Intentional self-harm in culturally and linguistically diverse communities: A study of hospital admissions in Victoria, Australia.

PURPOSE: To examine the rates and profiles of intentional self-harm hospital admissions among people from culturally and linguistically diverse and non-culturally and linguistically diverse backgrounds. METHODS: A retrospective analysis of 29,213 hospital admissions for self-harm among people aged 15 years or older in Victoria, Australia, was conducted using data from the Victorian Admitted Episodes Dataset between 2014/2015 and 2018/2019. The Victorian Admitted Episodes Dataset records all hospital admissions in public and private hospitals in Victoria (population 6.5 million). Population-based incidence of self-harm, logistic regression and percentages (95% confidence intervals) were calculated to compare between culturally and linguistically diverse groups by birthplaces and the non-culturally and linguistically diverse groups of self-harm admissions. RESULTS: When grouped together culturally and linguistically diverse individuals had lower rates of (hospital-treated) self-harm compared with the non-culturally and linguistically diverse individuals. However, some culturally and linguistically diverse groups such as those originating from Sudan and Iran had higher rates than non-culturally and linguistically diverse groups. Among self-harm hospitalised patients, those in the culturally and linguistically diverse group (vs non-culturally and linguistically diverse group) were more likely to be older, Metropolitan Victorian residents, from the lowest socioeconomic status, and being ever or currently married. Self-harm admissions by persons born in Southern and Eastern Europe were the oldest of all groups; in all other groups number of admissions tended to decrease as age increased whereas in this group the number of admissions increased as age increased. CONCLUSION: There was considerable heterogeneity in rates of hospital-treated self-harm in culturally and linguistically diverse communities, with some countries of origin (e.g. Sudan, Iran) having significantly higher rates. Some of this variation may be due to factors relating to the mode of entry into Australia (refugee vs planned migration), and future research needs to examine this possibility and others, to better plan for support needs in the culturally and linguistically diverse communities most affected by self-harm. Combining all culturally and linguistically diverse people into one group may obscure important differences in self-harm. Different self-harm prevention strategies are likely to be needed for different culturally and linguistically diverse populations.

Repeat self-harm and mental health service use after self-harm in Culturally and Linguistically Diverse communities: Insights from a data linkage study in Victoria, Australia.

PURPOSE: To examine the associations between Culturally and Linguistically Diverse backgrounds (vs non-Culturally and Linguistically Diverse) and in-hospital death due to self-harm, repeat self-harm and mental health service use after self-harm. METHOD: A retrospective study of 42,127 self-harm hospital inpatients aged 15+ years in Victoria, Australia, from July 2008 to June 2019. Linked hospital and mental health service data were used to assess in-hospital death, repeat self-harm and mental health service use in the 12 months following index self-harm hospital admission. Logistic regression and zero-inflated negative binomial regression models were used to estimate associations between cultural background and outcomes. RESULTS: Culturally and Linguistically Diverse people accounted for 13.3% of self-harm hospital inpatients. In-hospital death (0.8% of all patients) was negatively associated with Culturally and Linguistically Diverse background. Within 12 months, 12.9% of patients had self-harm readmission and 20.1% presented to emergency department with self-harm. Logistic regression components of zero-inflated negative binomial regression models showed no differences in the odds of (hospital-treated) self-harm reoccurrence between Culturally and Linguistically Diverse and non- Culturally and Linguistically Diverse self-harm inpatients. However, count components of models show that among those with repeat self-harm, Culturally and Linguistically Diverse people (e.g. born in Southern and Central Asia) made fewer additional hospital revisits than non-Culturally and Linguistically Diverse people. Clinical mental health service contacts following self-harm were made in 63.6% of patients, with Culturally and Linguistically Diverse people (Asian backgrounds 43.7%) less likely to make contact than the non-Culturally and Linguistically Diverse group (65.1%). CONCLUSIONS: Culturally and Linguistically Diverse and non-Culturally and Linguistically Diverse people did not differ in the likelihood of hospital-treated repeat self-harm, but among those with self-harm repetition Culturally and Linguistically Diverse people had fewer recurrences than non-Culturally and Linguistically Diverse people and utilised mental health services less following self-harm admissions.

The profunda artery perforator flap for head and neck reconstruction.

