Cost analysis of sialendoscopy for the treatment of salivary gland disorders in children

INTRODUCTION

Recent advances in Otolaryngology have changed the diagnosis and therapy for salivary gland disorders. Sialendoscopy-assisted surgery is a minimally invasive, conservative procedure for functional preservation of the affected gland. The goals of this study are to assess the indications, use, and outcomes of pediatric sialendoscopy at a tertiary pediatric institution as well as to analyze the direct cost related to the diagnosis and treatment of patients with sialolithiasis and Juvenile Recurrent Parotitis managed with sialendoscopy.

METHODS

Retrospective cohort study of pediatric patients undergoing diagnostic and/or therapeutic sialendoscopy at a tertiary level children's hospital between 2012 and 2020. Demographic, clinical, surgical variables and direct hospital costs 1 year before and after the sialendoscopy procedure were collected and analyzed.

RESULTS

Twenty-two pediatric patients were included. There was male predominance (59.3%). The most common indication for sialendoscopy was Juvenile Recurrent Parotitis. Average age of onset was 6.5 years for patients with JPR and 14.2 years for patients with sialolithiasis. All patients had an average of 4.5 episodes before the first procedure. 8 patients required repeat sialendoscopy for recurrent symptoms. Mean total hospital costs were significantly higher in patients with JRP 1 year before and after the sialendoscopy ($4308.8 vs. $3330) compared to patients with sialolithiasis. Costs of the sialendoscopy and related expenses including anesthesia and PACU cost were similar in both studied groups ($13,506 vs. $13,022.9). Complete resolution of symptoms was achieved in 14 patients with JRP and all patients with sialolithiasis.

CONCLUSION

Sialendoscopy is a low-risk procedure that aids in the treatment for pediatric salivary gland disorders. The costs related to sialendoscopy are substantial and patients with JRP incur higher hospital preoperative and postoperative costs compared to patients with sialolithiasis.

Poor treatment tolerance in head and neck cancer patients with low muscle mass

BACKGROUND

We ascertain the role of a low cervical paraspinal skeletal muscle index (CPSMI) as a biomarker for poor treatment tolerance in patients with operable mucosal head and neck squamous cell carcinoma (HNSCC).

METHODS

A prospective cohort of patients with operable HNSCC requiring microvascular reconstruction was evaluated. Low CPSMI was calculated using preoperative CT neck imaging. Poor treatment tolerance, a composite measure of incomplete therapy or severe morbidity/mortality during treatment, was the primary outcome.

RESULTS

One hundred and twenty-seven patients underwent extirpative surgery with a mean age was 60.5. Poor treatment tolerance occurred in 71 (56%) patients with 21 not completing recommended adjuvant therapy and 66 having severe treatment-related morbidity. A low CPSMI was independently associated with poor treatment tolerance (OR 2.49, 95%CI 1.10-5.93) and delay to adjuvant therapy (OR 4.48, 95%CI 1.07-27.6) after adjusting for multiple confounders.

CONCLUSION

Low CPSMI was independently associated with poor treatment tolerance in patients with operable HNSCC.

Cervical paraspinal skeletal muscle index outperforms frailty indices to predict postoperative adverse events in operable head and neck cancer with microvascular reconstruction

OBJECTIVE

Sarcopenia is increasingly being recognized as a negative prognostic factor in patients with head and neck cancer (HNC). We associate a sarcopenia biomarker measured radiographically from computed tomography (CT) of the neck to postoperative adverse events in patients with operable HNC.

PATIENTS AND METHODS

A prospective cohort of treatment-naïve HNC patients undergoing surgery with microvascular reconstruction was performed. Cervical paraspinal skeletal muscle index (CPSMI) was calculated using preoperative CT neck imaging and adjusted for height and sex. Postoperative adverse events, including Clavien-Dindo Grade 3+ complications and fistula, were recorded within 30-days of the index surgery. Multivariate logistic regression was used to evaluate the association between CPSMI and postoperative complications. The modified frailty index (mFI) and Risk Assessment Index (RAI) were compared with CPSMI outcomes.

RESULTS

A total of 127 patients with mucosal HNC were included in the study. The mean age was 60.5 years, and 87 (68.5%) patients were male. Sixty Clavien-Dindo grade 3+ events occurred; 17 patients developed an oro/pharyngocutaneous fistula. Low CPSMI was independently associated with Clavien-Dindo Grade 3+ events (OR 2.80, 95% CI of 1.18-6.99) and fistula (OR of 6.10, 95% CI of 1.53-24.3) when adjusted for multiple factors. CPSMI outperformed the mFI and RAI frailty indices to predict postoperative adverse events (p < .05).

CONCLUSION

Low CPSMI is independently associated with postoperative adverse events and outperforms current frailty indices inoperable HNC with microvascular reconstruction.

