Emergency Department Visits among Cancer Patients during SARS-CoV-2 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic has had a global impact. Patients with cancer, their caregivers, and physicians need to balance the challenges associated with COVID-19 while ensuring cancer care. Nevertheless, emotional distress and hospital departmental reorganization could have led to a decrease in ED admissions even among oncological patients. Methods: We compared the 72 days of the pandemic in 2020 with the same calendar days in 2019 and 2021, defining a 20% decrease in ED visits as clinically significant. We studied the cause for visit, its severity, outcome (admission vs. discharge vs. death vs. hospice/palliative care), the tumor site, and method of arrival to the ED for the 3 time periods. Results: A significant decrease in ED oncological visits was found in 2020 compared to 2019, before returning to similar numbers in 2021. Fear, anxiety, and worry, in addition to hospital departmental reorganization, surely had an important role in the delay of ED visits, which resulted in irreparable consequences.

The impact of near-infrared autofluorescence on postoperative hypoparathyroidism during total thyroidectomy: a case-control study

PURPOSE

Near-infrared autofluorescence is a new technology in thyroid surgery to better localize and preserve parathyroid glands. The purpose of this study is to assess if the adoption of NIR-AF can improve in short-, medium-, and long-term post-operative calcium and PTH levels compared to conventional "naked eye" surgery in patients undergoing TT for benign or malignant conditions.

METHODS

134 patients undergone total thyroidectomy between January 2020 and June 2022; 67 were treated with conventional thyroidectomy, the other 67 underwent surgery adopting an autofluorescence detecting device.

RESULTS

Significant differences were found between the two groups in percentage of patients with short-term hypocalcemia (p = 0.04) and short-term hypoparathyroidism (p = 0.011). Median short-term (p = 0.01) and medium-term (p = 0.03) PTH levels were significantly higher in autofluorescence group, while, short- (p = 0.001), medium- (p < 0.001) and long-term (p = 0.019) percentage variation of PTH levels from baseline were significantly higher in the standard-care group. Finally, the prescription of oral calcium (p < 0.01) after surgery were significantly lower in the autofluorescence group.

CONCLUSION

The adoption of near-infrared autofluorescence during total thyroidectomy is related to lower short-term hypocalcemia and hypoparathyroidism rates, decreased variation of post-operative PTH levels in short- and medium- and long-term, reducing the necessity of supplementation therapy with oral calcium compared to conventional surgery.

Head and neck pedicled flap autonomization using a new high-resolution indocyanine green fluorescence video-angiography device

In head and neck oncologic surgery a reconstructive phase is often required and pedicled flaps are still a viable option, though they may need a pedicle division performed at a later stage. Several techniques are commonly used for perfusion assessment of the flaps, with indocyanine green (ICG) fluorescence video-angiography representing a promising tool. We used ICG video-angiography to evaluate the perfusion of two of the most commonly adopted pedicled flaps in the head and neck field (the supraclavicular and the paramedian forehead flap) before and after second-stage pedicle division, allowing a safer in-setting. Moreover, the new high-resolution device that we have employed added further accuracy to the traditional video-angiography, providing a real-time flap-to-normal skin ICG ratio. Indeed, ICG video-angiography proved to be a useful tool in head and neck reconstructive surgery and it may allow an earlier second-stage pedicle division.

Pre-admission acetylsalicylic acid therapy and impact on in-hospital outcome in COVID-19 patients: The ASA-CARE study

Background

Patients with coronavirus disease 2019 (COVID-19) exhibit high thrombotic risk. The evidence on a potential independent prognostic role of antiplatelet treatment in those patients is limited. The aim of the study was to evaluate the prognostic impact of pre-admission low-dose acetylsalicylic acid (ASA) in a wide series of hospitalized patients with COVID-19.

Methods

This cohort study included 984 COVID-19 patients stratified according to ASA intake before hospitalization: ASA⁺ (n = 253) and ASA⁻ (n = 731). Patients were included in ASA⁺ group if they received it daily in the 7 days before admission. 213 (83%) were on ASA 100 mg daily. Primary endpoint was a composite of in-hospital death and/or need for respiratory support upgrade, secondary endpoints were in-hospital death and need for respiratory support upgrade.

Results

Mean age was 72 [62; 81] with 69% of male patients. ASA⁺ patients were significantly older, with higher prevalence of comorbidities. No significant differences regarding the degree of respiratory dysfunction were observed. At 30-day Kaplan-Meier analysis, ASA⁺ patients had higher survival free from the primary endpoint and need for respiratory support upgrade, conversely in-hospital death did not significantly differ between groups. At multivariate analysis ASA intake was independently associated with a lower probability of reaching primary endpoint (HR 0.697, 95% C.I. 0.525–0.924; p = 0.012).