INTRODUCTION: The profunda artery perforator (PAP) fasciocutaneous flap is underutilized in head and neck reconstruction, with advantages including ease of harvest and minimal donor site morbidity. METHODS: Cadaveric dissection of cutaneous perforators to origin at profunda femoris system to characterize vascular anatomy. RESULTS: 22 PAP flaps were studied. Each contained 1-6 cutaneous perforators originating from the profunda system, designated into A, B, or C vascular pedicle systems. Muscular perforators did not consistently extend to skin in systems A and C, but all dissections demonstrated myocutaneous perforator in system B. Average distance from groin crease to cutaneous perforators of A, B, and C respectively was 8 cm (range 3-15 cm), 11.4 cm (range 5-17 cm), and 17.5 cm (range 12.5-22 cm). Average pedicle length was 11.07 cm (range 7-16 cm), 11.78 cm (range 9-16 cm), and 11.23 cm (range 9-15 cm). Average vena comitans diameter at origin was 3.14 mm (range 1.27-4.46 mm). Average arterial diameter at origin was 2.07 mm (range 1.27-3.82 mm). Range of maximal primary closure was 6-11 cm. CONCLUSION: PAP free flap demonstrates reliable vascular anatomy in cadavers, with adequate pedicle length and vessel diameter. All specimens contained adequate myocutaneous perforator to support free tissue transfer.

The changes of parental functioning of the patients with bipolar disorder and major depression since discharging from hospital: A longitudinal study.

AIMS AND OBJECTIVES: This study examined the changes in patients' parental functioning and the associated factors, including manic, depressive symptoms and social support from before discharge to 6 months post-discharge. BACKGROUND: For parents with bipolar disorder and major depression, parenting is a recovery factor for patients, but little research examines the dynamic parental functioning from acute hospitalisation to a remission stage. DESIGN: A longitudinal design was used. The STROBE Checklist were used in presenting this research. METHODS: Participants were inpatients with bipolar disorder or major depression (n = 33) recruited within one week before discharge from the acute psychiatric ward in Taiwan. Data on parental functioning was collected four times: before discharge (T1), the 1st (T2), the 3rd (T3) and the 6th (T4) months of post-discharge. Baseline parental functioning before admitting to the acute word was retrospectively assessed at T0. The questionnaires included positive and negative domains of parenting practice, hypomanic/manic symptoms, depressive symptoms and social support. Generalised estimating equations were applied for data analysis. RESULTS: The negative parenting domains (poor monitoring, inconsistent discipline) decreased during hospitalisation but increased at one month post-discharge, except corporal punishment at 3-months discharge. The positive parenting domains (parental involvement and nurturance/responsiveness) did not recovery to baseline. While clinical symptoms remained stable during 6 months post-discharge, social support decreased at 3 and 6 months post-discharge. Higher depressive symptoms and low social support were associated with positive parenting domains but not related to negative parenting domains. Manic symptoms were not associated with positive or negative parenting domains. CONCLUSIONS: Positive parenting domains did not fully return to the usual situation during 6 months post-discharge. RELEVANCE TO CLINICAL PRACTICE: Parenting functioning recovery program targeting at the impacts of depressive symptoms on the parenting functioning and insufficient social support is needed from hospitalisation to post-discharge.

Management of Lateral Wall Insufficiency.

Lateral wall insufficiency is a commonly encountered etiology of nasal obstruction, resulting from dynamic collapse at the level of the internal or external nasal valve. Various management strategies exist to strengthen the lateral wall or stent the nasal valves to relieve nasal obstruction, and range from noninvasive devices, minimally invasive implants, or surgical reconstructive techniques. Surgical options to address the nasal valves are selected based on each patient's anatomic findings, aesthetic and functional goals, and surgeon preference. This article describes the anatomy and physiology of the nasal sidewall and nasal valves and diagnosis of lateral wall insufficiency, and provides a framework for treatment options.

The experiences of family resilience from the view of the adult children of parents with bipolar disorder in Chinese society.

AIMS: This study explored how adult children perceived family resilience, barriers to develop family resilience and how cultural values influence their experience of parents with bipolar disorder in Chinese society. DESIGN: A qualitative design with an interpretive phenomenological analysis of data was employed. METHODS: Twenty adults who had lived with parents with bipolar disorder during childhood were recruited from the acute psychiatric ward when their parents were admitted to the hospital. They described their experiences of perceived family resilience and barriers to resilience (October 2013-September 2015). Semi-structured interviews were conducted in the hospital meeting room or at a convenient location. FINDINGS: Six themes were identified in family resilience: ill parents try to be good parents, parents' personal strengths, parents' positive attitudes towards mental illness, flexibility of family role, cohesive relationships between family members, and families' social connections. Three themes were identified in the barriers to develop family resilience: poor parenting/family function, conflict between parents and poor mental health literacy. CONCLUSION: Children's views of family resilience could transform their suffering from lived experiences with a mentally ill parent to a positive growth experience. Family resilience includes well and ill parents' efforts and social network's help to maintain family function. However, the conflicts between well and ill parents and poor family function result in a traumatic growth experience. IMPACT: To enhance a positive growth experience, family resilience programs for a parent with bipolar disorder aiming to cultivate both the ill and well parents' inner strength and their competence of parenting skills with connecting their social network to maintain family function is needed. Moreover, early stress-reduction intervention needs to be developed for children who did not experience family resilience.

