Y-Chromosome-Linked Genes Are Associated With Sex-Related Head-Neck Squamous Cell Carcinoma Survival

OBJECTIVE

To define novel gene biomarkers for prognosis of head and neck squamous cell carcinoma (HNSCC) patients' survival.

STUDY DESIGN

Retrospective study.

SETTING

The Cancer Genome Atlas (TCGA) HNSCC RNA-Seq dataset.

METHODS

Coexpressed gene clusters were extracted from TCGA RNA-seq data using our previously published method (EPIG). Kaplan-Meier estimator was then used for overall survival-relevant analysis, with patients partitioned into 3 groups based on gene expression levels: female, male_low, and male_high.

RESULTS

Male had better overall survival than female and male with higher expression level of Y-chromosome-linked (Y-linked) genes had significantly better survival than those with lower expression levels. In addition, male with a higher expression level of Y-linked genes showed even better survival when they have a higher level of coexpressed cluster of genes related to B or T cell immune response. Other clinical conditions related to immune responses also consistently showed favorable effects on the Y-linked genes for survival estimation. Male patients with higher expression level of Y-linked genes also have significantly higher tumor/normal tissue (T/N) ratio of those genes and higher level of several immune responses related clinical measurements (eg, lymphocyte and TCR related). Male patients with lower expression level of Y-linked genes benefited from radiation-only treatment.

CONCLUSIONS

The favorable role of a cluster of coexpressed Y-linked genes in HNSCC patients' survival is potentially associated with elevated level of immune responses. These Y-linked genes could serve as useful prognostic biomarkers for HNSCC patients' survival estimation and treatment.

Exceptional response to cetuximab monotherapy after failure of immunotherapy with a checkpoint inhibitor in a patient with metastatic head and neck squamous cell cancer: case report and review of the literature

Immunotherapy with PD-1 inhibitors monotherapy or combined with chemotherapy comprises the first-line palliative treatment for patients with recurrent or metastatic head and neck squamous cell cancers (R/M HNSCC). The established survival advantage among responders is overshadowed by the high percentage of patients failing the standard PD-1 inhibitor-based treatments. Salvage therapies are direly needed. However, no current standards are available. We present the case of a 65-year-old patient with heavily pretreated laryngeal squamous cell carcinoma who had an exceptional response to cetuximab monotherapy following the failure of immunotherapy with the PD-1 inhibitor nivolumab. We reviewed the literature for other cases of exceptional response to cetuximab, clinical studies investigating the combined or sequential administration of cetuximab and PD-1 inhibitors, and the mechanistic rationale for consideration of cetuximab as a potential salvage treatment after immunotherapy with PD-1 inhibitors. In addition to the specific epidermal growth factor receptor inhibitory effect, cetuximab, as an immunoglobulin G1 isotype, binds NK cells and elicits antibody-dependent cellular toxicity, triggering a domino of immunostimulatory, and immunoinhibitory effects that actually might decrease the cetuximab anticancer efficacy. However, in a tumor microenvironment exposed to previous treatment with a PD-1 inhibitor, the effects of the PD-1 inhibitor followed by cetuximab on innate and adaptative immune response appear to synergize. Specifically, persistent immune checkpoint inhibitors' consequences may negate downstream immunosuppressive effects of cetuximab caused through PD-1/PD-L1 upregulation, making it a more potent treatment option. Besides the potential synergistic effect on antitumor immune response with previous immune checkpoint inhibitors therapy, cetuximab is the only targeted agent approved for treating R/M HNSCC, making it a most advantageous candidate for further treatment validation studies as salvage treatment post-immunotherapy.

Intensity-modulated radiotherapy with planned Gamma Knife radiosurgery boost for head and neck cancer with extensive disease in proximity to critical structures

BACKGROUND

To describe intensity-modulated radiotherapy (IMRT) with Gamma Knife Radiosurgery (GKRS) boost for locally advanced head and neck cancer (HNC) with disease near dose-limiting structures.

METHODS

Patients with HNC treated with IMRT/GKRS as part of a combined modality approach between 2011 and 2021 were reviewed. Local control, overall survival and disease-specific survival were estimated using the Kaplan Meier method.

RESULTS

Twenty patients were included. Nineteen patients had T3-4 tumors. Median follow-up was 26.3 months. GKRS site control was 95%. Two patients progressed at the treated primary site, one patient failed at the edge of the GKRS treatment volume, with no perineural or intracranial failure. 2-year OS was 94.7% (95% CI: 85.2%-100%). Concurrent chemotherapy was given in nine patients (45%). One patient (5%) received induction/concurrent chemotherapy. Brain radionecrosis occurred in three patients, one of which was biopsy-proven.

CONCLUSIONS

IMRT plus GKRS boost results in excellent disease control near critical structures with minimal toxicity.

Early [18]FDG PET/CT scan predicts tumor response in head and neck squamous cell cancer patients treated with erlotinib adjusted per smoking status

Translational Relevance

Evaluation of targeted therapies is urgently needed for the majority of patients with metastatic/recurrent head and neck squamous cell carcinoma (HNSCC) who progress after immunochemotherapy. Erlotinib, a targeted inhibitor of epidermal growth factor receptor pathway, lacks FDA approval in HNSCC due to inadequate tumor response. This study identifies two potential avenues to improve tumor response to erlotinib among patients with HNSCC. For the first time, this study shows that an increased erlotinib dose of 300 mg in smokers is well-tolerated and produces similar plasma drug concentration as the regular dose of 150 mg in non-smokers, with increased study-specific defined tumor response. The study also highlights the opportunity for improved patient selection for erlotinib treatment by demonstrating that early in-treatment [18]FDG PET/CT is a potential predictor of tumor response, with robust statistical correlations between metabolic changes on early in-treatment PET (4-7 days through treatment) and anatomic response measured by end-of-treatment CT.

Purpose

Patients with advanced HNSCC failing immunochemotherapy have no standard treatment options. Accelerating the investigation of targeted drug therapies is imperative. Treatment with erlotinib produced low response rates in HNSCC. This study investigates the possibility of improved treatment response through patient smoking status-based erlotinib dose optimization, and through early in-treatment [18]FDG PET evaluation to differentiate responders from non-responders.

Experimental design

In this window-of-opportunity study, patients with operable HNSCC received neoadjuvant erlotinib with dose determined by smoking status: 150 mg (E150) for non-smokers and 300 mg (E300) for active smokers. Plasma erlotinib levels were measured using mass spectrometry. Patients underwent PET/CT before treatment, between days 4-7 of treatment, and before surgery (post-treatment). Response was measured by diagnostic CT and was defined as decrease in maximum tumor diameter by ≥ 20% (responders), 10-19% (minimum-responders), and < 10% (non-responders).

Results

Nineteen patients completed treatment, ten of whom were smokers. There were eleven responders, five minimum-responders, and three non-responders. Tumor response and plasma erlotinib levels were similar between the E150 and E300 patient groups. The percentage change on early PET/CT and post-treatment PET/CT compared to pre-treatment PET/CT were significantly correlated with the radiologic response on post-treatment CTs: R=0.63, p=0.0041 and R=0.71, p=0.00094, respectively.

Conclusion

This pilot study suggests that early in-treatment PET/CT can predict response to erlotinib, and treatment with erlotinib dose adjusted according to smoking status is well-tolerated and may improve treatment response in HNSCC. These findings could help optimize erlotinib treatment in HNSCC and should be further investigated.

Clinical Trial Registration

https://clinicaltrials.gov/ct2/show/NCT00601913, identifier NCT00601913.

Comprehensive gene cluster analysis of head and neck squamous cell carcinoma TCGA RNA-seq data defines B cell immunity-related genes as a robust survival predictor

BACKGROUND

The authors aimed to define novel gene expression signatures that are associated with patients' survival with head and neck squamous cell carcinoma (HNSCC).

