Enhancer of zeste homolog 2 (EZH2)-dependent sirtuin-3 determines sensitivity to glucose starvation in radioresistant head and neck cancer cells

Sirtuin 3 (SIRT3) regulates mitochondrial function as a mitochondrial deacetylase during oxidative stress. However, the specific regulatory mechanism and function of SIRT3 in radioresistant cancer cells are unclear. In this study, we aim to investigate how SIRT3 determines the susceptibility to glucose deprivation and its regulation in p53-based radioresistant head and neck cancer cells. We observed mitochondrial function using two established isogenic radioresistant subclones (HN3R-A [p53 null] and HN3R-B [p53 R282W]) with intratumoral p53 heterogeneity. Cell counting analysis was performed to evaluate cell proliferation and cell death. The correlation between the regulation of SIRT3 and enhancer of zeste homolog 2 (EZH2) was confirmed by immunoblotting and chromatin immunoprecipitation assay. p53-deficient radioresistant cells (HN3R-A) expression reduced SIRT3 levels and increased sensitivity to glucose deprivation due to mitochondrial dysfunction compared to other cells. In these cells, activation of SIRT3 significantly prevented glucose deprivation-induced cell death, whereas the loss of SIRT3 increased the susceptibility to glucose deficiency. We discovered that radiation-induced EZH2 directly binds to the SIRT3 promoter and represses the expression. Conversely, inhibiting EZH2 increased the expression of SIRT3 through epigenetic changes. Our findings indicate that p53-deficient radioresistant cells with enhanced EZH2 exhibit increased sensitivity to glucose deprivation due to SIRT3 suppression. The regulation of SIRT3 by EZH2 plays a critical role in determining the cell response to glucose deficiency in radioresistant cancer cells. Therefore, EZH2-dependent SIRT3 could be used as a predictive biomarker to select treatment options for patients with radiation-resistance.

Sirt6-Mediated Cell Death Associated with Sirt1 Suppression in Gastric Cancer

BACKGROUND

Gastric cancer, one of the leading causes of cancer-related death, is strongly associated with H. pylori infection, although other risk factors have been identified. The sirtuin (Sirt) family is involved in the tumorigenesis of gastric cancer, and sirtuins can have pro- or anti-tumorigenic effects.

METHODS

After determining the overall survival rate of gastric cancer patients with or without Sirt6 expression, the effect of Sirt6 upregulation was also tested using a xenograft mouse model. The regulation of Sirt6 and Sirt1, leading to the induction of mouse double minute 2 homolog (MDM2) and reactive oxygen species (ROS), was mainly analyzed using Western blotting and immunofluorescence staining, and gastric cancer cell (SNU-638) death associated with these proteins was measured using flow cytometric analysis.

RESULTS

Sirt6 overexpression led to Sirt1 suppression in gastric cancer cells, resulting in a higher level of gastric cancer cell death in vitro and a reduced tumor volume. ROS and MDM2 expression levels were upregulated by Sirt6 overexpression and/or Sirt1 suppression according to Western blot analysis. The upregulated ROS ultimately led to gastric cancer cell death as determined via Western blot and flow cytometric analysis.

CONCLUSION

We found that the upregulation of Sirt6 suppressed Sirt1, and Sirt6- and Sirt1-induced gastric cancer cell death was mediated by ROS production. These findings highlight the potential of Sirt6 and Sirt1 as therapeutic targets for treating gastric cancer.

Effect of statin use on head and neck cancer prognosis in a multicenter study using a Common Data Model

Few studies have found an association between statin use and head and neck cancer (HNC) outcomes. We examined the effect of statin use on HNC recurrence using the converted Observational Medical Outcome Partnership (OMOP) Common Data Model (CDM) in seven hospitals between 1986 and 2022. Among the 9,473,551 eligible patients, we identified 4669 patients with HNC, of whom 398 were included in the target cohort, and 4271 were included in the control cohort after propensity score matching. A Cox proportional regression model was used. Of the 4669 patients included, 398 (8.52%) previously received statin prescriptions. Statin use was associated with a reduced rate of 3- and 5-year HNC recurrence compared to propensity score-matched controls (risk ratio [RR], 0.79; 95% confidence interval [CI], 0.61-1.03; and RR 0.89; 95% CI 0.70-1.12, respectively). Nevertheless, the association between statin use and HNC recurrence was not statistically significant. A meta-analysis of recurrence based on subgroups, including age subgroups, showed similar trends. The results of this propensity-matched cohort study may not provide a statistically significant association between statin use and a lower risk of HNC recurrence. Further retrospective studies using nationwide claims data and prospective studies are warranted.

A phase I trial of LXS196, a protein kinase C (PKC) inhibitor, for metastatic uveal melanoma

BACKGROUND

Up to 50% of patients with uveal melanoma develop metastases (MUM) with a poor prognosis and median overall survival of approximately 1 year.

METHODS

This phase I study evaluated the safety, tolerability, pharmacokinetics, pharmacodynamics and efficacy of the oral protein kinase C inhibitor LXS196 in 68 patients with MUM (NCT02601378). Patients received LXS196 doses ranging from 100-1000 mg once daily (QD; n = 38) and 200-400 mg twice daily (BID; n = 30).

RESULTS

First cycle dose-limiting toxicities (DLTs) were observed in 7/38 (18.4%) QD and 2/17 (11.8%) BID patients. Hypotension was the most common DLT, occurring at doses ≥500 mg/day, and manageable with LXS196 interruption and dose reduction. Median duration of exposure to LXS196 was 3.71 months (range: 1.81-15.28) for QD and 4.6 months (range: 0.33-58.32) for BID dosing. Clinical activity was observed in 6/66 (9.1%) evaluable patients achieving response (CR/PR), with a median duration of response of 10.15 months (range: 2.99-41.95); 45/66 had stable disease (SD) per RECIST v1.1. At 300 mg BID, the recommended dose for expansion, 2/18 (11.1%) evaluable patients achieved PR and 12/18 (66.7%) had SD.

CONCLUSION

These results suggest manageable toxicity and encouraging clinical activity of single-agent LXS196 in patients with MUM.

Personality traits and emotional status affecting academic achievements of medical students: testifying mediating effect of learning strategies

PURPOSE

The purpose of this study is to identify possible causal relationships among personality traits, emotional status, learning strategies, and academic achievements of medical students and to testify mediating effect of learning strategies in these relationships.

METHODS

The study subjects are 424 medical students in the academic year of 2020 at the Gyeongsang National University, Jinju, Korea. Using the Multi-dimensional Learning Strategy Test-II, we assessed the students' academic achievements with personality traits, emotional status, and learning strategies. This study employed Structural Equation Modelling to explore the causal relationships among the latent variables.

RESULTS

In the path model, personality traits directly affected academic achievements (β=0.285, p<0.05) and indirectly affected academic achievements via emotional status (β=0.063, p<0.01) and via learning strategies (β=0.244, p<0.05), respectively. Further, personality traits indirectly affected academic achievements via emotional status first and learning strategies next (β=0.019, p<0.05). Personality traits indirectly affected academic achievements through three multiple paths in the model (β=0.326, p<0.05). Learning strategies partially mediated the relationship between personality traits and academic achievements as well as the relationship between emotional status and academic achievements of medical students.