Auditory testing outcomes with hearing aids in patients with auditory neuropathy spectrum disorder.

OBJECTIVE: The objective of this study is to evaluate the audiologic outcomes with hearing aids in pediatric patients with auditory neuropathy spectrum disorder (ANSD) using the Infant Toddler-Meaningful Auditory Integration Scale (IT-MAIS), and the Ling 6 Sound Test (Ling 6). STUDY DESIGN: Case series. SETTING: Single tertiary care academic medical center. SUBJECTS AND METHODS: All pediatric patients with a confirmed diagnosis of ANSD on Auditory Brainstem Response (ABR) testing who presented to a single tertiary medical center between September 2008 and September 2018 were included. Only patients that underwent Infant Toddler-Meaningful Auditory Integration Scale (IT-MAIS) and/or Ling 6 Sound Test (Ling 6) were included in the study. Audiologic testing performed after cochlear implantation was excluded. RESULTS: 60 pediatric patients with ANSD were analyzed. There were 10 patients included in the study with documented hearing aid use who underwent IT-MAIS and/or Ling 6 testing. Average IT-MAIS score improved by 20.4% after initial or extended trial of amplification. Similarly, average Ling 6 score improved from 3.6 to 4.8 after initial or extended trial of amplification. The four patients who did not receive amplification had higher average IT-MAIS and Ling 6 scores. CONCLUSION: In most children with ANSD, IT-MAIS and Ling 6 Sound Test scores improved with initial hearing aid use and over time with extended hearing aid use. Long-term prospective, multi-institutional studies are needed to determine the impact of the natural history of ANSD, comorbidities, and socioeconomic variables on auditory function testing results in children with ANSD using hearing aids.

Quality of life in older adults with sensory impairments: a systematic review.

PURPOSE: Sensory impairments are common in older adults. Hearing and visual impairments affect their physical and mental health and quality of life adversely. However, systematic reviews of the relationship between hearing impairment, visual impairment, dual sensory impairment, and quality of life are scarce. The purpose of this systematic review was to determine the relationship between hearing impairment, visual impairment, dual sensory impairment, and quality of life. METHODS: Searches of EMBASE, PubMed, CINAHL, MEDLINE, Cochrane Library, and Airiti Library were conducted between January 2006 and December 2017 using the keywords "quality of life," "life satisfaction," "well-being," "hearing impairment," and "visual impairment." Two authors independently assessed methodologic quality using a modified Downs and Black tool. Data were extracted by the first author and then cross-checked by the second author. RESULTS: Twenty-three studies consisting mostly of community-dwelling older adults were included in our review. Sensory impairment was found to be in significant association with quality of life, with an increase in hearing impairment or visual impairment severity resulting in a lower quality of life. Quality of life for dual sensory impairment was worse than for hearing impairment or visual impairment individually. CONCLUSIONS: A significant association was confirmed between hearing impairment, visual impairment, dual sensory impairment, and quality of life. Our review can be used to enhance health care personnel's understanding of sensory impairment in older adults and enable health care personnel to actively assess older adults' sensory functions, so that they can help alleviate the negative impact of sensory impairments on QOL in older adults.

Dynamic changes in global and gene-specific DNA methylation during hibernation in adult thirteen-lined ground squirrels, Ictidomys tridecemlineatus.