METHODS

TCGA RNA-seq data were used for gene expression clusters extraction from 499 tumor samples by the "EPIG" method. Tumor samples were then partitioned into lower and higher than median level groups for survival relevant analysis by Kaplan-Meier estimator.

RESULTS

We found that two gene clusters (_1, _2) are favorably, while two (_3, _4) are unfavorably, associated with patients' survival with HNSCC. Notably, most genes on the top lists of cluster_2 are associated with B cells. A gene expression signature with combined genes from cluster_2 and _4 was further determined to be associated with HNSCC survival rate.

CONCLUSION

Our work strongly supported a favorable role of B cells in patients' survival with HNSCC and identified a novel coexpressed gene signature as prognostic biomarker for patients' survival with HNSCC estimation.

Oropharyngeal Carcinoma Treated with Surgery Alone: Outcomes and Predictors of Failure

OBJECTIVE

To analyze the oncologic outcomes and risk factors for recurrence in patients who underwent surgery for oropharyngeal squamous cell carcinoma (OPSCC), and in whom adjuvant therapy was not recommended or was declined.

METHODS

Retrospective cohort study of patients with OPSCC who were treated with transoral surgery only at a tertiary care academic medical center from April 2010 to March 2019.

RESULTS

Seventy-four patients met inclusion criteria. In 16, adjuvant therapy was recommended but declined. There were 8 recurrences, of which 6 had been given recommendations for adjuvant therapy. Of the 8 recurrences, 2 died, 2 are alive with disease, and 4 were successfully salvaged. Five patients died of unrelated causes. Lymphovascular invasion (LVI, P = .016) had a significant impact on recurrence, while other pathologic features of the primary tumor such as size, location, human papillomavirus (HPV) status, and margin status did not. Margins were classified as "positive" in 4 patients, "close" in 54, and "negative" in 16. There were 3 local recurrences (4.1%), each of whom had declined adjuvant therapy. Lymph node features such as N-stage (P = .0004), number of positive nodes (P = .0005), and presence of extra-nodal extension (ENE, P = .0042) had a statistically significant impact on relapse. Smoking history and surgical approach showed no significant impact on recurrence.

CONCLUSION

Patients who undergo surgery for HPV-positive OPSCC with negative margins, no PNI, no LVI, and ≤1 positive lymph node without ENE have low risk for recurrence. These patients can likely be safely treated with surgery alone. Patients with these risk factors who decline adjuvant therapy are at risk for recurrence, and should be monitored.

Impact of outcomes data on the management of postoperative hypocalcemia in head and neck endocrine surgery patients

Postoperative hypocalcemia is a well-described outcome following thyroid and parathyroid surgery with symptoms ranging from clinically insignificant laboratory findings to tetany and seizures. The aims of this study were 1. To identify the characteristics and management patterns of postoperative hypocalcemia in head and neck endocrine surgery patients and 2. To compare outcomes between patients treated with empiric calcium and patients treated using a biochemically driven calcium replacement algorithm. Clinical electronic medical record (EMR) data was collected from patients who had undergone total thyroidectomy, completion thyroidectomy, and/or parathyroidectomy at Wake Forest Baptist Medical Center (WFBMC), a tertiary referral and academic institution. Between July 1, 2016, and June 30, 2017, 298 adult patients underwent surgery by a WFBMC Head & Neck (H&N) endocrine surgeon. Objective calcium and parathyroid hormone levels, postoperative supplementation with calcium and Vitamin D, 30-day physician access line (PAL) phone call utilization, emergency department (ED) encounters, and readmission rates were queried. The overall rate of hypocalcemia was 17.4%. No statistically significant difference in PAL utilization, ED visits, or readmissions was found between the empiric supplementation group and those whose supplementation was biochemically directed (PAL 5.0% vs. 5.0% [p = 0.983], ED visit 3.3% vs. 2.5% [p = 0.744], Readmission 1.7% vs. 0% [p = 0.276]). The overall postoperative rates of hypocalcemia and hypoparathyroidism following H&N endocrine surgery were consistent with the reported literature. Neither method of calcium supplementation was superior in reducing PAL utilization, ED encounters, or readmission.

Surgical management of Eagle syndrome: A 17-year experience with open and transoral robotic styloidectomy

Eagle Syndrome (ES) is a rare disorder that can present with symptoms ranging from globus sensation to otalgia that is attributed to an elongated styloid process and/or calcified stylohyoid ligament. No standardized treatment algorithm exists, and although various surgical approaches have been described, data on the use of transoral robotic surgery (TORS) in this population is limited. To investigate the utility of TORS in the treatment of ES, a retrospective review in 19 ES patients was carried out at a single academic, tertiary medical center between 2000 and 2017. Nineteen patients underwent twenty-one styloid resections: 6 performed via TORS and 15 via transcervical approach. Across all patients, 90% reported some degree of lasting improvement in symptoms while 55% reported significant improvement. When TORS was compared to transcervical resection, there was no difference in the subjective rate of "meaningful" (83 vs. 57%) versus rate of "non-meaningful" symptom improvement (17 vs. 43%) (p = 0.35). There was a trend towards less estimated blood loss (EBL), operative time, and post-operative length of stay (LOS) with TORS versus transcervical cases (9.2 mL vs. 30.0 mL, 98 vs. 156 min, and 0.7 vs. 1.2 days); however, these did not reach statistical significance (p = .11, 0.13, and 0.42, respectively). Three patients experienced complications associated with an open approach, as compared to none with TORS. In select patients, TORS styloidectomy is a reasonable surgical alternative to traditional transoral and transcervical techniques as it provides similar symptom improvement, and reduced length of stay, blood loss, and operative time.

MicroRNA Profiling and Target Genes Related to Metastasis of Salivary Adenoid Cystic Carcinoma

BACKGROUND/AIM

Perineural invasion and distant metastasis lead to a poor prognosis of adenoid cystic carcinoma and there is no effective therapy available. MicroRNAs (miRNAs) are small non-coding RNAs that regulate target gene expression, which can be biomarkers or therapeutic targets for certain cancer types. We aimed to identify miRNAs and their target genes possibly involved in metastasis of salivary gland adenoid cystic carcinoma (SACC).

MATERIALS AND METHODS

Using Nanostring nCounter analysis, we examined miRNA expression in two SACC cell lines: SACC-83 and SACC-LM, with low and high lung metastasis rates, respectively. We then verified the differentially expressed miRNAs with real-time polymerase chain reaction in the cell lines and in tumor samples from patients with SACC. miRNA target-gene expression was also analyzed.

RESULTS

SACC-83 showed higher gene expression of miR-130a, miR-342, and miR-205; SACC-LM showed higher gene expression of miR-99a and miR-155. In human tissue, miR-205 was highly expressed in the primary SACC, while miR-155 and miR-342 were highly expressed in recurrent SACC. Six predicted target genes of miRNA-155 and miR-99a linked to tumorigenesis were further analyzed and RNA expression of ubiquitin-like modifier activating enzyme 2 (UBA2) was higher in SACC than normal salivary gland tissue, and higher in primary compared to recurrent SACC (p<0.05). RNA expression of retinoic acid receptors (RARS) was higher in tissue from primary than recurrent SACC and normal salivary gland (p<0.05), but that in recurrent SACC was not significantly higher than normal salivary gland tissue. RNA expression of minichromosome maintenance 8 homologous recombination repair factor (MCM8) and 24-dehydrocholesterol reductase (DHCR24) was higher in primary SACC than normal salivary gland tissue (p<0.05).

CONCLUSION

miR-99a, miR-155, miR-130a, miR-342, and miR-205 may play a role in metastasis of SACC. MiR-155 may be involved in SACC metastasis through UBA2 pathways, and UBA2 may function as a biomarker/mediator of SACC metastasis.