CONCLUSION

Study findings proved constructing the causal relationships among personality traits, emotional status, learning strategies, and academic achievements of medical students, thus supporting our hypotheses. Early habits of self-regulated learning are essential for the successful academic achievements of medical students. Therefore, medical students should know how to regulate personality traits and control emotional status, significantly affecting learning strategies.

Delayed Horner's Syndrome After Multiple Penetrating Stab Injury of the Neck

Horner's syndrome is characterized by a triad of symptoms (ipsilateral miosis, ptosis, and anhidrosis) with damage of the sympathetic nervous system. The condition may be congenital or acquired from traumatic conditions including cardiovascular surgery. Horner's syndrome can be also caused by neck trauma especially when cervical vital structures such as blood vessels, the aerodigestive tract, and nerves are disrupted. This report describes a 16-year-old woman with delayed Horner's syndrome who initially presented with internal jugular vein injury caused by multiple penetrating stab injury to the neck. To the best of our knowledge, this is the first reported case of Horner's syndrome resulting from neck trauma of which symptoms were presented after a couple of weeks after initial trauma. Understanding this rare clinical course may help surgeons pay attention to not only early hospital course but also long-term complications of patients with neck trauma.

Leveraging metabolic modeling to identify functional metabolic alterations associated with COVID-19 disease severity

OBJECTIVE

Since the COVID-19 pandemic began in early 2020, SARS-CoV2 has claimed more than six million lives world-wide, with over 510 million cases to date. To reduce healthcare burden, we must investigate how to prevent non-acute disease from progressing to severe infection requiring hospitalization.

METHODS

To achieve this goal, we investigated metabolic signatures of both non-acute (out-patient) and severe (requiring hospitalization) COVID-19 samples by profiling the associated plasma metabolomes of 84 COVID-19 positive University of Virginia hospital patients. We utilized supervised and unsupervised machine learning and metabolic modeling approaches to identify key metabolic drivers that are predictive of COVID-19 disease severity. Using metabolic pathway enrichment analysis, we explored potential metabolic mechanisms that link these markers to disease progression.

RESULTS

Enriched metabolites associated with tryptophan in non-acute COVID-19 samples suggest mitigated innate immune system inflammatory response and immunopathology related lung damage prevention. Increased prevalence of histidine- and ketone-related metabolism in severe COVID-19 samples offers potential mechanistic insight to musculoskeletal degeneration-induced muscular weakness and host metabolism that has been hijacked by SARS-CoV2 infection to increase viral replication and invasion.

CONCLUSIONS

Our findings highlight the metabolic transition from an innate immune response coupled with inflammatory pathway inhibition in non-acute infection to rampant inflammation and associated metabolic systemic dysfunction in severe COVID-19.

Two cases of extraluminal migration of fishbones into the thyroid gland and submandibular gland

Laryngopharyngeal or cervical pain following ingestion of foreign bodies is one of the most frequently encountered emergencies in otolaryngologic practice. Although most of these foreign bodies can be easily removed under laryngoscopic examination without any complications, surgical removal may be required when foreign bodies migrate extraluminally. This report describes two rare cases of ingested fishbones that had migrated, one each to the thyroid gland and submandibular gland. Extraluminal migration fishbones should always be considered in otolaryngologic clinics.

MDM2-dependent Sirt1 degradation is a prerequisite for Sirt6-mediated cell death in head and neck cancers

Sirt6 is involved in multiple biological processes, including aging, metabolism, and tumor suppression. Sirt1, another member of the sirtuin family, functionally overlaps with Sirt6, but its role in tumorigenesis is controversial. In this study, we focused on cell death in association with Sirt6/Sirt1 and reactive oxygen species (ROS) in head and neck squamous cell carcinomas (HNSCCs). Sirt6 induced cell death, as widely reported, but Sirt1 contributed to cell death only when it was suppressed by Sirt6 via regulation of MDM2. Sirt6 and Sirt6-mediated suppression of Sirt1 upregulated ROS, which further led to HNSCC cell death. These results provide insight into the molecular roles of Sirt6 and Sirt1 in tumorigenesis and could therefore contribute to the development of novel strategies to treat HNSCC.

New understanding of the interactions between three proteins sheds light on their role in either promoting or restricting the development of tumors called squamous cell carcinomas, which account for over 90% of all cancers in the head and neck. Researchers in South Korea led by Sang Yoon Kim and Seong Who Kim at the University of Ulsan, Seoul, investigated the role of the proteins Sirt6, Sirt1 and MDM2 in controlling the death of cancer cells caused by chemicals called reactive oxygen species (ROS). The effects of Sirt6 and Sirt1 combine to regulate ROS-induced cancer cell death. Sirt6 controls the activity of MDM2, stimulating ROS production. Sirt6 also influences MDM2 to suppress Sirt1 activity, thereby also promoting cancer cell death. Drugs affecting these three proteins could offer new approaches to anti-cancer therapy.

p53-dependent glutamine usage determines susceptibility to oxidative stress in radioresistant head and neck cancer cells

The manner in which p53 maintains redox homeostasis and the means by which two key metabolic elements, glucose and glutamine, contribute to p53-dependent redox stability remain unclear. To elucidate the manner in which p53 deals with glucose-deprived, reactive oxygen species (ROS)-prone conditions in this regard, two isogenic cancer subclones (HN3R-A and HN3R-B) bearing distinct p53 mutations as an in vitro model of intratumoral p53 heterogeneity were identified. Following cumulative irradiation, the subclones showed a similar metabolic shift to aerobic glycolysis and increasing NADPH biogenesis for cellular defense against oxidative damage irrespective of p53 status. The radioresistant cancer cells became more sensitive to glycolysis-targeting drugs. However, in glucose-deprived and ROS-prone conditions, HN3R-B, the subclone with the original p53 increased the utilization of glutamine by GLS2, thereby maintaining redox homeostasis and ATP. Conversely, HN3R-A, the p53-deficient radioresistant subclone displayed an impairment in glutamine usage and high susceptibility to metabolic stresses as well as ROS-inducing agents despite the increased ROS scavenging system. Collectively, our findings suggest that p53 governs the alternative utilization of metabolic ingredients, such as glucose and glutamine, in ROS-prone conditions. Thus, p53 status may be an important biomarker for selecting cancer treatment strategies, including metabolic drugs and ROS-inducing agents, for recurrent cancers after radiotherapy.

Therapeutic Effects of Intranasal Tofacitinib on Chronic Rhinosinusitis with Nasal Polyps in Mice

OBJECTIVES

The Janus kinase/signal transducer and activator of transcription (JAK-STAT) pathway play a key role in immune modulation, especially in the polarization of T helper cells. JAK inhibitors reduce inflammation by inhibiting the phosphorylation of STAT. We investigated whether a JAK inhibitor, tofacitinib, can reduce inflammation in a mouse model of chronic rhinosinusitis with nasal polyps (CRSwNP).

