cell carcinomas who presented to a single tertiary care center between January 1, 2010, and August 1, 2020, were reviewed. A ground truth cancer stage dataset and comprehensive staging rule book consisting of 135 rules encompassing p16 status, tumor, and nodal and metastatic stage were developed. Subsequently, 4 distinct models were trained: model T (entity relationship extraction) for anatomical location and invasion state, model S (numerical extraction) for lesion size, model M (sequential classification) for metastasis detection, and a p16 model for p16 status. For validation, results were compared against ground truth established by expert reviewers, and accuracy was reported. Data were analyzed from March to November 2023. Main Outcomes and Measures: The accuracy of algorithm cancer stages was compared with ground truth. Results: Among 806 patients with oropharyngeal cancer (mean [SD] age, 63.6 [10.6] years; 651 males [80.8%]), 421 patients (52.2%) were positive for human papillomavirus. The artificial intelligence engine achieved accuracies of 55.9% (95% CI, 52.5%-59.3%) for tumor, 56.0% (95% CI, 52.5%-59.4%) for nodal, and 87.6% (95% CI, 85.1%-89.7%) for metastatic stages and 92.1% (95% CI, 88.5%-94.6%) for p16 status. Differentiation between localized (stages 1-2) and advanced (stages 3-4) cancers achieved 80.7% (95% CI, 77.8%-83.2%) accuracy. Conclusion and Relevance: This study found that tumor and nodal staging accuracies were fair to good and excellent for metastatic stage and p16 status, with clinical relevance in assigning optimal treatment and reducing toxic effect exposures. Further model refinement and external validation with electronic health records at different institutions are necessary to improve algorithm accuracy and clinical applicability.

Lymph node yield: Impact on oncologic outcomes in oral cavity cancer.

BACKGROUND: Lymph node metastases are associated with poor prognosis in oral cavity squamous cell carcinoma (OCSCC). In other cancers, clinical guidelines on the number of lymph nodes removed during primary surgery, lymph node yield (LNY), exist. Here, we evaluated the prognostic capacity of LNY on regional failure, locoregional recurrence, and disease-free survival (DFS) in patients with OCSCC treated by primary neck surgery. METHODS: This retrospective cohort study took place at Sunnybrook Health Sciences Centre in Toronto, Canada and involved a chart review of all adult patients with treatment-naive OCSCC undergoing primary neck dissection. For each outcome, we first used the maximally selected rank statistics and an optimism-corrected concordance to identify an optimal threshold of LNY. We then used a multivariable Cox proportional hazards model to assess the association between high LNY (>threshold) and each outcome. RESULTS: Among the 579 patients with OCSCC receiving primary neck dissection, 61.7% (n = 357) were male with a mean age of 62.9 years (standard deviation: 13.1) at cancer diagnosis. When adjusting for sociodemographic and clinical factors, LNY >15 was significantly associated with improved DFS (adjusted HR [aHR]: 0.73, 95% CI: 0.54-0.98), locoregional recurrence (aHR: 0.68, 95% CI: 0.49-0.95), and regional failure (aHR: 0.61, 95% CI: 0.39-0.93). CONCLUSIONS: Our study findings suggested high LNY to be a strong independent predictor of various patient-level quality of surgical care metrics. The optimal LNY we found (15) was lower than the conventionally recommended (18), which calls for further research to establish validity in practice.