Chemokine and Chemokine Receptor Profiles in Metastatic Salivary Adenoid Cystic Carcinoma

AIM

To characterize the chemokine pattern in metastatic salivary adenoid cystic carcinoma (SACC).

MATERIALS AND METHODS

Real-time polymerase chain reaction (RT-PCR) was used to compare chemokine and chemokine receptor gene expression in two SACC cell lines: SACC-83 and SACC-LM (lung metastasis). Chemokines and receptor genes were then screened and their expression pattern characterized in human tissue samples of non-recurrent SACC and recurrent SACC with perineural invasion.

RESULTS

Expression of chemokine receptors C5AR1, CCR1, CCR3, CCR6, CCR7, CCR9, CCR10, CXCR4, CXCR6, CXCR7, CCRL1 and CCRL2 were higher in SACC-83 compared to SACC-LM. CCRL1, CCBP2, CMKLR1, XCR1 and CXCR2 and 6 chemokine genes (CCL13, CCL27, CXCL14, CMTM1, CMTM2, CKLF) were more highly expressed in tissues of patients without tumor recurrence/perineural invasion compared to those with tumor recurrence. CCRL1 (receptor), CCL27, CMTM1, CMTM2, and CKLF (chemokine) genes were more highly expressed in SACC-83 and human tissues of patients without tumor recurrence/perineural invasion.

CONCLUSION

CCRL1, CCL27, CMTM1, CMTM2 and CKLF may play important roles in the development of tumor metastases in SACC.

Dysphagia after Sequential Chemoradiation Therapy for Advanced Head and Neck Cancer

OBJECTIVES: Assess impact of sequential chemoradiation therapy (SCRT) for advanced head and neck cancer (HNCA) on swallowing, nutrition, and quality of life.

STUDY DESIGN: Prospective cohort study of 59 patients undergoing SCRT for advanced head and neck cancer. Follow-up median was 47.5 months.

SETTING: Regional Cancer Center.

RESULTS: Median time to gastrostomy tube removal was 21 weeks. Eighteen of 23 patients who underwent modified barium swallow demonstrated aspiration; none developed pneumonia. Six of 7 with pharyngoesophageal stricture underwent successful dilatation. Functional Assessment of Cancer Therapy—Head and Neck Scale questionnaires at median 6 months after treatment revealed “somewhat” satisfaction with swallowing. At the time of analysis, 97% have the gastronomy tube removed and take soft/regular diet.

CONCLUSION: Early after treatment dysphagia adversely affected weight, modified barium swallow results, and quality of life. Diligent swallow therapy, and dilation as needed, allowed nearly all patients to have their gastronomy tubes removed and return to a soft/regular diet.

SIGNIFICANCE: Dysphagia is significant after SCRT but generally slowly recovers 6 to 12 months after SCRT.

Increased Expression of MuRF1 Is Associated with Radiation-induced Laryngeal Muscle Atrophy

BACKGROUND

Laryngeal muscles play an important role in breathing, sound production and trachea protection against food. Laryngeal dysfunctions during radiotherapy for head and neck cancers are common. In the present study, we aimed to investigate the early effect of radiation on the laryngeal muscles in vivo and possible mechanisms involved in this process.

MATERIALS AND METHODS

Eight-week-old female C57bl/ mice received neck irradiation with a single dose of 25 Gy and bilateral thyroarytenoid (TA) muscles of mice were collected at day 3, 7 and 10 post-irradiation for evaluating muscle size, myosins, myosin heavy chain (MyHC) composition and MuRF1 protein levels.

RESULTS

A significant reduction in the size of muscle fibers and myosins in the TA muscles were observed at days 3, 7, 10 after radiation (p<0.05). The loss of IIB myosin was more severe than that of IIA/X myosins at day 7 post-irradiation (75% vs. 64%). MuRF1 protein level was markedly increased at day 7 and 10 after radiation (p<0.05).

CONCLUSION

Radiation induced an acute muscle fiber atrophy and myosin loss in the intrinsic laryngeal muscles. MuRF1 may play an important role in the radiation-induced protein degradation in the laryngeal muscles and warrants further investigation.

The Validity of Self-reported Recent Smoking in Head and Neck Cancer Surgical Patients

OBJECTIVE

In cancer patients, cigarette smoking causes poorer response to treatment, treatment toxicity, increased risk of recurrence, higher surgical complication rates, and poorer overall survival. As such a significant determinant of patient prognosis, accurate classification of current smoking status is important. Self-reported smoking status may lead to misclassification if patients conceal their true status. The purpose of this study was to assess the validity of self-reported tobacco use during the previous 48 hours in head and neck cancer patients on the day of surgery.

STUDY DESIGN

Cross-sectional.

SETTING

Two academic medical centers in the southeastern United States.

SUBJECTS AND METHODS

On the day of surgery, 108 head and neck cancer patients completed a survey asking about tobacco use during the past 48 hours and had semi-quantitative levels of urinary cotinine measured to biochemically validate self-reported recent smoking.

RESULTS

Self-reported smoking yielded a sensitivity of 60.9% (95% CI, 45.4%-74.9%) and a specificity of 98.4% (95% CI, 91.3%-100.0%). The sensitivity increased to 76.1% (95% CI, 61.2%-87.4%) when allowing for the possibility that exposure to secondhand smoke or use of nicotine-containing products could have caused a positive cotinine test.

CONCLUSION

In this patient population, self-reported recent smoking yielded a high (39%) proportion of false-negatives, and even 24% remained false-negatives after allowing for other sources of nicotine exposure. This magnitude of underreporting combined with the importance of tobacco use to patient prognosis supports the need for routinely biochemically verifying recent tobacco use in self-reported nonsmokers within the clinical setting.

Tobacco use and surgical outcomes in patients with head and neck cancer

BACKGROUND

Tobacco use is a risk factor for head and neck cancer, but effects on postoperative outcomes are unclear.

METHODS

Patients with head and neck cancer (n = 89) were recruited before surgery. We assessed self-reported tobacco use status (never, former, or current) at study entry and recent tobacco exposure via urinary cotinine on surgery day. Outcomes included hospital length of stay (LOS) and complications.

RESULTS

Most participants reported current (32.6%) or former (52.8%) tobacco use; 43.2% were cotinine-positive on surgery day. Complications occurred in 41.6% and mean LOS was 4.0 and 8.8 days in patients who received low and high acuity procedures, respectively. Current and former smokers were over 6 times more likely to have complications than never smokers (p = .03). For high acuity procedures, LOS was increased in current (by 4.4 days) and former smokers (by 2.3 days; p = .02).

CONCLUSION

Tobacco use status is associated with postoperative complications and may distinguish at-risk patients.

Head and Neck Cancer Quality of Life Study

Objectives:

(1) Evaluate quality of life (QOL) outcomes in head and neck cancer survivors at our institution. (2) Recognize areas of improvement in our head and neck cancer survivors in order to decrease morbidity and mortality.

Methods:

A total of 53 patients completed a 24-question QOL survey, previously validated by Terrell et al. The study was conducted between 2013 and the present day.

Results:

Sixty-two percent were male, and the average age was 64. Patients were on average 1.8 years past their definitive surgery. Thirty-eight percent were current tobacco users and 30% were former tobacco users. Most cases were squamous cell carcinoma (92%) of the oral cavity/oropharynx and hypopharynx/larynx (57% and 30%, respectively). All stages were represented (I: 19%, II: 28%, III: 13%, IV: 34%). Fifty-four percent underwent radiation therapy, and 26% underwent chemotherapy. Overall, patients were satisfied with speech, eating, pain, emotional toll, and overall disturbance (71% ± 27 [SD], 76% ± 19, 80% ± 23, 76% ± 22, and 70% ± 23 respectively). Overall, patients were very satisfied with their head and neck care at our institution (93% ± 12%). Most patients quit using tobacco products after their cancer treatments/diagnosis.