METHODS

An eosinophilic CRSwNP model was induced using 4-week-old BALB/c mice. The therapeutic effects of topical tofacitinib were compared with the effects of triamcinolone acetonide (TAC). Polyp formation and eosinophilic infiltration were assessed by histology. Levels of phosphorylated STAT (pSTAT), eosinophil cationic protein, and eotaxin were measured by immunohistochemistry. Gene expression levels of GATA-3 was measured using quantitative PCR. The production of cytokines in sinonasal tissues, including interleukin IL-4, IL-5, IL-12, and interferon-γ, were measured using enzyme-linked immunosorbent assays (ELISA).

RESULTS

Topical tofacitinib administration significantly reduced the number of polyp-like lesions and the degree of eosinophilic infiltration, with an efficacy comparable with that of systemic TAC administration. Similarly, the levels of pSTAT6, eosinophil cationic protein, and eotaxin decreased with tofacitinib treatment. Tofacitinib decreased the gene expression level of GATA-3. Lastly, tofacitinib significantly decreased IL-4 and IL-5 production to a similar extent as that by systemic or topical TAC administration. Tofacitinib, but not TAC, significantly increased the production of interferon-γ.

CONCLUSION

Topical tofacitinib administration may be an effective treatment for eosinophilic CRSwNP by inhibiting phosphorylation of STATs.

LEVEL OF EVIDENCE

N/A. Laryngoscope, 131:E1400-E1407, 2021.

Atypical Lipomatous Tumor/Well-Differentiated Liposarcoma Arising from the Tongue: case report

<p>Liposarcomas are common mesenchymal malignant tumors arising from adipose tissue. Although liposarcomas are the most frequent type of soft tissue sarcomas, accounting for approximately 20% of all soft tissue sarcomas, they are rare in the head and neck, particularly in the oral cavity. Oral liposarcomas have been reported to occur mainly on the buccal mucosa, with other sites including the floor of the mouth, tongue, palate, and mandible. This report describes a 76-year-old male patient with an atypical lipomatous tumor/well-differentiated liposarcoma of the tongue that underwent surgical excision. This report also reviews published data on these rare tumors.

Periostin Plays a Key Role in Radioresistance of Head and Neck Cancer Cells Via Epithelial-to-Mesenchymal Transition

BACKGROUND/AIM

Head and neck squamous cell carcinoma (HNSCC) is an aggressive head and neck malignancy. The aim of this study was to elucidate the role of periostin (POSTN) in the epithelial-to-mesenchymal transition (EMT) process mediating the acquisition of radioresistance in HNSCC.

MATERIALS AND METHODS

The expression levels of EMT hallmark genes including POSTN and Erk/Akt signaling pathways were compared between radiosensitive and radioresistant HNSCC cells.

RESULTS

POSTN mRNA expression was higher in radioresistant HNSCC cells, and silencing POSTN significantly impaired their invasiveness under the effect of EMT process represented by up-regulation of mesenchymal markers and down-regulation of an epithelial marker. Expression levels of Erk and Akt were higher in radioresistant cells.

CONCLUSION

POSTN in association with the Erk and Akt signaling pathways was up-regulated during the EMT process, leading to the conversion of radiosensitive to radioresistant HNSCC cells. POSTN may be a key marker for predicting the radioresistance and therapeutic target of HNSCC.

A rare case of thyroglossal duct cyst extending to the sublingual space: A case report

RATIONALE

Thyroglossal duct cyst (TGDC) is the most common congenital anomaly of midline neck masses. A thyroglossal duct cyst is especially difficult to diagnose and is treated differently when it appears in the sublingual area. Here, we report a rare case of TGDC extending to the sublingual space.

PATIENT CONCERNS

A 42-year-old female presented with a history of neck swelling in the submental region.

DIAGNOSIS

The final pathologic diagnosis was a TGDC.

INTERVENTIONS

Sistrunk operation was performed.

OUTCOMES

Recurrence of the disease has not been seen for the past year.

LESSION

Clinical awareness of the thyroglossal duct cyst in the sublingual area or on the oral floor area is important for an accurate diagnosis and the appropriated management.

P785 Left ventricular geometry and myocardial contractility modulate impact of statins on prognosis in patients with acute heart failure

Funding Acknowledgements

N/A

Background/Introduction: The benefit of statins in patients with heart failure (HF) remains controversial and the mechanism of action is largely speculative. We investigated whether survival benefit with statins differs according to left ventricular (LV) geometry and myocardial contractility in acute HF patients.

Methods

We enrolled 1792 acute HF patients receiving statins and 2296 patients not receiving statins admitted from 2009 to 2016. The LV and right ventricular (RV) global longitudinal strain (GLS) was assessed as a measure of myocardial contractility. Patients were classified into 2 groups based on ischemic etiology of HF and further divided into 4 subgroups according to the median values of LV-GLS or RV-GLS. The primary outcome was 5-year all-cause mortality. The study protocol was approved by the ethics committee at each institute and complied with the Declaration of Helsinki. The need for written informed consent was waived.

Results

During the 5-year follow-up, 1740 (40.4%) patients died and they had more unfavorable baseline characteristics. Statin therapy was significantly associated with improved survival in overall patients and in both groups with and without ischemic etiology (all p &lt;0.001). Patients with concentric remodeling/hypertrophy and eccentric hypertrophy demonstrated survival benefit with statin therapy (P = 0.033, 0.004, and 0.008, respectively), while those with normal geometry did not (p = 0.123). In the non-ischemic HF group, survival benefit with statin therapy was confined to patients with low LV-GLS (p = 0.045) or those with low RV-GLS p = 0.003). On the contrary, in ischemic HF group, survival benefit with statin therapy was observed in all patients regardless of the values of LV-GLS or RV-GLS. Significant interactions were present between statin use and diabetes mellitus and IHD (p for interaction = 0.027 and 0.003, respectively) regarding mortality.

Conclusions

LV geometry and myocardial contractility may modulate the effects of statins in patients with acute HF. These echocardiographic measures can provide prognostic information to guide tailored statin treatment in this population. Our findings may also help to develop more well-designed prospective studies, in terms of a more homogenous study population, to confirm survival benefit with statin therapy.