Relationship between socioeconomic status, exposure to airborne pollutants, and chronic rhinosinusitis disease severity

BACKGROUND

Air pollution directly interacts with airway mucosa, yet little is known about how pollutants affect upper airway inflammation. Studies have shown increased incidence of chronic rhinosinusitis (CRS), rhinitis, and asthma in areas with higher traffic pollution, and these neighborhoods are often associated with lower socioeconomic status (SES). The Area Deprivation Index (ADI) assesses neighborhood-level SES by zip code. The purpose of this study was to assess the relationship between SES and exposure to inhaled pollutants and CRS disease severity.

METHODS

CRS patients with and without nasal polyps (CRSwNP and CRSsNP, respectively) were identified (total patients = 234; CRSwNP patients = 138; CRSsNP patients = 96). Pollutant concentrations, including particulate matter 2.5 (PM_2.5 ), black carbon (BC), and nitrogen dioxide (NO₂ ), were measured at 70 sites within the defined countywide sites and used to estimate patient exposures. SES was measured by ADI state deciles. Disease severity metrics included the modified Lund-Mackay score (LMS), the need for systemic steroids, and functional endoscopic sinus surgery (FESS). Associations were analyzed and identified using linear, logistic, and Poisson multivariable regression.

RESULTS

The distribution of CRSsNP and CRSwNP patients across ADI state deciles was similar. ADI, however, was a predictor of exposure to airborne pollutants (PM_2.5 , BC, and NO₂ ) with a 1.39%, 2.39%, and 2.49% increase in PM_2.5 , BC, and NO₂ per increasing decile increment (p < 0.0001), respectively, which demonstrated a direct correlation between deprived neighborhoods and higher levels of exposure to PM_2.5 , BC, and NO₂ with an increase in pollutant levels per increase in ADI decile. Furthermore, ADI was a predictor for increased steroid treatment.

CONCLUSION

Lower SES predicted higher exposure to air pollution and increased disease severity in patients with CRS as demonstrated by the increased need for steroid treatment.

Tobacco Use and Skin Reactivity in Patients With Percutaneous Auditory Osseointegrated Implants

OBJECTIVES

To determine if there is an association between tobacco use and the development of postoperative skin reactions in patients undergoing percutaneous osseointegrated auditory implant (pOAI) surgery.

STUDY DESIGN

Single surgeon retrospective cohort study.

SETTING

Academic medical center.

SUBJECTS AND METHODS

Retrospective chart review was performed on all patients who underwent pOAI. Smoking status (current and former users versus never-users) was recorded as were numerous demographic and surgical variables. The primary outcome measure was skin reactivity as measured by Holgers score. Secondary outcomes studied included total number of problem visits, minor interventions, and major interventions.

RESULTS

126 patients, 73 with no tobacco history (NT) and 53 with a positive smoking tobacco history (T) underwent pOAI surgery in this study. The T group was found to have higher rates of first postoperative visit soft tissue reactions compared with the NT group (24.5% versus 6.8%, p 1/4 0.011, odds ratio [OR] 4.42, 95% confidence interval [CI]: 1.5, 13.3), but not at long-term follow-up. When former smokers were eliminated from analysis, differences were also found at long- term follow-up (40.9% versus 19.2%, p 1/4 0.037, OR 2.92, 95% CI [1.0 - 8.1]). There were no differences in total number of problem visits or total number of minor or major interventions.

CONCLUSIONS

Patients with a history of tobacco use have a significantly higher rates of skin reactivity compared with patients without, though smoking cessation may partially mitigate long-term risks. Surgeons should be aware of the risks of early skin reactivity and should counsel patients accordingly.

Population modelling and genetics of a critically endangered Madagascan palm Tahina spectabilis

Madagascar is home to 208 indigenous palm species, almost all of them endemic and >80% of which are endangered. We undertook complete population census and sampling for genetic analysis of a relatively recently discovered giant fan palm, the Critically Endangered Tahina spectablis in 2008 and 2016. Our 2016 study included newly discovered populations and added to our genetic study. We incorporated these new populations into species distribution niche model (SDM) and projected these onto maps of the region. We developed population matrix models based on observed demographic data to model population change and predict the species vulnerability to extinction by undertaking population viability analysis (PVA). We investigated the potential conservation value of reintroduced planted populations within the species potential suitable habitat. We found that the population studied in 2008 had grown in size due to seedling regeneration but had declined in the number of reproductively mature plants, and we were able to estimate that the species reproduces and dies after approximately 70 years. Our models suggest that if the habitat where it resides continues to be protected the species is unlikely to go extinct due to inherent population decline and that it will likely experience significant population growth after approximately 80 years due to the reproductive and life cycle attributes of the species. The newly discovered populations contain more genetic diversity than the first discovered southern population which is genetically depauperate. The species appears to demonstrate a pattern of dispersal leading to isolated founder plants which may eventually lead to population development depending on local establishment opportunities. The conservation efforts currently put in place including the reintroduction of plants within the species potential suitable habitat if maintained are thought likely to enable the species to sustain itself but it remains vulnerable to anthropogenic impacts.