Conclusions:

Overall, most patients were satisfied with pain, speech, eating, emotional impact, and overall disturbance. However, the standard deviation was large. This finding could be related to pooling of all the results. Future studies are planned to evaluate quality of life outcomes based on stage, location, and/or time since surgery.

Retrospective analysis of the impact of HPV status and smoking on mucositis in patients with oropharyngeal squamous cell carcinoma treated with concurrent chemotherapy and radiotherapy

OBJECTIVES

The standard concurrent radiotherapy and chemotherapy regimens for patients with oropharyngeal cancer are highly toxic. Human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) has recently emerged as a distinct biological and clinical entity with improved response to treatment and prognosis. A tailored therapeutic approach is needed to optimize patient care. The aim of our study was to investigate the impact of HPV and smoking status on early toxicities (primarily mucositis) associated with concurrent chemotherapy and radiotherapy in patients with OPSCC.

MATERIALS AND METHODS

We retrospectively evaluated 72 consecutive patients with OPSCC and known HPV status treated with concurrent radiotherapy and chemotherapy at our institution. Treatment-related toxicities were stratified by smoking and HPV status and compared using univariate and multivariate logistic regression.

RESULTS

HPV-positive patients had a 6.86-fold increase in the risk of having severe, grade 3-4 mucositis. This effect was preserved after adjusting for patient smoking status, nodal stage, radiotherapy technique and radiotherapy maximum dose. Additionally, HPV status had significant effect on the objective weight loss during treatment and at three months after treatment. Consistently, non-smokers had a significant 2.70-fold increase in the risk of developing severe mucositis.

CONCLUSION

Risk factors for OPSCC modify the incidence of treatment-related early toxicities, with HPV-positive and non-smoking status correlating with increased risk of high grade mucositis and associated outcomes. Retrospective single-institution studies need to be interpreted cautiously. However, this finding is important to consider when designing therapeutic strategies for HPV-positive patients and merits further investigation in prospective clinical trials.

Cotinine Level in Head and Neck Cancer Patients: An Objective Measure of Tobacco Use

Objectives:

1) Compare the prevalence of tobacco use in preoperative head and neck cancer patients as assessed by urinary cotinine and self-report. 2) Consider the importance of accurate measurement of tobacco use in pre-operative head and neck cancer surgical patients and potential implications for clinical interventions.

Methods:

Patients with squamous cell carcinoma of the upper aerodigestive tract undergoing a major head and neck surgical procedure were recruited from two academic medical centers from May 2011 to November 2012. We assessed preoperative tobacco exposure by self-report and urinary cotinine using a semiquantitative test strip.

Results:

We recruited 112 patients (mean age 59); 72.3% male, 82.1% white, 76.5% stages III-IV. The prevalence of tobacco use in the 48 hours prior to surgery was higher when assessed by urinary cotinine (41.1%) when compared to self-report (25.9%) (McNemar’s exact test, P < 0.0001). Sensitivity of self-reported tobacco use was 60.9% and specificity was 98.5%. Of those who denied tobacco use prior to surgery (N = 83), 18 (21.7%) had a positive urinary cotinine and 14 (16.9%) reported second-hand smoke exposure. There were no significant associations between second-hand exposure, gender, cancer stage, or prior treatment and positive cotinine.

Conclusions:

Accurate measurement of tobacco use is critical to care provision and intervention development for head and neck cancer patients. Self-report may fail to identify a significant number of tobacco users. Future analysis in this study will examine relationships among self-reported tobacco use, cotinine level, and postoperative outcomes including length of stay and wound infection.

Polymorphous low-grade adenocarcinoma: a 17 patient case series

Polymorphous low-grade adenocarcinoma (PLGA) is a rare malignancy most commonly seen in the minor salivary glands. First described in 1983, this entity has been recognized to have an indolent course with rare metastases or deaths. We describe our experience with 17 patients treated at our institution for PLGA from 1984 to 2012. All tumors were located in the oral cavity or soft palate. All patients were treated surgically, with the exception of one patient who declined therapy. No deaths or metastases have been identified in subsequent follow-up. Three patients in this series had undergone prior surgery up to 20 years previously and were treated for recurrences at our institution; no other recurrences have been noted. In summary, PLGA is best treated with wide excision to negative margins with excellent prognosis, but long-term follow-up is recommended given the propensity for late recurrences.

Validating Tobacco Use with Cotinine in Cancer Patients

Objective: Tobacco use may be a risk factor for poor outcomes following surgery for head and neck cancer patients. We sought to determine the prevalence of tobacco exposure prior to head and neck surgery using both patient report and urinary cotinine.

Method: Patients with squamous cell carcinoma of the upper aerodigestive tract undergoing a major head and neck procedure were recruited from 2 academic medical centers from 2011 to date. We assessed preoperative tobacco use by self-report and by cotinine level, a nicotine metabolite, in urine using a semiquantitative test strip.

Results: We have recruited 49 patients to date (mean age, 60 years), 71.4% male, 85.7% non-Hispanic white, 60.0% stages III-IV. In the 48 hours before surgery, 11 patients (22.5%) reported tobacco use; 18 (36.7%) were identified by intraoperative urine cotinine. In sum, 57.1% of women and 28.6% of men tested positive for cotinine ( P = .06). Of those who denied tobacco use, 7 out of 38 (18.4%) were positive for cotinine (>2); sensitivity for self-report was 61.1%. Secondhand exposure was reported by 6 of 38 (15.8%) nonusers, 2 being cotinine positive. There was no association between secondhand exposure and positive cotinine (Fisher’s Exact, P = .30).

Conclusion: Tobacco is a major risk factor for head and neck cancer. The use of a urine cotinine screening test demonstrated that self-report may fail to identify a significant number of tobacco users. Implementation of cotinine screening could facilitate precise understanding of tobacco use patterns and opportunities for intervention.

Parathyroid hormone early percent change: an individualized approach to predict postthyroidectomy hypocalcemia

PURPOSE

The purpose of this study is to evaluate a percent change model of postoperative parathyroid hormone level in thyroidectomy patients as a predictor of hypocalcemia.

MATERIALS AND METHODS

Chart review was completed on patients who had undergone total or completion thyroidectomy over a 22-month period in our department. Only those patients with a preoperative ionized calcium and parathyroid hormone (PTH) level and at least 1 postoperative result were included. Ionized calcium levels served as an internal control. The Student t test was used to compare PTH level between the normocalcemic and hypocalcemic groups at each time point. Logistic regression analysis was used to predict hypocalcemia based on the diagnostic criteria. Receiver operator curves were used to maximize sensitivity.

RESULTS

Fifty-two patients met the inclusion criteria during the study period. A total of 22 patients (42%) experienced hypocalcemia. We were unable to maximize both sensitivity and specificity at the same time point. When comparing preoperative to 6-hour postoperative PTH percent change, patients with a greater than 44% decrease are likely to have hypocalcemia, with a sensitivity of 100%. Likewise, in those patients without a greater than 44% decrease at 6 hours, early discharge can be considered safe, given the negative predictive value of 100%.

CONCLUSION

In our series, patients with a greater than 44% PTH decrease from preoperative to 6-hour postoperative are very likely to develop hypocalcemia. We would propose that these patients need further inpatient monitoring to progress to safe discharge. Likewise, patients with a less than 44% decrease at the 6-hour time point are unlikely to develop hypocalcemia and may be considered safe for discharge.