Conclusions

In COVID-19 patients undergoing hospitalization, pre-admission treatment with ASA is associated with better in-hospital outcome, mainly driven by less respiratory support upgrade.

Translation, Cultural Adaptation and Validation of the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) in Italian

BACKGROUNDS

Rhinoplasty necessarily concerns functional and cosmetic aspects, and outcomes of both should be assessed in each patient. There has been a lack in the literature in Italian for a comprehensive tool for assessing both aspects of rhinoplasty. The objective is to translate and validate the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) into Italian.

METHODS

Forward and back-translation was used. Content validity was evaluated by experts and by patient interviews. Internal consistency was assessed by a Cronbach's alpha. The structure validity was assessed by an exploratory factor analysis.

RESULTS

Cognitive interviews of 10 rhinoplasty patients resulted in a good overall comprehension of the SCHNOS. Of the 411 respondents, 281 (32%) were women, and the average age was 33.6 (11.3) years. The alpha was excellent for both the obstruction domain (SCHNOS-O) (0.90) and the cosmetic domain (SCHNOS-C) (0.94). All the correlations between repeated measures were moderate to very strong. The exploratory factor analysis demonstrated unidimensionality of both the SCHNOS-O and the SCHNOS-C scores.

CONCLUSIONS

The SCHNOS was successfully translated and validated in Italian and can be recommended for a clinical use among rhinoplasty patients.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

BH-index: A predictive system based on serum biomarkers and ensemble learning for early colorectal cancer diagnosis in mass screening

BACKGROUND AND OBJECTIVE

Colorectal cancer is one of the most common malignancies among the general population. Artificial Intelligence methodologies based on serum parameters are in continuous development to obtain less expensive tools for highly sensitive diagnoses. This study proposes a predictive system based on serum biomarkers and ensemble learning to predict colorectal cancer presence and the related TNM stage in patients.

METHODS

We have selected 17 significant plasmatic proteins, i.e., Carcinoembryonic Antigen, CA 19-9, CA 125, CA 50, CA 72-4, Tissue Polypeptide Antigen, C-Reactive Protein, Ceruloplasmin, Haptoglobin, Transferrin, Ferritin, α-1-Antitrypsin, α-2-Macroglobulin, α-1 Acid Glycoprotein, Complement C4, Complement C3, and Retinol Binding Protein, regarding 345 patients (248 affected by the neoplastic disease). The proposed system consists of two predictors, i.e., binary and staging; the former predicts the presence/absence of cancer, while the latter identifies the related TNM stage (I, II, III, or IV). The experiments were conducted by deploying and comparing Random Forest, XGBoost, Support Vector Machine, and Multilayer Perceptron with feature selection based on Gini Importance and with dimensionality reduction via PCA.

RESULTS

The results show that the system composed of XGBoost as binary and staging predictor reaches 91.30% accuracy, 90% sensitivity, and 93.33% specificity for the absence/presence outcome, while 66.66% accuracy for the staging response. With the expansion of the training set in favor of positive patients and majority voting, the system composed of the combination of Support Vector Machine, XGBoost, and Multilayer Perceptron as the binary predictor reaches 98.03% accuracy, 100% sensitivity, and 92.30% specificity, while the combination of Random Forest, XGBoost, and Multilayer Perceptron as staging predictor achieves 60% accuracy. The final system reaches, in terms of accuracy, 98.03%, and 66.66% for the binary and staging predictors, respectively. It was also found that the biomarkers which contribute most to the binary decision are Ceruloplasmin and α-2-Macroglobulin, while the least significant dimensions are CA 50 and α-1-Antitrypsin; instead, Carcinoembryonic Antigen and α-1 Acid Glycoprotein are the most significant to the staging decision.

CONCLUSIONS

The present study proves the effectiveness of deploying serum biomarkers as feature dimensions for early colorectal cancer diagnosis and of using majority voting for noise reduction in the prediction.

Evaluation of a large cohort of adult patients with Ménière's disease: bedside and clinical history

Objective

The purpose of this study was to assess vestibular findings and clinical history in a large cohort of patients affected by Ménière’s disease.

Methods

We retrospectively analysed 511 adult patients fulfilling criteria for definite unilateral Ménière’s disease according to Barany Society. Thorough clinical history, audiometric exam, central nervous system MRI, quantification of serum autoantibodies and complete vestibular function test were performed.