Creating Prognostic Systems for Well-Differentiated Thyroid Cancer Using Machine Learning

Updates to staging models are needed to reflect a greater understanding of tumor behavior and clinical outcomes for well-differentiated thyroid carcinomas. We used a machine learning algorithm and disease-specific survival data of differentiated thyroid carcinoma from the Surveillance, Epidemiology, and End Results Program of the National Cancer Institute to integrate clinical factors to improve prognostic accuracy. The concordance statistic (C-index) was used to cut dendrograms resulting from the learning process to generate prognostic groups. We created one computational prognostic model (7 prognostic groups with C-index = 0.8583) based on tumor size (T), regional lymph nodes (N), status of distant metastasis (M), and age to mirror the contemporary American Joint Committee on Cancer (AJCC) staging system (C-index = 0.8387). We showed that adding histologic type (papillary and follicular) improved the survival prediction of the model. We also showed that 55 is the best cutoff of age in the model, consistent with the changes from the most recent 8th edition staging manual from AJCC. The demonstrated approach has the potential to create prognostic systems permitting data driven and real time analysis that can aid decision-making in patient management and prognostication.

Green Plants in the Red: A Baseline Global Assessment for the IUCN Sampled Red List Index for Plants

Plants provide fundamental support systems for life on Earth and are the basis for all terrestrial ecosystems; a decline in plant diversity will be detrimental to all other groups of organisms including humans. Decline in plant diversity has been hard to quantify, due to the huge numbers of known and yet to be discovered species and the lack of an adequate baseline assessment of extinction risk against which to track changes. The biodiversity of many remote parts of the world remains poorly known, and the rate of new assessments of extinction risk for individual plant species approximates the rate at which new plant species are described. Thus the question 'How threatened are plants?' is still very difficult to answer accurately. While completing assessments for each species of plant remains a distant prospect, by assessing a randomly selected sample of species the Sampled Red List Index for Plants gives, for the first time, an accurate view of how threatened plants are across the world. It represents the first key phase of ongoing efforts to monitor the status of the world's plants. More than 20% of plant species assessed are threatened with extinction, and the habitat with the most threatened species is overwhelmingly tropical rain forest, where the greatest threat to plants is anthropogenic habitat conversion, for arable and livestock agriculture, and harvesting of natural resources. Gymnosperms (e.g. conifers and cycads) are the most threatened group, while a third of plant species included in this study have yet to receive an assessment or are so poorly known that we cannot yet ascertain whether they are threatened or not. This study provides a baseline assessment from which trends in the status of plant biodiversity can be measured and periodically reassessed.

Vanda tricolor Lindl. conservation in Java, Indonesia: genetic and geographic structure and history

Vanda tricolor Lindl. is widespread in cultivation in South East Asia, being relatively easily cultivated in the garden, and is often seen growing floriferously on garden trees, fence posts and verandas. Whilst the species is widespread in cultivation in its native regions of Java and Bali, wild populations are small and highly fragmented. The author’s recent field trip to Java and Bali found few wild examples of the species, and the few plants found were in the most inaccessible trees, due to massive over-collection, often with no other V. tricolor plants to be found in the area. 

Surgeon-controlled ultrasound-guided core biopsies in the breast--a prospective study and a new use for surgeons in the clinic

AIMS

This study was to assess the accuracy of a surgeon performing ultrasound-guided core biopsies of the breast.

METHODS

A prospective audit was carried out of 555 patients who underwent an ultrasound-guided core biopsy for a discrete solid mass [under 30 mm maximum diameter] by a single surgeon. The surgeon controlled the core biopsy needle and an ultrasonographer or radiologist provided the imaging with ultrasound.

RESULTS

The accuracy of the surgeon in sampling the lesions [n = 555 core biopsies] was independent of the size of the lesion. This saved 272 patients having unnecessary surgery for a benign lesion.

CONCLUSION

The practical involvement by the surgeon in breast ultrasound and performing core biopsies has reduced pressure on the breast radiologists, reduced the number of diagnostic surgical open biopsies and made the clinic more interesting for the surgeon. With increased surgical confidence in breast ultrasound, most small and impalpable cancers have pre-operative skin marking rather than X-ray wire localization prior to undergoing wide local excision. Trainee breast surgeons should be encouraged to learn breast ultrasound and core biopsies.

Indicators of hospital closure under PPS and Blue Cross/Blue Shield cost-based reimbursements

Using an adaptation of discriminant analysis on a sample of 120 hospitals in the state of Alabama, this paper illuminates characteristics of hospitals closed due to financial failure under PPS and cost-based Blue Cross/Blue Shield reimbursement systems. The results show high debt levels, poor revenue and cost ratios, poor utilization management, and the inability to collect effectively on outstanding accounts in the year prior to hospital failure.