Hibernating mammals conserve energy in the winter by undergoing prolonged bouts of torpor, interspersed with brief arousals back to euthermia. These bouts are accompanied by a suite of reversible physiological and biochemical changes; however, much remains to be discovered about the molecular mechanisms involved. Given the seasonal nature of hibernation, it stands to reason that underlying plastic epigenetic mechanisms should exist. One such form of epigenomic regulation involves the reversible modification of cytosine bases in DNA by methylation. DNA methylation is well known to be a mechanism that confers upon DNA its cellular identity during differentiation in response to innate developmental cues. However, it has recently been hypothesized that DNA methylation also acts as a mechanism for adapting genome function to changing external environmental and experiential signals over different time scales, including during adulthood. Here, we tested the hypothesis that DNA methylation is altered during hibernation in adult wild animals. This study evaluated global changes in DNA methylation in response to hibernation in the liver and skeletal muscle of thirteen-lined ground squirrels along with changes in expression of DNA methyltransferases (DNMT1/3B) and methyl binding domain proteins (MBDs). A reduction in global DNA methylation occurred in muscle during torpor phases whereas significant changes in DNMTs and MBDs were seen in both tissues. We also report dynamic changes in DNA methylation in the promoter of the myocyte enhancer factor 2C (mef2c) gene, a candidate regulator of metabolism in skeletal muscle. Taken together, these data show that genomic DNA methylation is dynamic across torpor-arousal bouts during winter hibernation, consistent with a role for this regulatory mechanism in contributing to the hibernation phenotype.

Supraorbital Rim and Roof Reconstruction with Vascularized Fascia Lata and Autogenous Rib Graft.

OBJECTIVE: Describe a novel technique for reconstruction of complex defects involving supraorbital rim and orbital roof. METHODS: Retrospective chart review and description of surgical technique. RESULTS: Four patients underwent tumor resection with neurosurgery (2 intraosseous hemangioma, 1 meningioma, and 1 ossifying fibroma), with mean tumor size of 42.6 cubic centimeters on preoperative imaging. All defects involved supraorbital rim and orbital roof. Patients were reconstructed with autogenous osseous rib graft for structure and contour and anterolateral thigh fascia lata (ALTFL) free flap to provide robust vascularity to rib bone and as a barrier between skull base dura and the orbit and/or sinonasal cavities. Two patients underwent resection and reconstruction using minimal access incisions, and two underwent major cranial and skull base resections. All flaps are vascularized via superficial temporal vessels. On postoperative follow-up (mean 33.5 months, range 8-48), all patients report no vision change or diplopia, with excellent contour symmetry to contralateral orbit. Follow-up imaging (mean 29.5 months, range 3-48) demonstrated maintained orbital volume and retention of rib bone graft compared to immediate postoperative imaging. There were no complications related to graft use. Minor complications include 1 patient with cerebrospinal fluid leak managed with lumbar drain placement and 1 patient with mild enophthalmos at 7-month follow-up. CONCLUSION: We describe a series of patients who underwent a novel technique for reconstruction of complex defects involving supraorbital rim and orbital roof with autogenous osseous rib and vascularized ALTFL-free flap with excellent functional and cosmetic outcomes. This can be accomplished using minimal access techniques to minimize patient morbidity. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:654-658, 2024.

Mandibular Osteoradionecrosis: Defining the Microbial Milieu and Antimicrobial Resistance at the Time of Rescue Flap Surgery.

OBJECTIVE: To report the microorganisms and their antibiotic sensitivity profile from tissue cultures and stains at the time of anterolateral thigh fascia lata (ALTFL) rescue flap for management of mandibular osteoradionecrosis (ORN). METHODS: Retrospective chart review of patients who underwent ALTFL rescue flap for native mandibular ORN between 2011 and 2022. RESULTS: Twenty-six cases comprising 24 patients (mean age 65.4 years, 65.4% male) with mandibular ORN from whom tissue cultures and gram stain were obtained at the time of ALTFL rescue flap. 57.7% grew bacterial species, while 34.6% grew fungal species. Multibacterial speciation was noted in 26.9% of cultures. A combination of bacterial and fungal growth was also seen in 15.4% of cases. All gram-positive cocci (GPC) were pansensitive to antibiotics except for one case of Staphylococcus aureus, which was resistant to levofloxacin. Gram-negative bacilli (GNB) species were isolated in 50.0% of cases. All fungal growth was due to Candida species. No growth was noted in 23.1% of cases. Multidrug resistance was noted in 53.8% of cases when GNB was isolated. CONCLUSION: We report 76.9% of our cases of mandibular ORN had microbial growth from tissue cultures obtained at the time of the ALTFL rescue flap. Fungal growth was noted in a substantial number of cases and should be obtained as a specimen when pursuing culture-driven antibiotic therapy. Most GPCs were pansensitive to antibiotics, while GNBs were often the harbinger of multidrug resistant mandibular ORN. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:166-169, 2024.

Suicide and mortality following self-harm in Culturally and Linguistically Diverse communities in Victoria, Australia: insights from a data linkage study.