Results

Mean age at clinical record was 55.4 years, while age at onset of the first vertigo attack was 47.4 ± 14.3 years. Ménière’s disease overlapped with migraine in 43.4% of patients. In 31.7% of cases, positivity was found for at least one autoantibody. Forty-nine patients (9.6%) had family history for Ménière’s disease. Bedside examination resulted in 14.7% positivity for video head impulse test, 58.9% for skull vibration-induced nystagmus, 38.7% for the positional test and 23.1% for the post head shaking test. Complete negative examination was reported in 115 cases.

Conclusions

Ménière’s disease was seen to present a characteristic phenotypic pattern in our cohort, confirming the crucial role of thorough anamnesis and bedside examination in diagnosis.

Personal Protective Equipment (PPE) in COVID 19 Pandemic: Related Symptoms and Adverse Reactions in Healthcare Workers and General Population

OBJECTIVES

To assess prevalence of Personal Protective Equipment (PPE)-related symptoms and adverse reactions during Coronavirus Disease 2019 pandemics.

METHODS

We conducted an observational study among people exposed to various degree of infectious risk. Data were collected with a self-administered online questionnaire.

RESULTS

The entire cohort complained about a wide range of adverse reactions: respiratory symptoms affected 80.3% of respondents, 68.5% referred pressure-related skin lesions, fewer manifested a dermatosis of different grade or ocular symptoms. Most of the affected individuals belonged to healthcare staff and manifestations were predicted by wearing time (more than 6 h/d). Moreover, symptoms were higher in the healthcare staff wearing N95/FFP2 respirator mask.

CONCLUSIONS

Given the crucial role of PPE to contain the pandemic infection, more attention has to be paid to exposed categories, establishing preventive measure of side effects to ensure total safety.

Combination of Mustardè cheek advancement flap and paramedian forehead flap as a reconstructive option in orbital exenteration

PURPOSE

To describe a combinatory technique made of Mustardè cheek advancement flap and paramedian forehead flap as a reconstructive option after orbital exenteration.

METHODS

We retrospectively reviewed all patients who underwent orbital exenteration and subsequent reconstruction with this technique at our Head and Neck Department, Divisions of Ophthalmology and Otolaryngology, at San Raffaele Hospital, Milan, Italy.

RESULTS

Three patients were treated with the aforementioned technique, following orbital exenteration due to malignancies. All of them were affected by recurrent diseases arising from the ocular components or periorbital structures: one basal cell carcinoma and two squamous cell carcinomas. Excellent result was achieved considering skin texture and colour match, aesthetic results and intra and post-operative complications (only minor, surgically controlled haemorrhage and minimal dehiscence subsequent to defective healing occurred).

CONCLUSION

The proposed technique can be considered by the head and neck reconstructive surgeon as a good option in extended orbital exenteration.

Stereotactic radiosurgery for acoustic neuromas: a survey of the American Neurotology Society

OBJECTIVE

The purpose of this study was to better understand the complications, outcomes, and surgical difficulties in treating acoustic neuroma patients who have undergone stereotactic radiosurgery (SRS).

STUDY DESIGN

A six-page, 28-item questionnaire was mailed to 395 members of the American Neurotology Society.

SETTING

The study was conducted through an academic neurotologic practice. Questionnaire respondents were neurotologic physicians in private and academic practice.

PATIENTS

A total of 46 patients who had undergone SRS were evaluated.

INTERVENTIONS

Twelve (26%) of the 46 patients required microsurgery after SRS.

MAIN OUTCOME MEASURES

Posttreatment cranial nerve status and the development of complications such as cerebrospinal fluid leak, meningitis, and cerebrovascular accident were evaluated.

RESULTS

In the group of 12 patients who underwent microsurgery after SRS, 11 patients had some form of postoperative facial paralysis. Anacusis was present in all 12 patients. Two of the 12 patients had new-onset trigeminal neuropathy postoperatively.

CONCLUSION

Microsurgical resection of acoustic neuroma after SRS is technically difficult. The difficulty exists regardless of the time of microsurgical resection after SRS. Patients who underwent microsurgery after SRS had uniformly poor cranial nerve results.

Evaluation of three intraoperative auditory monitoring techniques in acoustic neuroma surgery

OBJECTIVE

To assess the efficacy of three intraoperative auditory monitoring techniques: auditory brainstem response (ABR), electrocochleography (ECoG), and direct eight nerve monitoring (DENM).

STUDY DESIGN

A retrospective review of the intraoperative recordings of ABR, ECoG, and DENM was performed.

SETTING

A private, neurotologic practice.

PATIENTS

Sixty-six patients with usable preoperative hearing underwent intraoperative auditory monitoring with ABR, ECoG, or DENM.

INTERVENTIONS

Intraoperative auditory monitoring.

MAIN OUTCOME MEASURES

Postoperative pure-tone hearing threshold and word recognition scores.