Abstract P785 Figure. Multivariate Cox survival curves

Abstract 2251: Nanocage therapeutics FHSIRPα mediating immune checkpoint blockade awakens immunity against cancer with an albumin-binding caspase-cleavable doxorubicin prodrug EMC-DEVD-S-DOX

Clinical efficacy of immune checkpoint blockade is often enhanced by their co-administration with immunogenic chemotherapy. Here a novel chemo-immunotherapy combination is reported that successfully overcomes the immunosuppressive tumor microenvironment to elicit an effective anti-tumor immune response. The CD47-SIRPα innate immune checkpoint was blocked by surface engineering human ferritin with a SIRPα variant, and this FHSIRPα efficiently inhibited the “don’t-eat-me” signal of cancer cells, thereby enhancing cancer cell phagocytosis in a colon carcinoma (CT26) model in immunocompetent mice. Doxorubicin prodrug, EMC-DEVD-S-DOX, that binds to circulating albumin following intravenous administration showed enhanced half-life, and the active drug was released via caspase-3 at tumor site following radiation treatment. Radiation-induced apoptosis of cancer cells resulted in release of active drug doxorubicin and upregulation of CD47 on cancer cell surface, sensitizing cancer cells to FHSIRPα treatment. The induction of immunogenic cell death (ICD) by the prodrug was confirmed in vitro by upregulation of calreticulin, translocation of HMGB1 and increased release of chaperone proteins in CT26.CL25 mouse colon cancer cells by flow cytometric analysis and confocal microscopy. The ICD effect of the prodrug correlated well in vivo and increased phagocytosis of tumor cells by antigen-presenting cells (APCs) in immunocompetent mice as analyzed by flow cytometry of tumor tissue and draining lymph nodes. Tumor infiltrates analyzed by flow cytometry also showed enrichment of APCs; and T cell-mediated elimination of immunogenic tumors was confirmed by the tumor-specific activation of T cells ex vivo as detected by secretion of IFNγ. Whereas FHSIRPα monotherapy showed modest tumor growth inhibition, combination with a doxorubicin prodrug resulted in effective inhibition of tumor growth by 95.2% (p&lt;0.001) compared to the control group, in an established tumor model. The combination therapy resulted in tumor free mice (57% complete response), also in an established tumor model, compared to none in monotherapy groups and controls.Taken together, we demonstrated that the synergistic anti-cancer effect and tumor targetability of the combination therapy FHSIRPα and EMC-DEVD-S-DOX successfully led to the linkage of innate to adaptive immunity to elicit a lasting anti-cancer immune response.

Citation Format: Na Kyeong Lee, Jeong Uk Choi, Jung Je Park, Ji-Hyun Seo, Mi Ra Kim, Hyo Won Chang, Sang Yoon Kim, In-San Kim, Youngro Byun. Nanocage therapeutics FHSIRPα mediating immune checkpoint blockade awakens immunity against cancer with an albumin-binding caspase-cleavable doxorubicin prodrug EMC-DEVD-S-DOX [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 2251.

A Case of Malignant Lymphoma Misdiagnosed as Acute Tonsillitis with Subsequent Lymphadenitis

<p>A 56-year-old female presented with clinical features of acute tonsillitis with subsequent cervical lymphadenitis. After taking empirical antibiotics for 1 week, the acute infection symptoms and signs were resolved. However, an asymmetric enlargement of the left palatine tonsil with ipsilateral neck swelling remained. Subsequent tonsillectomy and lymph node excisional biopsy were performed due to the possibility of malignancy. The patient was eventually diagnosed as malignant lymphoma according to pathological confirmation. We demonstrate the diagnostic challenges in such a rare case and emphasize the importance of differentiating malignant lymphoma from an atypically presenting acute infectious disease.</p>

A Novel Collateral Imaging Method Derived from Time-Resolved Dynamic Contrast-Enhanced MR Angiography in Acute Ischemic Stroke: A Pilot Study

BACKGROUND AND PURPOSE

Assessment of the collateral status has been emphasized for appropriate treatment decisions in patients with acute ischemic stroke. The purpose of this study was to introduce a multiphase MRA collateral imaging method (collateral map) derived from time-resolved dynamic contrast-enhanced MRA and to verify the value of the multiphase MRA collateral map in acute ischemic stroke by comparing it with the multiphase collateral imaging method (MRP collateral map) derived from dynamic susceptibility contrast-enhanced MR perfusion.

MATERIALS AND METHODS

From a prospectively maintained registry of acute ischemic stroke, MR imaging data of patients with acute ischemic stroke caused by steno-occlusive lesions of the unilateral ICA and/or the M1 segment of the MCA were analyzed. We generated collateral maps using dynamic signals from dynamic contrast-enhanced MRA and DSC-MRP using a Matlab-based in-house program and graded the collateral scores of the multiphase MRA collateral map and the MRP collateral map independently. Interobserver reliabilities and intermethod agreement between both collateral maps for collateral grading were tested.

RESULTS

Seventy-one paired multiphase MRA and MRP collateral maps from 67 patients were analyzed. The interobserver reliabilities for collateral grading using multiphase MRA or MRP collateral maps were excellent (weighted κ = 0.964 and 0.956, respectively). The agreement between both collateral maps was also excellent (weighted κ = 0.884; 95% confidence interval, 0.819-0.949).

CONCLUSIONS

We demonstrated that the dynamic signals of dynamic contrast-enhanced MRA could be used to generate multiphase collateral images and showed the possibility of the multiphase MRA collateral map as a useful collateral imaging method in acute ischemic stroke.

Guidelines for the Surgical Management of Oral Cancer: Korean Society of Thyroid-Head and Neck Surgery

Korean Society of Thyroid-Head and Neck Surgery appointed a Task Force to provide guidance on the implementation of a surgical treatment of oral cancer. MEDLINE databases were searched for articles on subjects related to “surgical management of oral cancer” published in English. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. The quality of evidence was rated with use RoBANS (Risk of Bias Assessment Tool for Nonrandomized Studies) and AMSTAR (A Measurement Tool to Assess the Methodological Quality of Systematic Reviews). Evidence-based recommendations for practice were ranked according to the American College of Physicians grading system. Additional directives are provided as expert opinions and Delphi questionnaire when insufficient evidence existed. The Committee developed 68 evidence-based recommendations in 34 categories intended to assist clinicians and patients and counselors, and health policy-makers. Proper surgical treatment selection for oral cancer, which is directed by patient- and subsite-specific factors, remains the greatest predictor of successful treatment outcomes. These guidelines are intended for use in conjunction with the individual patient’s treatment goals.

Establishment and verification of a mouse model of nasal wound healing

OBJECTIVES

Poor wound healing as reflected by the development of synechia and osteitis after endoscopic sinus surgery may trigger disease recurrence. Animal models provide insights into the pathogenesis of poor wound healing and may aid in the development of new therapeutics. Here, we established a mouse model of nasal wound healing and confirmed its utility.

STUDY DESIGN

Animal study.

METHODS

Unilateral intranasal wounds were induced using a small interdental brush in 6-week-old C57BL/6 mice. Forty-five mice were divided into three groups (each n = 15): one control and two experimental groups (intranasal vs. intraperitoneal dexamethasone). Mice were sacrificed on days 2, 14, and 28 after injury (each n = 5). Serial changes in nasal wound histopathology were described, and intergroup differences were analyzed.

RESULTS

On day 2, mucosal detachment, hemorrhage, and exudate were observed. On day 14, synechiae featuring neo-osteogenesis (bone lacunae, osteoblasts, and multinucleated osteoclasts) between the septum and the maxilloturbinate were prominent, followed by wound maturation on day 28: fewer lacunae and smaller osteoblasts. Macrophages were evident only on day 2, and lymphocytes were predominant on day 28. The amount of exudate on day 2 and the synechial area on day 28 were significantly reduced in mice that received dexamethasone systemically compared with control mice, with similar trends in those treated intranasally.

