Youth mental health-related presentations at a quaternary centre: Who comes, What are their needs, and Can we meet their needs.

Background: Mental health issues are increasingly prevalent across Canada, reflected in rising presentations to emergency departments. To effectively address the needs of children and youth seeking mental health-related care in the emergency department and to judiciously use scarce mental health-related resources, we need to better identify the specific areas of psychosocial needs and accessibility of associated services. Objective: To describe the types and severity of paediatric mental health-related presentations evaluated at a quaternary paediatric emergency department, and to explore the accessibility of community mental health-related resources. Methods: We conducted a retrospective cohort study of children and youth presenting to a quaternary paediatric emergency department who were assessed using HEARTSMAP, a validated mental health assessment and management tool. We reported the proportion who sought care for a psychiatric, social, or youth health-related mental health complaint. We contacted community mental health-related resources for their estimated wait times to determine accessibility. Results: Of 1,530 paediatric emergency presentations, 98.8% of patients had psychiatric issues (40.1% were severe), 78.0% of patients had social issues (17.1% were severe), and 71.5% had youth health issues (18.1% were severe). We contacted 123 community mental health-related resources. Community youth health and social services were somewhat accessible, with 50.0% and 38.7%, respectively, able to intake youth within a week of referral. Community psychiatric programs were least accessible, with 59.3% having wait times greater than 1 month. Conclusions: Many psychiatric concerns presenting in paediatric emergency departments have complex psychosocial challenges requiring non-psychiatric support. A need exists for improved accessibility to community psychiatric programs.

Function but not phenotype of melanoma peptide-specific CD8(+) T cells correlate with survival in a multiepitope peptide vaccine trial (ECOG 1696).

ECOG 1696 was a Phase II multi-center trial testing vaccination with melanoma peptides, gp100, MART-1 and tyrosinase delivered alone, with GM-CSF, IFN-α2b or both cytokines to HLA-A2(+) patients with metastatic melanoma. Here, the frequency of circulating CD8(+) tetramer(+) (tet(+) ) T cells and maturation stages of responding T cells were serially monitored and compared with baseline values in a subset of patients (n = 37) from this trial. Multiparameter flow cytometry was used to measure the frequency of CD8(+) T cells specific for gp100, MART-1, tyrosinase and influenza (FLU) peptides. Expression of CD45RA/CCR7 on CD8(+) tet(+) T cells and CD25, CD27, CD28 on all circulating T cells was determined. Vaccine-induced changes in the CD8(+) tet(+) T cell frequency and phenotype were compared with results of IFN-γ ELISPOT assays and with clinical responses. The frequency of CD8(+) tet(+) T cells in the circulation was increased for the melanoma peptides (p < 0.03-0.0001) but not for FLU (p < 0.9). Only gp100- and MART-1-specific T cells differentiated to CD45RA(+) CCR7(-) effector/memory T cells. In contrast to the IFN-γ ELISPOT frequency, previously correlated with overall survival (Kirkwood et al., Clin Cancer Res 2009;15:1443-51), neither the frequency nor differentiation stage of CD8(+) tet(+) T cells correlated with clinical responses. Delivery of GM-CSF and/or IFN-α2b had no effects on the frequency or differentiation of CD8(+) tet(+) , CD8+ or CD4+ T cells. Phenotypic analyses of CD8(+) tet(+) T cells did not correlate with clinical responses to the vaccine, indicating that functional assessments of peptide-specific T cells are preferable for monitoring of anti-tumor vaccines.

Treatment of chronic frontal sinusitis with difficult anatomy: A hybrid balloon technique in four cases.

The presence of frontal cells poses unique challenges when using endoscopic approaches. This study describes the use of a balloon dilation system as an aid for functional endoscopic sinus surgery (FESS) to access the frontal sinus in cases that would traditionally require open approaches. We present a case series of four patients with chronic rhinosinusitis refractive to medical management who underwent FESS with the aid of a balloon dilation system at a tertiary referral center. All patients had variant forms of frontal sinus anatomy. Surgical techniques will be described and use of the balloon system will be reviewed. All patients (aged 13-68 years) successfully underwent fontal sinusotomies with the assistance of a balloon dilation system, which was used in a variety of ways: to dilate the narrow infundibulum of a high intersinus septal cell, to remove an anteriorly located type III frontal sinus cell, to expand the natural frontal ostium in the presence of excessive agger nasi pneumatization, and to remove a type IV frontal sinus cell. All patients were spared an osteoplastic flap or trephination, and there were no intraoperative complications. No postoperative bleeding, infection, or cerebral spinal fluid leaks were reported. Balloon dilation in combination with standard frontal sinus dissection techniques may be beneficial for a select group of patients with complex frontal anatomy. In this series of patients, the balloon dilation system was used as a tool during FESS and eliminated the need for open approaches.

Pedicled extranasal flaps in skull base reconstruction.

Cerebrospinal fluid (CSF) leaks most commonly arise during or after skull base surgery, although they occasionally present spontaneously. Recent advances in the repair of CSF leaks have enabled endoscopic endonasal surgery to become the preferred option for management of skull base pathology. Small defects (<1 cm) can be repaired by multilayered free grafts. For large defects (>3 cm), pedicled vascular flaps are the repair method of choice, resulting in much lower rates of postoperative CSF leaks. The pedicled nasoseptal flap (NSF) constitutes the primary reconstructive option for the vast majority of skull base defects. It has a large area of potential coverage and high rates of success. However, preoperative planning is required to avoid sacrificing the NSF during resection. In cases where the NSF is unavailable, often due to tumor involvement of the septum or previous resection removing or compromising the flap, other flaps may be considered. These flaps include intranasal options - inferior turbinate or middle turbinate flaps - as well as regional pedicled flaps: pericranial flap, temporoparietal fascial flap, or palatal flap. More recently, novel alternatives such as the pedicled facial buccinator flap and the pedicled occipital galeopericranial flap have been added to the arsenal of options for skull base reconstruction. Characteristics of and appropriate uses for each flap are described.