Proceedings from the Ice Hockey Summit on concussion: a call to action

The objective of this proceedings is to integrate the concussion in sport literature and sport science research on safety in ice hockey to develop an action plan to reduce the risk, incidence, severity, and consequences of concussion in ice hockey. A rationale paper outlining a collaborative action plan to address concussions in hockey was posted for review two months prior to the Ice Hockey Summit: Action on Concussion. Focused presentations devoted specifically to concussion in ice hockey were presented during the Summit and breakout sessions were used to develop strategies to reduce concussion in the sport. This proceedings and a detailed scientific review (a matrix of solutions) were written to disseminate the evidence-based information and resulting concussion reduction strategies. The manuscripts were reviewed by the authors, advisors and contributors to ensure that the opinions and recommendations reflect the current level of knowledge on concussion in hockey. Six components of a potential solution were articulated in the Rationale paper and became the topics for breakout groups that followed the professional, scientific lectures. Topics that formed the core of the action plan were: metrics and databases; recognizing, managing and return to play; hockey equipment and ice arenas; prevention and education; rules and regulations; and expedient communication of the outcomes. The attendees in breakout sessions identified action items for each section. The most highly ranked action items were brought to a vote in the open assembly, using an Audience Response System (ARS). The strategic planning process was conducted to assess: Where are we at?; Where must we get to?; and What strategies are necessary to make progress on the prioritized action items? Three prioritized action items for each component of the solution and the percentage of the votes received are listed in the body of this proceedings.

Topical mithramycin-A modulates submucosal collagen deposition after esophageal burn injury in rats

OBJECTIVE

To evaluate efficacy of a drug-eluting, dissolvable esophageal (DEDE) stent for the prevention of submucosal collagen deposition in a rat model of acute esophageal injury.

SETTING

University laboratory.

STUDY DESIGN

Interventional randomized controlled trial.

SUBJECTS AND METHODS

Forty two adult, male, age-matched Sprague Dawley rats were randomized to undergo either sham esophageal surgery, esophageal burn injury, or esophageal burn injury and placement of a DEDE stent. All animals underwent open gastrotomy under anesthesia. In group 1, a cautery device was inserted through the gastrotomy into the distal esophagus and removed without creating an injury. In group 2, the cautery was placed in the distal esophagus and a circumferential thermal burn injury was created. In group 3, an identical burn injury was created and a DEDE stent was placed at the site of injury and secured. On postoperative day 28, animals were sacrificed, and the distal esophagi were harvested and processed for histology. Submucosal collagen area was quantified histologically and compared across the 3 experimental groups.

RESULTS

After the investigators controlled for luminal circumference and multiple measurements, submucosal collagen area was increased in group 2 (burn) compared with group 1 (sham) (P = .012). Submucosal collagen area was decreased in group 3 (DEDE stent) compared with group 2 (P = .042). No statistically significant difference in submucosal collagen area was observed between animals in group 1 and group 3 (P = .800). CONCLUSIONS;Topical application of mithramycin-A via a DEDE stent modulates collagen deposition after acute thermal injury in the rat esophagus.

Combined antegrade and retrograde esophageal dilation for head and neck cancer-related complete esophageal stenosis

OBJECTIVES/HYPOTHESIS

Assess the safety and efficacy of combined antegrade and retrograde esophageal dilation (CARD) for complete esophageal stenosis following head and neck cancer (HNC) treatment. Review HNC dysphagia management.

STUDY DESIGN

Retrospective review of all patients undergoing CARD following HNC treatment between May 2001 and September 2008.

METHODS

Forty-five patients were identified for review. Parameters assessed included: ability to obtain intraoperative esophageal patency, complications, number of dilations required, diet, and gastric tube (GT) status. Factors associated with dilation failure were analyzed.

RESULTS

Intraoperative esophageal patency was obtained in 91% of patients. Median number of all dilations per patient was three. Median number of CARDs per patient was one. Resumption of oral intake occurred in 36/45 (80%). Diet results included: regular or soft diet 32/45 (71%), GT removal 27/45 (60%), and GT dependence with nothing by mouth 9/45 (20%). Laryngeal and pharyngeal stenosis, radionecrosis, tracheotomy dependence, and elongated stenosis were associated with dilation failure. Complications occurred in 18/63 (29%) CARD procedures: eight pneumomediastinum, seven GT site problems, two esophageal perforations, and one pharyngeal infection. All complications resolved spontaneously or with minimal interventions.

CONCLUSIONS

CARD was safe and effective. Intraoperative patency was achieved in 91% of patients. Eighty percent resumed oral intake. The majority of patients had their GTs removed and resumed a soft or regular diet. Dilation failure was associated with laryngeal, pharyngeal, and excessively long esophageal stenosis, often resulting from radionecrosis. Complications were minor. CARD should be considered before relegating patients with complete esophageal stenosis to chronic GT dependence or subjecting them to laryngopharyngo esophagectomy.

In-vitro reconstitution of three-dimensional human salivary gland tissue structures

This study aimed to achieve functional reconstitution of salivary units from human salivary gland cells in an in vitro three-dimensional culture system. Human salivary cells were isolated from human salivary gland tissue, cultured, expanded, and placed into a three-dimensional culture system containing collagen and matrigel. Morphogenesis of reconstituted salivary structures was assessed by histomorphometry and transmission electron microscopy. Phenotypic and functional characteristics were assessed by immunohistochemistry and reverse transcription polymerase chain reaction (occludin, claudin 1, ZO-1, aquaporin 5, amylase) as well as spectrophotometric biochemical assay to measure amylase production. In a novel gel culture system, single human salivary cells divided and assembled into three-dimensional acinar and ductal structures in the presence of collagen and matrigel. All salivary gland units produced amylase and expressed aquaporin-5, a critical water channel protein. Tight junction proteins ZO-1, occludin, and claudin-1 were expressed under all culture conditions. Electron microscopy demonstrated desmosomes, microvilli, and secretory granules. This study showed that functional, differentiated salivary units containing acini and ducts formed from single salivary cells in a three-dimensional culture system. This in vitro culture system could be used to engineer functional salivary tissue in vivo.

Examining the need for neck dissection in the era of chemoradiation therapy for advanced head and neck cancer

OBJECTIVES

To (1) determine clinical factors that predict pathologic complete response (pCR) on neck dissection after sequential chemoradiotherapy (SCRT) for advanced head and neck cancer and (2) compare survival parameters between those who underwent neck dissection and those who did not among those patients with a clinical complete response (cCR) in the neck after SCRT, thus assessing the benefit of neck dissection in patients with a cCR in the neck.

DESIGN

Retrospective review with a mean follow-up of 3.5 years.

SETTING

Regional cancer center.

PATIENTS

The study population comprised 55 patients undergoing SCRT for advanced head and neck cancer with N2 or N3 neck disease. Three patients developed progressive disease and were excluded, and 28 patients underwent neck dissection.

INTERVENTIONS

Patients were assessed by physical examination and radiographically after SCRT.

MAIN OUTCOME MEASURES

Physical examination and radiographic assessments of residual neck disease were compared with pathologic findings in those patients who underwent neck dissection. Survival comparisons were made between patients with a cCR in the neck who underwent neck dissection and those who did not.

RESULTS

Of 28 patients who underwent neck dissection, 8 had persistent pathologically positive nodal disease: 5 (45%) of 11 had N3 and 3 (18%) of 17 had N2 disease. Individual clinical neck assessments after SCRT were fairly predictive of a negative pathologic finding at neck dissection. The negative predictive values were physical examination (75%), computed tomography or magnetic resonance imaging (71%), and positron emission tomography (75%). However, when physical examination, imaging studies, and positron emission tomography all indicated a complete response, this accurately predicted a pCR on neck dissection. There appeared to be no improvement in survival parameters when a neck dissection was performed on patients with a cCR in the neck.

CONCLUSIONS

Patients with N3 disease are at high risk for residual neck metastasis after SCRT. Patients with N2 disease can be assessed with physical examination, imaging studies, and positron emission tomography. If these all indicate a cCR, then neck dissection is likely not needed. Neck dissection did not appear to further improve survival parameters for patients with a cCR in the neck.