CONCLUSION

Our mouse model of nasal wound healing was characterized by the development of bony synechia and neo-osteogenesis, not soft-tissue synechia. The model may be useful in the assessment of novel therapeutics to prevent those wounds.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:E266-E271, 2019.

Not CD68 but stabilin-1 expression is associated with the risk of recurrence in patients with oral cavity squamous cell carcinoma

BACKGROUND

This study's aim was to identify CD68 and stabilin-1 expressions and their prognostic implications in patients with oral cavity cancer (OCC).

METHODS

Stabilin-1 and CD68 immunochemical staining was conducted in samples from patients with OCC who underwent curative surgery in our institute. We retrospectively analyzed patients' clinical information. We investigated the relationship between CD68 and stabilin-1 expression levels and their effect on prognostic factors and survival.

RESULTS

Fifty-four patients' data were analyzed. CD68 and stabilin-1 expressions were positively correlated (P = .008). CD68 and stabilin-1 expressions were not correlated with other prognostic factors (eg, T classification or lymph node metastasis). Stabilin-1 expression and tumor recurrence risk were positively correlated (P = .015). CD68 expression was neither associated with recurrence-free nor OCC-specific survival.

CONCLUSION

CD68 and stabilin-1 expressions in OCC were positively correlated. Stabilin-1 expression was significantly associated with OCC recurrence risk, but the prognostic value of CD68 was not confirmed.

Comparative study between an intensive small group teaching and a 1-year clinical practice on OSCE

Our school introduced a new curriculum based on faculty-directed, intensive, small-group teaching of clinical skills in the third-year medical students. To examine its effects, we compared the mean scores on an OSCE between the third- and fourth-year medical students. Methods Third- and fourth-year students did rotations at the same five OSCE stations. They then completed a brief self-reporting questionnaire survey to examine the degree of satisfaction with new curriculum in the third-year students and clinical practice in the fourth-year students, as well as their perception of confidence and preparedness. We analyzed the OSCE data obtained from 158 students, 133 of whom also completed the questionnaire. Results Mean OSCE scores on the breast examination and wet smear stations were significantly higher in the third-year group (P &lt; 0.001). But mean OSCE scores of motor-sensory examination and lumbar puncture were significantly higher in the fourth-year group (P &lt; 0.05). The mean OSCE scores had no significant correlation with satisfaction. In addition, the self-ratings of confidence had a high degree of correlation with satisfaction with new curriculum (r = 0.673) and clinical practice (r = 0.692). Furthermore, there was a moderate degree of correlation between satisfaction and preparedness in both groups (r = 0.403 and 0.449). Conclusions There is no significant difference in the effect on the degree of clinical performance and confidence between an intensive-small group teaching and a 1-year clinical practice. If combined, intensive small group teaching and clinical practice would be useful to improve the degree of ability and confidence in medical students.

Ultrasonography-guided core needle biopsy of cervical lymph nodes for diagnosing head and neck lymphoma compared with open surgical biopsy: Exploration for factors that shape diagnostic yield

PURPOSE

This study was conducted to compare the diagnostic yields of Ultrasonography-guided core needle biopsy (USG-CNB) and open surgical biopsy (OSB) in head and neck (HN) lymphoma and to identify the factors that shape USG-CNB diagnostic yield.

MATERIALS AND METHODS

All consecutive patients who were diagnosed with HN lymphoma in our hospital were analyzed. The frequencies with which these first-line procedures yielded a sample that permitted histological confirmation of lymphoma were determined. To identify the factors that shape the diagnostic yield of USG-CNB, the patients in whom USG-CNB was and was not sufficiently confirmatory were compared in terms of demographics, computed tomography (CT) and pathological findings.

RESULTS

In total, 83 patients underwent USG-CNB (n = 26, 31.3%) or OSB (n = 57, 68.7%) for confirming lymphoma. USG-CNB yielded a fully sufficient diagnosis in 18 (69.2%) patients. By contrast, OSB yielded a confirmative diagnosis in 56 (98.2%) patients. Maximal standardized uptake value (SUVmax) of targeted LN on positron emission tomography-CT (PET-CT) in confirmatively diagnosed subjects was much higher than deferred counterparts (22.9 ± 13.4 vs. 10.1 ± 5.2, p = 0.017), however, there was no significant difference in other parameters associated with the first-line USG-CNB diagnostic success.

CONCLUSIONS

First-line USG-CNB was less frequently successful than OSB for diagnosing HN lymphoma involving cervical LN. Mean SUVmax of LN on PET-CT in confirmatively diagnosed subjects was higher than deferred counterparts on USG-CNB.

Transoral Dermoid Cyst Excision: A Multicenter Prospective Observational Study

OBJECTIVE

Transoral surgery is becoming a preferred technique because it does not leave any scar after surgery. However, transoral surgery for a dermoid cyst of the oral cavity is not standardized yet, due to the anatomic complexity of this region. The aim of this study was to evaluate the safety and efficacy of a transoral dermoid cyst excision.

STUDY DESIGN

Multicenter prospective observational study.

SETTING

University hospital.

SUBJECTS AND METHODS

This study was designed as a 4-year prospective multicenter evaluation of dermoid cyst excisions within the floor of mouth. Clinical outcomes and complications related to procedures were evaluated among patients. The primary outcome was the efficacy of the procedure, and the secondary outcome was cosmetic satisfaction of each procedure.

RESULTS

Twenty-one patients underwent transoral dermoid cyst excisions, and 22 underwent transcervical excisions. In the transoral surgery group, the mean size of the dermoid cyst was 5.35 cm (95% CI, 4.79-5.91), and in the transcervical surgery group, it was 6.19 cm (95% CI, 5.67-6.71). There was no significant differences with respect to overall demographic characteristics between the groups. However, the duration of the operation was shorter with the transoral group than with the transcervical group ( P = .001), and cosmetic satisfaction was much better in the transoral group ( P < .001).

CONCLUSION

Transoral dermoid cyst excision is a potentially safe and effective method that can lead to easy and quick removal of an oral cavity dermoid cyst, with excellent cosmetic outcomes.