Background: While cultural backgrounds are well-documented to be relevant to intentional self-harm, little is known about how cultural and linguistically diverse (CALD) backgrounds affect mortality outcomes following self-harm. Aim: This study aimed to compare the risk of all-cause mortality and suicide after intentional hospital admissions for self-harm among people from CALD (vs. non-CALD) backgrounds. Method: Linked hospital and mortality data in Victoria, Australia, was used to assess suicide and all-cause death after hospital admissions for self-harm among patients aged 15+ years. All-cause death was identified by following up on 42,122 self-harm patients (hospitalized between 01 July 2007 and 30 June 2019) until death or 15 February 2021. Suicide death was evaluated in 16,928 self-harm inpatients (01 January 2013 and 31 December 2017) until death or 28 March 2018. Cox regression models were fitted to compare mortality outcomes in self-harm patients from CALD vs. non-CALD backgrounds. Outcomes: During the follow-up periods, 3,716 of 42,122 (8.8%) participants died by any cause (by 15 February 2021), and 304 of 16,928 (1.8%) people died by suicide (by 28 March 2018). Compared to the non-CALD group, CALD intentional self-harm inpatients had a 20% lower risk of all-cause mortality (HR: 0.8, 95% CI: 0.7-0.9) and a 30% lower risk of suicide (HR: 0.7, 95% CI: 049-0.97). Specifically, being from North Africa/Middle East and Asian backgrounds lowered the all-cause mortality risk; however, the suicide risk in Asians was as high as in non-CALD people. Conclusion: Overall, people from CALD backgrounds exhibited lower risks of all-cause mortality and suicide following hospital admission for self-harm compared to the non-CALD group. However, when comparing risks based on regions of birth, significant variations were observed. These findings underscore the importance of implementing culturally tailored background-specific suicide preventive actions. The study focussed on outcomes following hospital admission for self-harm and did not capture outcomes for cases of self-harm that did not result in hospital admission. This limits generalisability, as some CALD people might avoid accessing healthcare after self-harm due to cultural factors. Future research that not limited to hospital data is suggested to build on the results.

Minimally Invasive Approach to Access Vessels for Microvascular Anastomosis in Head and Neck Reconstruction.

OBJECTIVES: To describe our technique, review indications, and evaluate the outcomes of the minimal access approach for recipient vessel identification in microvascular tissue transfer. METHODS: Retrospective chart review of all patients who underwent microvascular reconstruction using the minimal access technique between 2015 and 2021. RESULTS: We report 236 cases, comprising 214 patients with a mean age of 60.2 years (3-88). The most common primary defect sites were the mandible (22.6%), cranium (14%), maxilla (13.2%), skull base (12.8%), and nose/nasal cavity (10.6%). Indications for free flap reconstruction included head and neck cancer extirpation (32.2%), osteoradionecrosis (29.7%), acquired deformity (14.0%), chronic wound (11.9%) and oral motor dysfunction (7.2%). Free flap donor sites used were the anterolateral thigh (84.3%), fibula (7.2%), and radial forearm (6.4%). Vessels utilized include superficial temporal (49.8%), facial (38.3%), angular (11.1%), and transverse cervical (0.4%). The overall complication rate was 14% (n = 33), with surgical complications at the recipient site accounting for 67.6% (n = 25). Flap failure occurred in 3.4% of procedures. Prior head and neck surgery and free flaps were associated with an increased risk of major recipient site complications (n = 20, p = 0.0257 and n = 14, p = 0.0117, respectively). CONCLUSION: Minimal access techniques allow consistent recipient vessel identification for microvascular-free tissue transfer. These approaches may be utilized in reconstructing a broad range of head and neck defects, are low morbidity, and contribute to an overall shorter length of stay. LEVEL OF EVIDENCE: 2 Laryngoscope, 134:2177-2181, 2024.

Management, Referral Patterns, and Outcomes in Bell's Palsy: A Single-Institution 903 Patient Series.