Missed lumbar transverse process fractures in a high school football player

OBJECTIVE

To discuss the case of a football player who had suffered a transverse process fracture of the lumbar spine that was overlooked on initial chiropractic and medical examination.

CLINICAL FEATURES

A 17-year-old male football player had been speared in the back by another player. He reported severe initial pain that caused him to fall to the ground, and there was a moderate degree of pain at the time of his chiropractic examination 1 week after injury.

INTERVENTION AND OUTCOME

Initial chiropractic treatment consisted of spinal manipulation to the lumbar spine. Follow-up care consisted of lumbar spine radiographs that showed evidence of a lumbar transverse process fracture at 2 levels. The boy was referred to his medical doctor, who was not convinced of the presence of a fracture and returned him to play. A computed tomography scan was subsequently performed; this confirmed fractures of the transverse processes of L2 and L3. The patient was precluded from contact sports for 4 weeks. Chiropractic care 3 weeks after injury included physiotherapy and drop table mobilization to the sacroiliac joints. The patient returned to play 4 weeks after the injury.

CONCLUSION

Transverse process fractures commonly occur secondary to blunt trauma in contact sports such as football. With high-force direct trauma, radiographs should be performed to rule out fracture before returning the athlete to play or commencing spinal manipulation.

Micro-trabeculae, macro-plaques or mini-basement membranes in human term fetal membranes?

Immunocytochemical confocal laser scanning microscopy and ultrastructural analysis, including immunoelectron microscopy, reveals the distribution of structures in human term amniochorion similar in some respects to basement membranes but with unusually restricted dimensions. On the basis of their immunoreactivity, these trabecular structures, found on the fibroblast layer side of the spongy layer of human term amniochorion and adjacent reticular layer, have been shown to contain type IV collagen, laminin, and nidogen. The origin of these components may be from primitive epithelial structures which pumped fluid into the lakes that eventually coalesced to form the extraembryonic coelom separating the extraembryonic somatic mesoderm from the extraembryonic splanchnic mesoderm. Such a theory of their origin might link them with the mysterious 'cellular layer', a single-cell-thick layer of cells which is usually no longer present in fetal membranes at term. The similarity in composition but not in size of these structures to anchoring plaques for type VII collagen is possible support for the view that these structures are integrators of extracellular matrix polymeric proteins. The 'pseudobasement' membrane associated with the trophoblast layer, on investigation, appears to be typical by six criteria. 'Coiled' fibrous structures in the extracellular matrix of the spongy layer may aid adjustments under tension at this shear surface by a detachable 'Velcro' or 'two spring' fastening system. The coils are rich in fibronectin. The suggestion is made that the compact layer is a giant lamina reticularis associated with the amniotic epithelial basement membrane.

Confocal and conventional immunofluorescent and immunogold electron microscopic localization of collagen types III and IV in human placenta

Confocal and conventional indirect immunofluorescence and immunogold electron microscopic methods were applied to examine the distribution of extracellular matrix constituents (collagens types III and IV) in the villi of immature and term human placentae. The immunofluorescence study revealed that collagen type III is more distinct in the villous stroma of term placenta as compared with that of the first trimester. Collagen type IV was detected mainly in endothelial and epithelial basement membranes and interestingly also to a certain extent in the stroma. Results obtained using immunoelectron microscopy support the proposal that collagen types III and IV are characteristic of stromal and basement membranes, respectively. Stromal collagen type IV is apparently localized in association with the interstitial types of collagen (I and III), in the villous stroma of term placenta.

Interferon alfa-n1 (Wellferon) in juvenile onset recurrent respiratory papillomatosis: results of a randomized study in twelve collaborative institutions

Sixty-six patients with clinically severe juvenile-onset recurrent respiratory papillomatosis (RRP) were entered into a 12-month randomized crossover study to evaluate interferon alpha-n1 Wellferon (WFN) as an adjuvant to CO2 laser surgical excision. Eligibility required disease onset to be before age 16, and an endoscopic excision requirement of at least three operations in the 6 months immediately prior to entry. Patients were randomized to Observation versus WFN at a dose of 5 MU/m2 daily for 28 days and three times weekly for 5 months. The patient groups were comparable in extent of disease at entry. Total extent of disease was determined by a composite score derived from the number of diseased anatomic sites and extent of surface area and lumen encroachment present at each site. Standard endoscopic excisions were performed every 2 months and clinical courses compared on a basis of composite scores determined at each endoscopy. Statistically significant improvement occurred in the patient group which received WFN. We conclude that interferon alpha n-1 is an effective adjuvant to surgery in RRP management.