Abstract 2405: P53-dependent mitophagy controls glycolytic shift in radioresistant head and neck cancer cells

P53 is an important biomarker in response to genotoxic stress, but it is also known to plays a key role in the regulation of metabolic homeostasis. The loss of p53 is a well-established contributor to the malignant transformation and glycolytic phenotype acquisition of cells during cancer development. However, the role of p53 in genotoxic therapy-induced metabolic shift in cancers remains unclear. Here, we attempted to elucidate how p53 participates in the glycolytic shift of head and neck cancer cell lines following irradiation. We established a stable radioresistant head and neck cancer cells (HN30-R; p53 wild type and UMSCC1-R; p53 null type) through cumulative irradiation and then analyzed their glucose metabolic profiles and mitochondria respiration. As a result, the metabolic analysis revealed no changes glycolysis of HN30-R cells, but UMSCC1-R cells exhibited increased glycolysis through increased glucose uptake and lactate production and glycolytic intermediates as well as related glycolytic enzymes, compared to UMSCC1 cells. Also, we confirmed that the mitochondrial respiration was reduced by the maximal respiration parameters of oxygen consumption rate (OCR) and that abnormal mitochondria were accumulated by electron microscopy in UMSCC1-R cells. Thus, UMSCC1-R cells exhibited an increased sensitivity to glycolysis-targeting drugs such a hexokinases inhibitor (2-deoxy-D-glucoes; 2-DG) and a lactate dehydrogenase-A inhibitor (AT101), but HN30-R cells did not shown any changes. Moreover, we identified that mitophagy limits glycolytic shift through the p53-dependent clearance of abnormal mitochondria. Taken together, these results suggest that p53 null type cells increased aerobic glycolysis to overcome the accumulation of abnormal mitochondria in radioresistnat cells. Conversely, p53 wild type cells inhibited the glycolytic shift by regulating a integrity through p53-dependent mitophagy. Thus, glycolysis-targeted drugs could be an alternative strategy for overcoming recurrent cancers after radiotherapy, and p53 status could be a biomarker for selecting participants for clinical trials.

Citation Format: Hyo Won Chang, Ji Won Kim, Mi Ra Kim, Hae Yun Nam, Myungjin Lee, Won Hyeok Lee, Song Hee Kim, Da Seul Seong, Myung Woul Han, Jong Cheol Lee, Jung Je Park, Ji-hyun Seo, Seong Who Kim, Sang Yoon Kim. P53-dependent mitophagy controls glycolytic shift in radioresistant head and neck cancer cells [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 2405.

No-Scar Transoral Thyroglossal Duct Cyst Excision in Children

BACKGROUND

No-scar transoral thyroglossal duct cyst (TGDC) excision is a newly developed treatment for TGDC, but limited information is available regarding the clinical outcomes in children. The aim of this study was to evaluate the safety, efficacy, and effects of transoral TGDC excision in children.

METHODS

Forty-four children <10 years of age received operative treatment for TGDC from January 2013 to December 2014, and follow-up was performed over 24 months. Clinicopathologic, surgical, and follow-up data were collected and analyzed. The primary outcome variable was feasibility of the procedure, and the secondary outcome was patient's cosmetic satisfaction after each operation.

RESULTS

Twenty-one patients underwent transoral TGDC excision, and 21 patients underwent conventional excision. No significant differences were observed between the two groups in terms of the overall patient and operation factors. However, the rate of identifying the thyroglossal duct during transoral excision was superior to that during conventional excision (p < 0.05), and cosmetic satisfaction was much better in the transoral TGDC excision group (p < 0.001).

CONCLUSION

No-scar transoral TGDC excision in children is a potentially safe and effective methodology that can achieve easy removal of the thyroglossal duct and excellent cosmetic outcomes.

Association of clinicopathological features of melanoma with total naevus count and a history of dysplastic naevi: a cross-sectional retrospective study within an academic centre

BACKGROUND

High naevus count (HNC) (≥ 50 naevi) and presence of dysplastic naevi (DN) are risk factors for malignant melanoma (MM); however, MMs also occur in patients with low naevus count (LNC) (< 50 naevi) and in patients without DN. Little is known about differences between MMs in these groups.

AIM

To characterize the clinicopathological differences between MMs in patients with HNC and those in patients with LNC, with or without biopsy-proven DN.

METHODS

This was a cross-sectional retrospective chart review of 281 patients with MM seen between April 2013 and March 2014 at an academic pigmented lesion clinic (Boston, MA, USA).

RESULTS

Patients with LNC MMs were diagnosed at an older age (51 vs. 41 years, P < 0.001, OR = 0.95, 95% CI 0.93-0.97), with more aggressive MM features, including greater Breslow thickness (1.1 vs. 0.8 mm, P = 0.01), more mitoses (2 vs. 1 mitoses/mm² , P < 0.001), lower rate of superficial spreading subtype (58 vs. 78%, P < 0.01, OR = 2.57, 95% CI 1.31-5.03) and higher MM stage (P < 0.001), compared to patients with HNC. Patients with DN had similar trends as those in patients with HNC described above, and in addition, were more likely to have a truncal MM (55 vs. 39%, P < 0.01, OR = 1.97, 95% CI 1.22-3.18) with less ulceration (13 vs. 29%, P < 0.01, OR = 0.36, 95% CI 0.19-0.71). Patients without DN were more likely to have a history of a non-MM skin cancer (32 vs. 19%, P = 0.01, OR = 0.49, 95% CI 0.28-0.85) and an amelanotic MM (33 vs 21%, P = 0.03, OR = 0.55, 95% CI 0.31-0.96).

CONCLUSIONS

Patients with LNC may develop MMs with more aggressive features at an older age than patients with HNC. A history of biopsy-proven DN reveals distinct MM differences compared to patients without DN.

Idiopathic benign paroxysmal positional vertigo in the elderly: a long-term follow-up study

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) is the most common cause of peripheral-type vertigo in the elderly. While some studies have investigated BPPV among the elderly, no study has focused on the isolated idiopathic BPPV (iBPPV) in the elderly.

AIMS

To investigate the clinical features and recurrence rate in elderly patients diagnosed with iBPPV.

METHODS

The authors prospectively reviewed the medical records of 627 patients diagnosed with BPPV, and a total of 370 patients fulfilled the inclusion criteria. The subjects were divided into two groups by age (experimental group ≥65 years and control group 17-64 years), and the gender, numbers of canalith reposition maneuver (CRM) for successful treatment, time elapsed from onset of symptoms to clinic visit, the affected semicircular canal, and the 1- and 5-year recurrence proportion were analyzed.

RESULTS

The gender, numbers of CRM for successful treatment, affected semicircular canal, and the 1- and 5-year recurrence proportion showed no statistically significant difference between two groups (p > 0.05). The only exception was the experimental group which took a longer duration from manifestation of symptoms to hospital visit than control group (student's t test, p = 0.021).

DISCUSSION

Several previous studies report that the elderly with iBPPV shows more protracted clinical course and much higher recurrence rate than younger adult. Unlike those reports, our study showed no significant differences about the clinical features and recurrence rate between age groups.

CONCLUSION

The elderly with iBPPV could be treated as effective as general population.

Protective effects of alpha lipoic acid on radiation-induced salivary gland injury in rats

Purpose

Radiation therapy is a treatment for patients with head and neck (HN) cancer. However, radiation exposure to the HN often induces salivary gland (SG) dysfunction. We investigated the effect of α-lipoic acid (ALA) on radiation-induced SG injury in rats.

Results

ALA preserved acinoductal integrity and acinar cell secretary function following irradiation. These results are related to the mechanisms by which ALA inhibits oxidative stress by inhibiting gp91 mRNA and 8-OHdG expression and apoptosis of acinar cells and ductal cells by inactivating MAPKs in the early period and expression of inflammation-related factors including NF-κB, IκB-α, and TGF-β1 and fibrosis in late irradiated SG. ALA effects began in the acute phase and persisted for at least 56 days after irradiation.