Organ Preservation and Treatment Toxicity With Induction Chemotherapy Followed by Radiation Therapy or Chemoradiation for Advanced Laryngeal Cancer

OBJECTIVES

The authors reviewed records of patients with advanced laryngeal cancer treated with induction chemotherapy (IC) and hyperfractionated radiation therapy (RT) or chemoradiation (CRT) to determine the rates of organ preservation and function.

METHODS

A total of 29 patients with stage III (45%) and stage IV (55%) squamous cell carcinoma of the larynx (SCCL), were treated with IC and RT or CRT in 1 of 7 consecutive trials. Fifty-five percent had clinically node-positive disease. Fifty-five percent and 45% had T3 or T4 tumors, respectively. All received 3 cycles of platinum-based IC. Daily RT was given to 48%, twice-daily RT to 45%, and concomitant boost RT to 7%. CRT was carboplatin (28%) or docetaxel (28%). Those treated with twice-daily RT did not receive CRT.

RESULTS

The median follow-up is 52 months. Overall survival is 66%. Relapse occurred in 12 patients (41%), and 6 underwent salvage laryngectomy (5 stage III, 1 stage IV). Fifty-nine percent of patients (17 of 29) are alive at last follow-up with an anatomically intact larynx, and 48% (14 of 29) are alive with a functional larynx. Of the 23 patients for whom detailed information on gastrostomy tube (g-tube) placement/removal was available, median time with g-tube was 12 months, and 15 of 23 patients (65%) had a g-tube for 6 months or more. Twenty-three of all 29 patients (79%) retained an anatomically intact larynx, but 7 of 23 (30%) never resumed their pretreatment organ function. The overall rate of functional organ preservation, regardless of survival, was 55% (16/29). The 7 of 29 patients (26%) who retained a nonfunctional larynx required permanent g-tube or were unable to return to pretreatment oral intake capability. Nine of 13 with T4 SCCL (69%) compared with 7 of 16 (44%) T3 SCCL retained a functional larynx.

CONCLUSION

The rate of larynx preservation is high, but toxicity remains significant with IC followed by hyperfractionated RT or CRT in advanced laryngeal cancer. Half of all patients were alive, able to retain their larynx, and return to pretreatment function. Advanced stage was not an indicator of poor outcome.

Chemoradiation-induced cell loss in human submandibular glands

OBJECTIVES

Chemoradiation-induced xerostomia affects approximately 40,000 head and neck cancer patients annually in the United States. No human histopathologic or immunohistochemical data exist that characterize chemoradiation-related salivary gland damage. The objective of this study was to describe the histopathologic and immunohistochemical features of the non-acute phase of human submandibular gland damage after chemoradiation therapy.

METHODS

Pathologic materials were retrieved from patients who had undergone neck dissection after protocol-driven chemoradiotherapy for stage IV head and neck cancer at a tertiary head and neck cancer institute. Histologic and immunohistochemical analyses were performed on representative sections of chemoradiated submandibular glands, and findings were compared to age- and sex-matched, untreated control glands.

RESULTS

Forty patients were identified who had undergone neck dissection an average of 11 weeks after treatment with induction chemotherapy and chemoradiation therapy for non-oral head and neck cancer. In the chemoradiated glands, light microscopic findings included pronounced acinar cell loss with accompanying ductal metaplasia and ductal proliferation and increased fibrosis, chronic inflammation, nuclear atypia, and cytoplasmic vacuolization when compared with controls. Microvascular density was marginally affected by chemoradiation; cytokeratin staining showed preservation of ductal epithelium when compared to controls.

CONCLUSIONS

Nonacute changes seen in human submandibular glands after chemoradiation therapy are compared to those seen in previously described irradiated animal and human models. Primary dysfunction in humans appears to be related to a reduction in function and number of submandibular gland acinar cells. The ductal system appears to be preserved after chemoradiation therapy. Implications for management of xerostomia are discussed.

Tissue engineering of functional salivary gland tissue

OBJECTIVES

Treatment of conditions that lead to salivary hypofunction, such as radiation induced xerostomia, is currently limited to the administration of saliva substitutes and sialogogues. The transient effect of these medications necessitates frequent administration, and systemic side effects may be intolerable. The creation of implantable, functional salivary gland tissue from autologous glandular cells would provide a physiologic solution to this problem. We investigated the feasibility of engineering such tissue in vivo.

METHODS

Primary human salivary gland cells were grown, expanded, and seeded on biodegradable polymer scaffolds. A total of 48 scaffolds with cells and 16 control polymers without cells were implanted subcutaneously in athymic mice. The implants were retrieved 2, 4, and 8 weeks after the implantation for phenotypic and functional analyses.

RESULTS

Human salivary gland epithelial cells retained their phenotypic and functional characteristics at all culture stages. Histologically, formation of acinar gland-like structures was observed within the engineered tissue by 4 weeks after implantation. Immunocytochemical and Western blot analyses of the implanted tissues demonstrated the expression of human a-amylase, cytokeratins AE1/AE3, and aquaporin-5 using cell-specific antibodies. Reverse-transcription polymerase chain reaction analyses confirmed the expression of human salivary type of alpha-amylase (sigma-amylase) mRNA. The retrieved tissues demonstrated the production of human alpha-amylase over time using a biochemical amylase detection system.

Endoscopic management of hypopharyngeal stenosis after organ sparing therapy for head and neck cancer

OBJECTIVES

The objective of this study was to describe and evaluate the efficacy of an endoscopic technique for the management of postchemoradiation hypopharyngeal stenosis in head and neck cancer patients.

STUDY DESIGN

Retrospective review.

METHODS

Patients with postchemoradiation hypopharyngeal stenoses were identified from the Dana Farber Cancer Institute head and neck database. Patients who had undergone extirpative surgery and reconstruction were excluded. All patients underwent either anterograde dilatation (AD) by the lead author (C.A.S.) or transgastric retrograde esophagoscopy with anterograde dilatation (TREAD) (C.A.S., M.T.J.). Chemoradiation records, clinic notes, operative reports, and swallowing test data were reviewed. Removal of the gastric feeding tube was considered the endpoint of rehabilitation.

RESULTS

Seventeen patients had postcricoid stenoses identified by modified barium swallow. Endoscopy confirmed 15 postcricoid stenoses and 2 proximal esophageal stenoses. Nine (53%) patients had partial stenoses, and eight (47%) had complete stenoses. Eight partial stenosis patients underwent 10 AD procedures and 3 TREAD procedures. Eight complete stenosis patients underwent 9 TREAD procedures and 26 subsequent AD procedures. Fifteen of 16 (93%) patients resumed swallowing after dilatation. Thirteen (81%) patients maintained their weight on an oral diet and had their gastric feeding tubes removed. Complications included hypopharyngeal perforation (13%), abdominal wall infection (6%), stomach wall dehiscence (6%), and chondroradionecrosis of the cricoid cartilage (6%).

CONCLUSIONS

Postcricoid hypopharyngeal stenosis may be partial or complete after organ sparing chemoradiation for head and neck cancer. Using the TREAD technique, successful rehabilitation of swallowing can be achieved with a low incidence of complications.

Fetal nasal bone length in euploid and aneuploid fetuses between 11 and 20 weeks' gestation: a prospective study

OBJECTIVE

To develop normative data for nasal bone length between 11 and 20 weeks' gestation and to assess the utility of nasal bone hypoplasia in the detection of fetal aneuploidy in the second trimester.

METHODS

Well-dated, nonanomalous fetuses were examined between 11 and 20.9 weeks' gestation. The nasal bone was assessed and measured, and normative data from 11 to 20 weeks' gestation were determined. The nasal bone lengths in fetuses with confirmed aneuploidy were compared with the normative data.