RESULTS

Of the 66 patients, 16 (24%) had postoperative serviceable hearing. Five (18%) of the 28 with ABR monitoring, 3 (17%) of the 18 with ECoG monitoring, and 8 (40%) of the 20 with DENM monitoring had serviceable hearing after surgery.

CONCLUSIONS

This study suggests that DENM may be more effective than ABR or ECoG, although the differences in hearing preservation rates are not statistically significant.

Persistent trigeminal artery as a cause of dizziness

Complaints of vertigo and dizziness are common problems referred to otolaryngologists for evaluation. Awareness of uncommon causes of dizziness increases the physician's ability to diagnose and treat these patients. We present the case of a middle-aged woman who presented with episodes of vertigo and symptoms suggestive of vertebrobasilar insufficiency. These symptoms were the result of a persistent trigeminal artery (PTA) and occlusive carotid artery disease. A PTA is a carotid-basilar anastomosis that has been reported to be demonstrated on 0.1% to 0.6% of all cerebral angiograms. Persistence of this vessel usually leads to hypoplasia or agenesis of the ipsilateral posterior communicating artery, and leaves the internal carotid artery as the main source of blood supply to the region of the upper brainstem. The appearance and clinical significance of this unusual condition will be discussed.

Evaluation of residual acoustic schwannoma using gadolinium-DTPA enhanced magnetic resonance imaging with the fat suppression technique

After subtotal resection of acoustic schwannomas, radiographic evaluation is necessary to evaluate tumor growth. With conventional gadolinium-DTPA T1-weighted magnetic resonance imaging, tumor delineation is often obscured by surgically placed fat. This occurs because fat has the same intensity as enhanced acoustic tumor. T1-weighted magnetic resonance fat suppression techniques can be used to eliminate the strong signal of fat tissue. When this technique is used in combination with gadolinium-DTPA, the definition of pathologic structures is improved in those areas containing large amounts of fat. Twelve patients who had subtotal resection of an acoustic schwannoma underwent gadolinium-DTPA enhanced magnetic resonance imaging using the fat suppression technique. Residual tumors were more conspicuous and had improved margin definition using the fat suppression technique compared to conventional gadolinium-DTPA T1-weighted images. These refinements in magnetic resonance imaging represent a significant advance in the assessment of residual acoustic tumors.

Ossiculoplasty with composite prostheses. Overview and analysis

Aeration of a mucosa-lined tympanic cavity is essential for a functioning middle ear. Extrusions of even the best-designed prostheses occur from abnormal middle ear conditions such as atelectasis, middle ear fibrosis, recurrent cholesteatoma, tympanic membrane perforation, and otitis media. Various polymers have been developed in an attempt to maximize prosthetic biocompatibility and ease of use while minimizing the chance of extrusion. One such polymer is a composite of hydroxyapatite and Silastic, known as Flex H/A. This material has been incorporated into two ossicular prostheses, the Universal Plus and the Causse Flex H/A prostheses. Certainly, refinements will continue to be made in the chemical makeup of the bioceramics in order to achieve optimal biocompatibility. In addition to biocompatibility, cost containment issues have influenced the development of ossicular prostheses. A universal prosthesis eliminates the need to stock multiple designs, thereby reducing the cost to institutions. One of the greatest challenges in the future will be to define the appropriate prosthetic design for optimal sound transmission. Consideration of prosthesis weight, head size, and footplate attachment are future research questions that need to be addressed in a scientific biologic model.

Far-advanced otosclerosis

Far-advanced otosclerosis (FAO) is an uncommon diagnosis. Hearing levels in patients with FAO may range from profound loss, by air conduction and fragmentary bone conduction thresholds, to no measurable air or bone conduction thresholds. Thus, FAO may be difficult to distinguish from a sensorineural hearing loss. This report presents the results of surgery in 73 ears with FAO, 77 percent of which had improvement in air conduction thresholds of greater than 20 dB. Discrimination was improved by more than 15 percent in 54 percent of cases, and 75 percent realized improvement in use of a hearing aid. There was no evidence that success was related to preoperative hearing. The surgical results of a subgroup of 14 patients having bilateral FAO were also analyzed. For all 14, similar surgical outcomes were achieved in both the initial and the contralateral ear, with six successes bilaterally and eight failures bilaterally. Although far advanced otosclerosis is uncommon and difficult to diagnose, surgery is worthwhile.

Small fenestra stapedotomy: technique and results

Small fenestra stapedotomy can improve hearing, improve speech discrimination, and reduce the associated risks of conventional stapedectomy. The authors discuss the advantages and disadvantages of small fenestra, as well as the results of their own stapedotomies.