Materials and Methods

Rats were assigned to followings: control, ALA only (100 mg/kg, i.p.), irradiated, and ALA administered 24 h and 30 min prior to irradiation. The neck area including the SG was evenly irradiated with 2 Gy per minute (total dose, 18 Gy) using a photon 6-MV linear accelerator. Rats were killed at 4, 7, 28, and 56 days after radiation.

Conclusions

Our results show that ALA could be used to ameliorate radiation-induced SG injury in patients with HN cancer.

Anti-PD-1 therapy in patients with advanced melanoma and preexisting autoimmune disorders or major toxicity with ipilimumab

Background

Anti-PD-1 antibodies (anti-PD-1) have clinical activity in a number of malignancies. All clinical trials have excluded patients with significant preexisting autoimmune disorders (ADs) and only one has included patients with immune-related adverse events (irAEs) with ipilimumab. We sought to explore the safety and efficacy of anti-PD-1 in such patients.

Patients and methods

Patients with advanced melanoma and preexisting ADs and/or major immune-related adverse events (irAEs) with ipilimumab (requiring systemic immunosuppression) that were treated with anti-PD-1 between 1 July 2012 and 30 September 2015 were retrospectively identified.

Results

One hundred and nineteen patients from 13 academic tertiary referral centers were treated with anti-PD-1. In patients with preexisting AD (N = 52), the response rate was 33%. 20 (38%) patients had a flare of AD requiring immunosuppression, including 7/13 with rheumatoid arthritis, 3/3 with polymyalgia rheumatica, 2/2 with Sjogren's syndrome, 2/2 with immune thrombocytopaenic purpura and 3/8 with psoriasis. No patients with gastrointestinal (N = 6) or neurological disorders (N = 5) flared. Only 2 (4%) patients discontinued treatment due to flare, but 15 (29%) developed other irAEs and 4 (8%) discontinued treatment. In patients with prior ipilimumab irAEs requiring immunosuppression (N = 67) the response rate was 40%. Two (3%) patients had a recurrence of the same ipilimumab irAEs, but 23 (34%) developed new irAEs (14, 21% grade 3-4) and 8 (12%) discontinued treatment. There were no treatment-related deaths.

Conclusions

In melanoma patients with preexisting ADs or major irAEs with ipilimumab, anti-PD-1 induced relatively frequent immune toxicities, but these were often mild, easily managed and did not necessitate discontinuation of therapy, and a significant proportion of patients achieved clinical responses. The results support that anti-PD-1 can be administered safely and can achieve clinical benefit in patients with preexisting ADs or prior major irAEs with ipilimumab.

Sacral nerve stimulation can be an effective treatment for low anterior resection syndrome

AIM

Sacral nerve stimulation has become a preferred method for the treatment of faecal incontinence in patients who fail conservative (non-operative) therapy. In previous small studies, sacral nerve stimulation has demonstrated improvement of faecal incontinence and quality of life in a majority of patients with low anterior resection syndrome. We evaluated the efficacy of sacral nerve stimulation in the treatment of low anterior resection syndrome using a recently developed and validated low anterior resection syndrome instrument to quantify symptoms.

METHOD

A retrospective review of consecutive patients undergoing sacral nerve stimulation for the treatment of low anterior resection syndrome was performed. Procedures took place in the Division of Colon and Rectal Surgery at two academic tertiary medical centres. Pre- and post-treatment Cleveland Clinic Incontinence Scores and Low Anterior Resection Syndrome scores were assessed.

RESULTS

Twelve patients (50% men) suffering from low anterior resection syndrome with a mean age of 67.8 (±10.8) years underwent sacral nerve test stimulation. Ten patients (83%) proceeded to permanent implantation. Median time from anterior resection to stimulator implant was 16 (range 5-108) months. At a median follow-up of 19.5 (range 4-42) months, there were significant improvements in Cleveland Clinic Incontinence Scores and Low Anterior Resection Syndrome scores (P < 0.001).

CONCLUSION

Sacral nerve stimulation improved symptoms in patients suffering from low anterior resection syndrome and may therefore be a viable treatment option.

Prospective analysis of the sealing ability of the ENSEAL® G2 Articulating Tissue Sealer and transector on human mesenteric vessels in colorectal surgery

BACKGROUND

The sealing and transection of mesenteric vessels is a crucial step in minimally invasive colorectal surgery. We examined the sealing quality of the ENSEAL^® G2 Articulating Tissue Sealer in three different articulations in mesenteric vessels.

METHODS

This was a prospective experimental study within a tertiary healthcare center, and 30 patients were recruited. Burst pressures for each specimen were measured as the primary outcome. Ten specimens at each of the three articulations were also histologically assessed for the quality of seal.

RESULTS

We evaluated 54 sets of specimens from 30 patients for bursting pressure, all of which were harvested and sealed in the operating room. No statistical difference was seen in burst pressures from seals recorded at no angulation, half-maximal angulation, or maximal angulation (1604, 1507, 1478 mmHg; p = 0.07). Histological analysis showed no statistical differences in the average vessel diameter (p = 0.57), lateral extent of thermal injury (p = 0.48), degree of vascular sclerosis, or the integrity of seal at the three articulations. No cases of intraoperative or postoperative bleeding were observed in any of the patients. Five (16.7%) of the ENSEAL^® devices developed breaks in the black, heat-shrink, polyethylene covering as a result of repeated articulation and disarticulation. Electrical arcing did not appear to have occurred as a result of the break, although this was not formally examined.

CONCLUSIONS

The maximum sustainable pressure in mesenteric vessels sealed with a bipolar electrothermal device is supraphysiological, and consequently, the device can be safely used at various articulations to seal vessels during colorectal surgery.

Tracheobronchial foreign body removal in infants who had very small airways: A prospective clinical trial

BACKGROUND AND AIMS

Tracheobronchial foreign body aspiration is a life-threatening emergency. Using a rigid bronchoscope with optical forceps is the most effective method for foreign body removal. However, occasionally for some infants these instruments could not be used, as they may be too large for their small airways. Here, they present the apnea technique with only an optical forceps for foreign body removal in infants with very small airways.

METHODS

Foreign bodies were removed using only an optical forceps for infants who had very small diameter airways. After general anesthesia, the suspension laryngoscope was set just above the vocal cord, and the inserted ventilation tube was pulled out, followed by a new one being inserted through the suspension laryngoscope and placed at the trachea. With the oxygen saturation at 100%, we pulled out the ventilation tube and inserted the optical forceps with an endoscope. After that, the foreign body was removed by the optical forceps.

RESULTS

The foreign body removal using only an optical forceps is technically feasible for an infant. The mean operation time was 40.33 ± 8.06 min, and the hospital stay was 2.25 ± 0.62 days. When we pulled out the ventilation tube, the O₂ saturation mean time (apnea time) was 106.25 ± 14.30 sec. In 12 infants, the foreign body was removed completely without a need for a second procedure.