OBJECTIVE: In 2013, the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) published guidelines for Bell's palsy (BP), including recommendations for workup, management, and specialist referral. Patients with BP often present to primary care; however, adherence to guidelines may vary by setting. This study sought to evaluate the management of patients with BP presenting to primary care, emergency department (ED), and urgent care settings. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary care center. METHODS: Retrospective chart review of patients identified by diagnosis code for BP. RESULTS: A total of 903 patients were included; 687 (76.1%) presented to ED, 87 (9.6%) to internal medicine, 77 (8.5%) to family medicine, and 52 (5.8%) to urgent care. On presentation, 804 (89.0%) patients were prescribed corticosteroids and 592 (65.6%) antiviral therapy. Steroid therapy ranged from 1 dose to greater than a 14-day course, with 177 (19.6%) receiving an adequate duration of 10 days or greater. Referrals were provided to facial plastics and/or otolaryngology for 51 patients (5.6%). For all comers, 283 (31.3%) had complete resolution, 197 (21.8%) had an incomplete resolution, 62 (6.9%) had persistent palsy, and 361 (40.0%) lost to follow-up. In assessing the association between clinic setting and management, appropriate corticosteroid therapy (p < .01), imaging (p < .01), and eye care (p < .01) were statistically significant. CONCLUSION: Adherence to guidelines for BP management varies amongst providers. In our study cohort, 15.5% of patients received medical therapy in accordance with AAO-HNS guidelines, and only 5.6% were referred to facial plastics. To facilitate more appropriate care, tertiary care institutions may benefit from system-wide care pathways to manage acute BP.

Evaluation of Anterolateral Thigh Fascia Lata Rescue Flap for Mandibular Osteoradionecrosis.

Importance: Mandibular osteoradionecrosis (ORN) is a progressive disease that can be difficult to treat. Conservative measures often fail, while conventional definitive management requires a morbid segmental resection with osteocutaneous reconstruction. Evidence of the anterolateral thigh fascia lata (ALTFL) rescue flap technique's safety, effectiveness, and long-term outcomes is needed. Objective: To determine the long-term outcomes of the ALTFL rescue flap procedure for treating patients with mandibular ORN. Design, Settings, and Participants: This was a retrospective medical record review performed at a single tertiary-level academic health care institution with patients who were appropriate candidates for the ALTFL procedure to treat mandibular ORN from March 3, 2011, to December 31, 2022. Data analyses were performed from January 1 to March 26, 2023. Main Outcomes and Measures: Patient characteristics, preoperative radiographic Notani staging, intraoperative defect size, length of stay, complication rates, and clinical and radiographic findings of progression-free intervals. Results: The study population of 43 patients (mean [SD] age, 66.1 [47-80] years; 24 [55.8%] male individuals) included 52 cases of mandibular ORN. The preoperative Notani staging of the study population was known for 46 of the 52 total cases: 11 cases (23.9%) were stage I; 21 (45.7%), stage II; and 14 (30.4%), stage III. The mean defect area was 20.9 cm2. Successful arrest of ORN disease progression was noted in the clinical and radiographic findings of 50 of the 52 (96.2%) cases, with only 2 (3.8%) cases subsequently requiring fibular free flap reconstruction. The major complication rate was 1.9% (1 case). Clinical and radiographic progression-free intervals were assessed, and no statistically significant differences were noted between Notani staging groups (log-rank P = .43 and P = .43, respectively); ie, patients with stage III disease had no significant difference in risk of clinical (HR, 0.866; 95% CI, 0.054-13.853) or radiographic (HR, 0.959; 95% CI, 0.059-15.474) progression vs those with stage I disease. Weibull profiling revealed 96.9%, 94.6%, and 93.1% successful mandibular ORN arrest at 1, 3, and 5 years, respectively. The major complication rate was 1.9%. Mean (SD) length of stay was 2.7 (0.0-7.0) days. Mean (SD) radiographic follow-up was 29.3 (30.7) months. Conclusions and Relevance: The findings of this large retrospective patient case series support the continued success of the ALTFL rescue flap technique, a safe and highly effective long-term treatment for mandibular ORN in carefully selected patients.

Definitions of Culturally and Linguistically Diverse (CALD): A Literature Review of Epidemiological Research in Australia.

Objective: To identify how Culturally and Linguistically Diverse (CALD) communities are defined in epidemiological research in Australia and provide a definition of CALD status that aids the consistency and interpretability of epidemiological studies. Methods: Peer-reviewed literature from January 2015 to May 2020 was searched via four databases (Ovid Medline combined with PubMed, Embase, Emcare, and CINAHL) to identify quantitative studies of CALD people in Australia. Results: A total of 108 studies met the criteria for inclusion in the review. Country of birth was the most commonly used CALD definition (n = 33, 30.6%), with combinations of two or more components also frequently used (n = 31, 28.7%). No studies used all the components suggested as core to defining CALD status. including country of birth, languages other than English spoken at home, English proficiency, and indigenous status. Conclusions: There was considerable inconsistency in how CALD status was defined. The review suggests that CALD status would best be defined as people born in non-English speaking countries, and/or who do not speak English at home. Additionally, indigenous peoples should be considered separately. This recommended definition will support the better identification of potential health disparity and needs in CALD and indigenous communities.