RESULTS

The fetal nasal bone length increased linearly with advancing gestational age. Nomograms including the 10th, 50th, and 90th percentiles were created. Nasal bone hypoplasia was seen in 6 of 6 cases of fetal trisomy in the second trimester.

CONCLUSIONS

Nasal bone hypoplasia in the early second trimester identifies a cohort of fetuses at high risk for aneuploidy.

Effects of the herbicide hexazinone on nutrient cycling in a low-pH blueberry soil

The herbicide hexazinone was applied as the commercial formulation Velpar L at field-rate (FR) concentrations of FR (14.77 microg ai g(-1)), FRx5 (73.85 microg ai g(-1)), FRx10 (147.70 microg ai g(-1)), FRx50 (738.50 microg ai g(-1)), and FRx100 (1477.00 microg ai g(-1)) to acidic soil, pH 4.12, taken from a lowbush blueberry field. Hexazinone was tested for inhibitory effects on various transformations of the nitrogen cycle and soil respiration. Nitrogen fixation was unaffected by hexazinone levels up to FRx100 following a 4-week incubation period. Ammonification was initially inhibited by all levels of hexazinone, but after 4 weeks, ammonification in all treatment systems was equal to or greater than the control. Nitrification was more sensitive to hexazinone; however, application at a field-rate level caused no inhibition. Inhibitory effects were noted above FR after a 2-month endpoint analysis and above FRx5 after a 6-month endpoint analysis. Hexazinone concentrations up to and including FRx100 stimulated denitrification. Soil respiration was also stimulated over a 3-week period when applied at a level up to 100 times the recommended field rate. In general, it was found that when applied at the recommended field application rate, hexazinone does not adversely affect the nitrogen cycle or soil respiration in acidic lowbush blueberry soils.

The sharing of water between society and ecosystems: from conflict to catchment-based co-management

Human uses of freshwater resources are increasing rapidly as the world population rises. As this happens, less water is left to support aquatic and associated ecosystems. To minimize future human water shortages and undesirable environmental impacts, more equitable sharing of water resources between society and nature is required. This will require physical quantities and social values to be placed on both human and aquatic ecosystem requirements. Current water valuation systems are dominated by economic values and this paper illustrates new quantification and valuation methods that take more account of human well-being and environmental impacts. The key to the effective implementation of these more equitable water allocation methods is the use of catchment-based integrated water resources management. This holistic framework makes it possible for human and ecosystem water requirements and the interactions between them to be better understood. This knowledge provides the foundation for incorporating relevant social factors so that water policies and laws can be developed to make best use of limited water resources. Catchment-based co-management can therefore help to ensure more effective sharing of water between people and nature.

Docetaxel, cisplatin, 5-fluorouracil (TPF)-based induction chemotherapy for head and neck cancer and the case for sequential, combined-modality treatment

Since the publication of the Veterans Affairs study in the early 1990s, much has been learned regarding the role of chemotherapy, radiation therapy, and more importantly, the role of combined-modality treatment with chemoradiation in the therapy of locally advanced head and neck cancer. There continues to be widespread variation and controversy in the timing, schedule, and intensity of chemotherapy and chemoradiation. Herein, we present the various approaches currently used in the year 2003 with a specific emphasis on the role of sequential combined-modality therapy combining chemotherapy, chemoradiotherapy, and surgery in the treatment of these malignancies.

Etiology and treatment of achalasia in the pediatric age group

Achalasia in children bears many similarities to the disorder in adults, both in terms of clinical features and in terms of the approach to therapy. Pharmacologic management is of limited temporary benefit until more definitive therapy is undertaken. Intrasphincteric injections of botulinum toxin provides safe but short-term relief from symptoms. Based on our review of the safety and effectiveness of pneumatic dilation, we advocate this procedure as the primary form of definitive therapy for achalasia in children. In patients who do not achieve satisfactory results from a series of graduated pneumatic dilations, Heller myotomy provides safe and effective surgical treatment.

Cytokine regulation of host defense against parasitic gastrointestinal nematodes: lessons from studies with rodent models

Studies with rodents infected with Trichinella spiralis, Heligmosomoides polygyrus, Nippostronglyus brasiliensis, and Trichuris muris have provided considerable information about immune mechanisms that protect against parasitic gastrointestinal nematodes. Four generalizations can be made: 1. CD4+ T cells are critical for host protection; 2. IL-12 and IFN-gamma inhibit protective immunity; 3. IL-4 can: (a) be required for host protection, (b) limit severity of infection, or (c) induce redundant protective mechanisms; and 4. Some cytokines that are stereotypically produced in response to gastrointestinal nematode infections fail to enhance host protection against some of the parasites that elicit their production. Host protection is redundant at two levels: 1. IL-4 has multiple effects on the immune system and on gut physiology (discussed in this review), more than one of which may protect against a particular parasite; and 2. IL-4 is often only one of multiple stimuli that can induce protection. Hosts may have evolved the ability to recognize features that characterize parasitic gastrointestinal nematodes as a class as triggers for a stereotypic cytokine response, but not the ability to distinguish features of individual parasites as stimuli for more specific protective cytokine responses. As a result, hosts deploy a set of defense mechanisms against these parasites that together control infection by most members of that class, even though a specific defense mechanism may not be required to defend against a particular parasite and may even damage a host infected with that parasite.

Tongue replantation in an animal model

Although the tongue is not a vital organ in sustaining life, it may be a vital organ in sustaining the will to live in many people. As carcinoma of the tongue represents the majority of the 30,000 oral cavity cancers diagnosed per year in the United States, many patients face the potential consequences of resection of part or all of the tongue for cure. To date, reconstructive options do not restore optimal tongue function including articulation, swallowing, taste, or sensation. With the ultimate goal of improving tongue reconstruction, we report on a successfully performed autograft transplantation of the tongue in an animal model. Before undertaking allograft transplantation of the tongue, an autograft tongue transplant would be attempted to identify the feasibility of such a procedure and to determine the similarity of an animal model with human techniques. The dog's neck, tongue, and oral anatomy represent an excellent animal model for tongue reconstruction. This procedure can be performed successfully in an animal model. The only previously published replantation of the tongue involved the reattachment of the anterior portion of a human tongue after physical trauma. To our knowledge, the enclosed report represents the first successful total excision and replantation of the tongue in either a human or animal model.

Prenatal diagnosis of total arhinia

Complete or total arhinia, in which there is absence of the soft tissue of the nose, is extremely rare. The embryological origin of the defect is thought to be maldevelopment of the paired nasal placodes. Available neonatal case descriptions have reported the frequent coexistence of other facial anomalies. This report is the first to describe the antenatal diagnosis of total arhinia confirmed after delivery. Sonographic views of the fetal profile, showing an absence of the nose led to consideration of the diagnosis.

Asthma patients' satisfaction with the frequency and content of pharmacist counseling

OBJECTIVE

To assess the level of expectation and satisfaction of patients with asthma regarding the counseling provided by community pharmacists, and to identify the counseling information patients consider important in helping them manage their asthma.

DESIGN

Mailed survey.

PARTICIPANTS

208 patients seen in the University of Utah Asthma Clinic for at least 3 months, age 18 years or older, and on at least 1 asthma medication.

MAIN OUTCOME MEASURES

Frequency of pharmacist-provided asthma medication counseling, patients' perception of the importance of counseling, and their satisfaction with counseling.