CONCLUSIONS

The apnea technique for the removal of foreign body from the airway, using only an optical forceps with an endoscope, is useful in infants who had very small airways.

Factors Associated with Removal of Impactted Fishbone in Children, Suspected Ingestion

PURPOSE

The management and clinical course in pediatric patients who had ingested foreign body were investigated retrospectively to evaluate the frequency and factor associated with successful removal of fishbone foreign body.

METHODS

Based on the medical records of patients younger than 15 years old who visited emergency room because of foreign body ingestion from January 1999 to December 2012, the authors reviewed clinical characteristics including type of ingested foreign bodies, time to visits, managements and complications.

RESULTS

Fishbone (50.1%) was the most common ingested foreign body in children. Among 416 patients with ingested fishbone, 245 (58.9%) were identified and removed using laryngoscope, rigid or flexible endoscope from pharynx or upper esophagus by otolaryngologists and pediatric gastroenterologists. The kind of ingested fish bone in children was diverse. The mean age of identified and removed fishbone group was 7.39 years old, and higher than that of unidentified fishbone group (5.81 years old, p<0.001). Identified and removed fishbone group had shorter time until hospital visit than the unidentified fishbone group (2.03 vs. 6.47 hours, p<0.001). No complication due to ingested fishbone or procedure occurred.

CONCLUSION

Older age and shorter time from accident to hospital visit were the different factors between success and failure on removal of ingested fish bone in children.

The prevalence and factors associate with vocal nodules in general population: Cross-sectional epidemiological study

The purpose of this study was to analyze the prevalence of vocal nodules and to identify factors related with an increased risk for vocal nodules.This study was conducted using data from the Korean National Health and Nutrition Examination Survey 2008 to 2011. The subjects consisted of 19,636 men and women aged ≥19 years. Related factors such as age, marital status, incomes, and education level were assessed in individual interviews, and health-related behaviors including smoking, alcohol, and activity were assessed with self-administered questionnaires. Also, examination survey such as laryngoscopy examination, basic physical examination, and blood sampling was conducted.The prevalence of vocal nodules was 1.31% (n = 258). Among variable factors, age, education level, and voice disorder were related with the presence of vocal nodules (P < 0.05). Other factors including sex, alcohol, smoking, physical activities, hypertension, obesity, waist circumference and metabolic syndrome, hypercholesterolemia, serum calcium, and vitamin D did not show any meaningful relationship with the presence of vocal nodules.This result may help reduce the incidence of vocal nodules and offer proper management for patients with vocal nodules, and may also facilitate efficient allocation of public health resources.

Suggested Protocol for Managing Acute Suppurative Cervical Lymphadenitis in Children to Reduce Unnecessary Surgical Interventions

OBJECTIVES

The indications and benefits of surgery in the management of pediatric acute suppurative cervical lymphadenitis (ASCL) remain unclear. We aimed to design a management protocol focusing on the avoidance of unnecessary operation in pediatric ASCL patients.

METHODS

The study population consisted of 45 pediatric patients with ASCL treated with antibiotics alone and 30 surgically treated patients. The primary outcome was the determination of differences in patient characteristics and radiologic findings in the 2 groups. The secondary outcome, after matching 20 cases with 20 controls, was to determine the benefits of surgery to patients.

RESULTS

There were no significant differences between the 2 groups in patient characteristics and radiologic findings at initial presentation. In the matched case-control analysis, intravenous antibiotics alone yielded successful treatment outcomes when compared with surgery, with no significant differences in time to symptom resolution, normalized laboratory test results, and duration of hospitalization (all P > .05).

CONCLUSIONS

The size and location of suppurated lymph nodes are not absolute determinants for surgical drainage in the stable pediatric ASCL patients. If patients show no clinical improvements despite appropriate second- and third-line antibiotics, patients should be carefully reevaluated and image-guided aspiration considered.

Extra-Esophageal Pepsin from Stomach Refluxate Promoted Tonsil Hypertrophy

Background

Gastroesophageal reflux is associated with numerous pathologic conditions of the upper aerodigestive tract. Gastric pepsin within reflux contributes to immunologic reactions in the tonsil. In this study, we aimed to find the relationships between pepsin and tonsillar hypertrophy.

Methods and finding

We explored the notion whether tonsillar hypertrophy was due to pepsin-mediated gastric reflux in tonsil hypertrophy. Fifty-four children with tonsil hypertrophy and 30 adults with tonsillitis were recruited before surgical treatment. Blood and tonsil tissues from each patient were harvested for analysis of changes in lymphocyte and macrophage numbers coupled with histological and biochemical analysis. Pepsin was expressed at different levels in tonsil tissues from each tonsillar hypertrophy. Pepsin-positive cells were found in the crypt epithelium, surrounding the lymphoid follicle with developing fibrosis, and also surrounding the lymphoid follicle that faced the crypt. And also, pepsin staining was well correlated with damaged tonsillar squamous epithelium and TGF-β1 and iNOS expression in the tonsil section. In addition, pepsin and TGF-β1-positive cells were co-localized with CD68-positive cells in the crypt and surrounding germinal centers. In comparison of macrophage responsiveness to pepsin, peripheral blood mononuclear cells (PBMNCs) were noticeably larger in the presence of activated pepsin in the child group. Furthermore, CD11c and CD163-positive cells were significantly increased by activated pepsin. However, this was not seen for the culture of PBMNCs from the adult group.

Conclusions

The lymphocytes and monocytes are in a highly proliferative state in the tonsillar hypertrophy and associated with increased expression of pro-inflammatory factors as a result of exposure to stomach reflux pepsin.

Self-expandable metal stents for malignant esophageal obstruction: a comparative study between extrinsic and intrinsic compression

Self-expandable metal stents (SEMSs) are effective for malignant esophageal obstruction, but usefulness of SEMSs in extrinsic lesions is yet to be elucidated. This study is aimed at evaluating the clinical usefulness of SEMSs in the extrinsic compression compared with intrinsic. A retrospective review was conducted for 105 patients (intrinsic, 85; extrinsic, 20) with malignant esophageal obstruction who underwent endoscopic SEMSs placement. Technical and clinical success rates were evaluated and clinical outcomes were compared between extrinsic and intrinsic group. Extrinsic group was mostly pulmonary origin. Overall technical and clinical success rate was 100% and 91%, respectively, without immediate complications. Extrinsic and intrinsic group did not differ significantly in clinical success rate. The median stent patency time was 131.3 ± 85.8 days in intrinsic group while that of extrinsic was 54.6 ± 45.1 due to shorter survival after stent insertion. The 4-, 8-, and 12-week patency rates were 90.5%, 78.8%, and 64.9% respectively in intrinsic group, while stents of extrinsic group remained patent until death. Uncovered, fully covered, and double-layered stent were used evenly and the types did not influence patency in both groups. In conclusion, esophageal SEMSs can safely and effectively be used for malignant extrinsic compression as well as intrinsic.