Evaluating compliance with process-related quality metrics and survival in oral cavity squamous cell carcinoma: Multi-institutional oral cavity collaboration study.

BACKGROUND: Process-related measures have been proposed as quality metrics in head and neck cancer care. A recent single-institution study identified four key metrics associated with increased survival. This study sought to validate the association of these quality metrics with survival in a multi-institutional cohort. METHODS: Multicenter retrospective study of patients with oral cavity squamous cell (1/2005-1/2015). Baseline patient and disease characteristics and compliance with quality metrics was evaluated. Association between compliance with quality metrics with overall survival (OS), disease-free survival (DFS), and disease-specific survival (DSS) was evaluated using Cox proportional hazards models. RESULTS: Failure to comply with two or more of the quality metrics was associated with worse OS, DFS, and DSS. Adherence to all or all but one of the quality metrics was found to be associated with improved survival. CONCLUSIONS: Process-related quality metrics are associated with increased survival in patients with oral cavity squamous cell carcinoma in a multi-institutional cohort.

Recurrence and Progression of Head and Neck Paragangliomas after Treatment.

OBJECTIVE: To characterize the recurrence of head and neck paragangliomas and the factors associated with disease progression after treatment. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary care center. SUBJECTS AND METHODS: In total, 173 adults with 189 paragangliomas (41.3% carotid body, 29.1% glomus jugulare, 19.0% glomus tympanicum, and 10.6% glomus vagale) treated between 1990 and 2010 were evaluated to determine the incidence and risk of recurrence using Cox proportional hazards. RESULTS: The mean (SD) follow-up duration was 8.6 (9.1) years. The incidence was 2.92 recurrences per 100 person-years. The rate of recurrence was 8.2% (95% confidence interval [CI], 3.7-12.7) after 4 years and 17.1% (95% CI, 10.2-24.0) after 10 years. Glomus jugulare tumors were more likely to recur (hazard ratio [HR], 3.69; 95% CI, 1.70-8.01; P < .001) while carotid body tumors were less likely (HR, 0.44; 95% CI, 0.21-0.97; P = .041). Radiation had a lower risk of recurrence or progression compared to surgical excision (HR, 0.30; 95% CI, 0.10-.94; P = .040). Recurrence was associated with right-sided paragangliomas (HR, 3.60; 95% CI, 1.63-7.75; P = .001). The median time to recurrence was 18.4 years. Six (3.2%) patients developed metastasis, which was more common with local recurrence (9.5% vs 1.4%, P = .015). CONCLUSIONS: Recurrence is more common with glomus jugulare tumors and less common with carotid body tumors. Radiation may have a lower risk of recurrence or progression than surgery for some paraganglioma types. Metastasis is rare but more likely with recurrent disease. Surveillance neck imaging is recommended every several years for decades after treatment.

Degree of Self-Reported Facial Impairment Correlates with Social Impairment in Individuals with Facial Paralysis and Synkinesis.