RESULTS

Response rate was 55% (106 of 194 surveys returned). The majority of patients (> 90%) indicated that their community pharmacist "never" or "sometimes" discussed the management of their asthma with them. Frequency of counseling in three predefined areas of asthma education (role of medications, inhaler technique, and prevention of asthma attacks) was 1.91, 1.72, and 1.31, respectively (1 = never, 4 = always). Most patients (76%) considered these areas of counseling to be important for the management of their asthma. Most patients (62%) were "somewhat" to "pretty" satisfied with the type and amount of asthma counseling provided by their pharmacist. Counseling sessions averaged less than 3 minutes. Only 25% of patients would be willing to pay an additional amount for pharmaceutical care.

CONCLUSION

Self-reported rates of patient counseling concerning asthma medications in the community pharmacy setting are low and adequately address neither the educational needs of patients nor the recommendations of the National Asthma Education and Prevention Program.

Complications of rhytidectomy in an otolaryngology training program

OBJECTIVES/HYPOTHESIS

Complications of rhytidectomy have been widely reported in the literature. This study examines the incidence of complications after rhytidectomy in the hands of chief residents under appropriate attending supervision in an otolaryngology-head and neck surgery training program.

MATERIALS AND METHODS

The charts of 96 consecutive SMAS rhytidectomy patients were retrospectively reviewed. Patients were selected for surgery from a clinic designed exclusively for cosmetic facial surgery patients. This clinic was run by the otolaryngology chief resident and was supervised by an attending staff surgeon. Most patients elected local anesthesia and sedation administered by the surgical team. Submental liposuction was performed followed by SMAS plication rhytidectomy.

RESULTS

Follow-up ranged from 1 to 60 months. Complications included expanding hematoma (1%), temporary facial nerve weakness (3%), pretragal/mastoid skin slough (4.2%), permanent ear numbness (1%), hypertrophic scar (3.1%), wound infection (1%), and dissatisfaction with result (4%). There were no cases of permanent facial nerve injury.

CONCLUSION

These complication rates compare favorably with reported rates of larger studies over the past 30 years. These data support the conclusion that rhytidectomy can be performed safely by otolaryngology residents with little morbidity and good patient satisfaction.

Sleep patterns in pregnancy: a longitudinal study of polysomnography recordings during pregnancy

OBJECTIVE

To evaluate the differences in sleep of women throughout pregnancy compared with those of nonpregnant control subjects.

STUDY DESIGN

Four pregnant women were studied longitudinally during their pregnancy using inpatient polysomnography. Measurements included electroencephalography, electrocardiography, and continuous-pulse oximetry. Four healthy nonpregnant women matched for age and weight were used as control subjects. The total sleep time was recorded, and percentages of each sleep stage were generated.

RESULTS

Qualitative differences in sleep between pregnancy patients and control subjects were evident. Control subjects displayed a normal appearance of slow-wave sleep in stages 3 and 4 (delta sleep). When pregnant patients did display delta sleep, it appeared abnormal secondary to extensive alpha-wave intrusion. Even when including this abnormal delta sleep in a quantitative comparison, the pregnant patients had a significantly shorter percentage of total sleep time in delta sleep (4.9+/-1.9% vs 21.9+/-6.0%, p=0.03).

CONCLUSION

Sleep in pregnancy is characterized by loss of normal slow-wave sleep. Thus, sleep stages 3 and 4 are shortened during pregnancy. This sleep alteration is persistent when followed longitudinally during pregnancy.

Sonographic evaluation of the uterine cervix

Ultrasonographic evaluation of the uterine cervix has been shown to help predict patients who may be at an increased risk for preterm delivery. The use of ultrasound in at-risk patients may improve the selection of those needing obstetric intervention, which therefore, may improve outcome and lower overall health care costs. Cervical competence, once thought to be a categorical variable, should now be thought of as a continuous variable, as the shortest cervical lengths are found in those women with a history of very early preterm delivery (> 24 weeks). Adjunctive tests, such as fetal fibronectin Bishop scoring and bacterial vaginosis may help to improve the accuracy of prediction of preterm birth; therefore a multifaceted risk approach to preterm birth is suggested in this article.

Dose-related tissue effects of the CO2 and noncontact Nd:YAG lasers in the canine glottis

OBJECTIVES

The CO2 laser is the standard for control of recurrent respiratory papillomatosis because of its predictable action on laryngeal tissue. The noncontact neodymium:yttrium aluminum garnet (Nd:YAG) 1064-nm laser is generally not used in the larynx owing to the lack of data on its tissue effects, and its potential lack of safety in the larynx. Combined Nd:YAG and CO2 laser treatments have been used safely in the tracheobronchial tree to eradicate recurrent respiratory papillomas. The objectives of this study were to describe and evaluate a method for applying the noncontact Nd:YAG laser to the larynx, to compare the tissue effects of the Nd:YAG, CO2, and combined Nd:YAG and CO2 lasers in the canine larynx, and to extrapolate canine tissue data to the human.

METHODS

The CO2, Nd:YAG, and combined Nd:YAG/CO2 lasers were applied to the glottis in four mongrel dogs. Laryngectomy was performed and the tissue was examined histologically. The nature and degree of tissue injury were analyzed relative to laser type and energy data.

RESULTS

In the canine larynx, the CO2 laser vaporized the surface epithelium and caused varying degrees of edema and necrosis of the lamina propria. The Nd:YAG laser did not cause ulceration but did show a greater degree of thermal damage to the lamina propria. Combined Nd:YAG/CO2 applications resulted in separation of the perimysial fibers from the muscle fibers of the vocalis muscle.

CONCLUSION

These findings suggest that the noncontact Nd:YAG laser can be applied in a controlled fashion to the canine larynx at appropriate power densities. Anatomical differences between human and canine larynges are considered. Extrapolation to humans is proposed.

Cesarean delivery for the second twin in the vertex-vertex presentation: operative indications and predictability

BACKGROUND

The incidence of second twin delivery by cesarean section and whether obstetric parameters are predictive should be studied.

METHODS

In this retrospective study, all vertex-vertex twin deliveries during a 48-month period were reviewed.

RESULTS

During the study period, 106 sets of vertex-vertex twins were identified. In 68 pairs, both were delivered vaginally (group 1), and 21 pairs were born via cesarean section. In the 17 pairs in group 2, the first infant was delivered vaginally and the second by cesarean section because of fetal distress in 6 cases (35%), cord prolapse in 6 (35%), abnormal/unstable lie in 4 (23%), and abruptio placenta in 1 case (6%). The only maternal factor associated with abdominal delivery for twin B was greater maternal age. When cesarean delivery was required for twin B, a longer interval between deliveries and a lower Apgar score were noted.

CONCLUSION

Cesarean birth of twin B is a more common clinical event than previously reported but is not easily predicted by obstetric parameters.

Combining medical and mechanical methods of cervical ripening. Does it increase the likelihood of successful induction of labor?

OBJECTIVE

To determine if combining two commonly used methods or cervical ripening (intracervical prostaglandin E2 [Pge2] gel and Foley balloon catheter) would result in a higher number of successful inductions and fewer cesarean sections when compared to PGE2 gel alone.

STUDY DESIGN

Seventy-eight patients with unfavorable cervixes eligible for induction of labor were prospectively randomized to receive either one dose (0.5 mg) of PGE2 gel followed by insertion of a 24-French Foley catheter (group 1, 41 patients) or two doses of 0.5 mg of intracervical gel (group 2, 37 patients). Outcome parameters included change in Bishop score, number of failed inductions, rate of cesarean section, rate of uterine hyperstimulation and postpartum infection.

RESULTS

Patients in group 1 had a significant increase in posttreatment Bishop scores (7.26 +/- 2.0 SD vs. 4.82 +/- 1.8 P = .0001) and fewer failed inductions (0 vs. 6, P = .009) when compared to patients in group 2. Abdominal delivery rates, uterine hyperstimulation and infections complications were not different between the two groups.

CONCLUSION

The combination of the Foley balloon and prostaglandin gel significantly improved the Bishop score and led to fewer failed inductions, although it did not increase the vaginal delivery rate.