Cochlear implantation in unique pediatric populations.

PURPOSE OF REVIEW: Over the last decade, the selection criteria for cochlear implantation have expanded to include children with special auditory, otologic, and medical problems. Included within this expanded group of candidates are those children with auditory neuropathy spectrum disorder, cochleovestibular malformations, cochlear nerve deficiency, associated syndromes, as well as multiple medical and developmental disorders. Definitive indications for cochlear implantation in these unique pediatric populations are in evolution. This review will provide an overview of managing and habilitating hearing loss within these populations with specific focus on cochlear implantation as a treatment option. RECENT FINDINGS: Cochlear implants have been successfully implanted in children within unique populations with variable results. Evaluation for cochlear implant candidacy includes the core components of a full medical, audiologic, and speech and language evaluations. When considering candidacy in these children, additional aspects to consider include disorder-specific surgical considerations and child/caregiver counseling regarding reasonable postimplantation outcome expectations. SUMMARY: Cochlear implants are accepted as the standard of care for improving hearing and speech development in children with severe-to-profound hearing loss. However, children with sensorineural hearing loss who meet established audiologic criteria for cochlear implantation may have unique audiologic, medical, and anatomic characteristics that necessitate special consideration regarding cochlear implantation candidacy and outcome. Individualized preoperative candidacy and counseling, surgical evaluation, and reasonable postoperative outcome expectations should be taken into account in the management of these children.

Selective neck dissection and deintensified postoperative radiation and chemotherapy for oropharyngeal cancer: a subset analysis of the University of Pennsylvania transoral robotic surgery trial.

OBJECTIVES/HYPOTHESIS: The purpose of this study was to determine the regional recurrence rate of node-positive oropharyngeal squamous cell carcinoma (OPSCC) in patients undergoing transoral robotic surgery (TORS) and selective neck dissection (SND) followed by observation, radiation, or concurrent chemoradiation. STUDY DESIGN: A prospective, phase I, single-arm study was conducted. All OPSCC patients who voluntarily participated in a surgical trial with TORS and SND at an academic tertiary referral center from May 2005 to July 2007 were included. METHODS: Thirty-one patients with previously untreated OPSCC undergoing TORS and SND (29 unilateral and two bilateral) were included. There were 29 males and two females, with ages ranging from 36 to 76 years (median = 55 years) with one palate, one lateral wall, 17 tonsil, 11 base of tongue, and one vallecula primary tumor classified as follows: T1 (n = 9, 29%), T2 (n = 15, 48.4%), T3 (n = 7, 22.6%), N0 (n = 6, 19.4%), N1 (n = 15, 48.4%), N2b (n = 10, 32.3%), and N2c (n = 1, 3.2%). There were three stage I (9.7%), two stage II (6.5%), 15 stage III (48.4%) and 11 stage IVa (35.5%) patients. Twenty-two patients were treated postoperatively with adjuvant therapy (12 radiation alone and 12 combined radiation and chemotherapy). Primary outcome measured was regional recurrence rate. RESULTS: There was one regional recurrence on the contralateral, non-operated neck and one distant recurrence among the 31 patients who underwent SND. CONCLUSIONS: SND after TORS resection of primary OPSCC enables the use of selective and deintensified adjuvant therapy to reduce regional recurrence rates.

Immune responses to p53 in patients with cancer: enrichment in tetramer+ p53 peptide-specific T cells and regulatory T cells at tumor sites.

OBJECTIVE: A majority of human cancers, including head and neck cancer (HNC), "overexpress" p53. Although T cells specific for wild-type (wt) sequence p53 peptides are detectable in the peripheral blood of patients with HNC, it is unknown whether such T cells accumulate in tumor-involved tissues. Also, the localization of "regulatory" T cells (Treg) to tumor sites in HNC has not been investigated to date. METHODS: Tumor infiltrating lymphocytes (TIL), tumor-involved or non-involved lymph node lymphocytes (LNL) and peripheral blood mononuclear cells (PBMC) were obtained from 24 HLA-A2.1+ patients with HNC. Using tetramers and four-color flow cytometry, the frequency of Treg and CD3+CD8+ T cells specific for wt p53 epitopes as well as their functional attributes were determined. RESULTS: The CD3+CD8+ tetramer+ cell frequency was significantly higher (P<0.001) in TIL than autologous PBMC as was the percentage of CD4+CD25+ T cells (P<0.003). TIL were enriched in FOXp3+, GITR+ and CTLA-4+ Treg. CD8+ TIL had low Zeta expression and produced little IFN-gamma after ex vivo stimulation relative to autologous PBMC or PBMC from NC. CONCLUSIONS: Anti-wt p53 epitope-specific T cells and Treg preferentially localize to tumor sites in patients with HNC. However, despite enrichment in tumor peptide-specific T cells, the effector cell population (CD3+CD8+) in TIL or PBMC was unresponsive to activation in the tumor microenvironment enriched in Treg.