Importance: Facial paralysis leads to both aesthetic and functional deficits placing patients at risk for sociopsychological sequelae and social impairment. Objective: To examine the effect of facial paralysis and synkinesis on social impairment and quality of life (QOL). Design, Setting, and Participants: This is a cross-sectional study at a tertiary care medical center. Adults with a history of facial palsy were broadly categorized by self-reported degree of facial paralysis and synkinesis. Main Outcomes and Measures: Clinical demographic information, self-reported degrees of facial paralysis and synkinesis, and facial palsy-specific QOL as measured by the Facial Clinimetric Evaluation (FaCE) Scale and the Synkinesis Assessment Questionnaire (SAQ) were collected. FaCE and SAQ scales were evaluated as predictors of social impairment outcomes, as measured by the Brief Fear of Negative Evaluation-II (BFNE-II), the Social Anxiety Questionnaire (SAQ-A30), and Social Avoidance and Distress (SAD) scales, in addition to health utility scores from the Short-Form 6D (SF-6D). Results: Fifty-six participants with facial palsy were included (30% male; average age: 56.4 [standard deviation (SD): 15] years). Sixty-three percent of participants reported history of Bell's palsy; 37% reported other etiologies. Forty-seven percent of participants reported moderate or severe facial impairment and 46% of participants reported involuntary facial movement. Participants with moderate or severe facial impairment exhibited increased BFNE-II (p = 0.03), SAQ-A30 (p = 0.04), and SAD (p < 0.01) scores and lower health valuation on SF-6D (p = 0.04). FaCE scores moderately correlated with lower health valuation (r = 0.39, p < 0.01), and moderately and inversely correlated with SAD (r = -0.33, p = 0.01) and BFNE-II (r = -0.35, p < 0.01) scores. Furthermore, worsening FaCE scores predicted worsening SAQ (p < 0.01), SAD (p = 0.01), BFNE-II (p < 0.01), and SF-6D (p < 0.01) scores. Worse degrees of synkinesis correlated with higher BFNE-II scores (r = 0.38, p < 0.01) and worsening SAQ scores predicted worsening FaCE (p < 0.01) and BFNE-II (p < 0.01) scores. Females demonstrated significantly worse BFNE-II scores (p = 0.04) when compared with men, and female gender significantly predicted worse FaCE scores (p < 0.01). Seventy-one percent of women with self-reported moderate or severe facial impairment met criteria for social anxiety, as did 67% of women with self-reported moderate or severe synkinesis. Conclusions and Relevance: Individuals with self-reported moderate or severe facial impairment exhibit a higher degree of social impairment and poorer health valuation than those with no or mild facial impairment. Facial palsy-specific QOL moderately and inversely correlated with social impairment and moderately correlated with health valuation. Our results indicate that FaCE scores may be used as a predictor of SAD, BFNE-II, and SF-6D scores and that facial palsy QOL and its relationship with social impairment should be considered when treating patients with a history of facial palsy.

Comparative Study of Functional Nasal Reconstruction Using Structural Reinforcement.

IMPORTANCE: Nasal reconstruction after Mohs surgery is a unique challenge in that it must satisfy both functional and aesthetic goals. Despite some advocacy in the literature for using structural reinforcement to achieve both functional and aesthetic outcomes in soft-tissue reconstruction, no study has validated this claim by comparing reconstruction with and without structural support. OBJECTIVE: To evaluate the effectiveness of and need for structural reinforcement when reconstructing the nasal alar and sidewall subunits. DESIGN, SETTING, AND PARTICIPANTS: This study was a retrospective review of the medical records of 190 patients 18 years or older who underwent nasal reconstruction after Mohs surgery in a tertiary care academic center between January 1, 2013, and August 31, 2015. Data on each patient included demographics, comorbidities, smoking status, details of the lesion, size of defect, subunits involved, and reconstructive technique. Patients were divided into 2 cohorts composed of those who had reconstruction with structural reinforcement (ie, cartilage grafting or suspension suture) and those with only soft-tissue reconstruction. Patients with nasal obstruction from the functional collapse of the reconstructed area and no history of nasal obstruction were included (n = 38). Patients who had a follow-up of less than 2 months, no alar or sidewall involvement, nasal obstruction secondary to turbinate hypertrophy, septal deflection or other nonstructural causes, and incomplete documentation for analysis were excluded (n = 102). MAIN OUTCOMES AND MEASURES: Rates of postoperative nasal obstruction secondary to nasal sidewall collapse and need for revision surgery. RESULTS: Of the 38 patients who met the inclusion criteria, 22 were men and 16 were women with a mean (range) age of 64.5 (35-92) years. Twenty-three patients (61%) underwent reconstruction by a facial plastic surgeon and 15 (39%) by 2 dermatologic surgeons. Three (8%) underwent reconstruction without reinforcement and experienced postoperative nasal obstruction. The mean size of reconstructed defects that resulted in nasal valve collapse was 2.1 cm in diameter (range, 1.2-2.6 cm). Defect size was associated with incidence of postoperative nasal obstruction. For defects greater than 1.2 cm in diameter, patients reconstructed without reinforcement had a statistically significant increase of nasal obstruction secondary to functional nasal collapse compared with patients reconstructed with reinforcement (3 of 14 [21%] vs 0 of 17; 95% CI, 0.005-0.358; P = .04). CONCLUSIONS AND RELEVANCE: Nasal defects greater than 1.2 cm in diameter and involving the alar and sidewalls were associated with lower incidence of postoperative nasal obstruction when a structural reinforcement technique was used in reconstruction. The findings of this study support the structural reinforcement of the nasal functional subunits during Mohs reconstructive surgery to achieve optimal outcomes. LEVEL OF EVIDENCE: 3.