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Background Mental health issues are increasingly prevalent across Canada, reflected in rising presentations to emergency departments. To effectively address the needs of children and youth seeking mental health-related care in the emergency department and to judiciously use scarce mental health-related resources, we need to better identify the specific areas of psychosocial needs and accessibility of associated services. Objective To describe the types and severity of paediatric mental health-related presentations evaluated at a quaternary paediatric emergency department, and to explore the accessibility of community mental health-related resources. Methods We conducted a retrospective cohort study of children and youth presenting to a quaternary paediatric emergency department who were assessed using HEARTSMAP, a validated mental health assessment and management tool. We reported the proportion who sought care for a psychiatric, social, or youth health-related mental health complaint. We contacted community mental health-related resources for their estimated wait times to determine accessibility. Results Of 1,530 paediatric emergency presentations, 98.8% of patients had psychiatric issues (40.1% were severe), 78.0% of patients had social issues (17.1% were severe), and 71.5% had youth health issues (18.1% were severe). We contacted 123 community mental health-related resources. Community youth health and social services were somewhat accessible, with 50.0% and 38.7%, respectively, able to intake youth within a week of referral. Community psychiatric programs were least accessible, with 59.3% having wait times greater than 1 month. Conclusions Many psychiatric concerns presenting in paediatric emergency departments have complex psychosocial challenges requiring non-psychiatric support. A need exists for improved accessibility to community psychiatric programs. [ABSTRACT FROM AUTHOR]

ECOG 1696 was a Phase II multi-center trial testing vaccination with melanoma peptides, gp100, MART-1 and tyrosinase delivered alone, with GM-CSF, IFN-α2b or both cytokines to HLA-A2+ patients with metastatic melanoma. Here, the frequency of circulating CD8+tetramer+ (tet+) T cells and maturation stages of responding T cells were serially monitored and compared with baseline values in a subset of patients ( n = 37) from this trial. Multiparameter flow cytometry was used to measure the frequency of CD8+ T cells specific for gp100, MART-1, tyrosinase and influenza (FLU) peptides. Expression of CD45RA/CCR7 on CD8+tet+ T cells and CD25, CD27, CD28 on all circulating T cells was determined. Vaccine-induced changes in the CD8+tet+ T cell frequency and phenotype were compared with results of IFN-γ ELISPOT assays and with clinical responses. The frequency of CD8+tet+ T cells in the circulation was increased for the melanoma peptides ( p < 0.03-0.0001) but not for FLU ( p < 0.9). Only gp100- and MART-1-specific T cells differentiated to CD45RA+CCR7- effector/memory T cells. In contrast to the IFN-γ ELISPOT frequency, previously correlated with overall survival (Kirkwood et al., Clin Cancer Res 2009;15:1443-51), neither the frequency nor differentiation stage of CD8+tet+ T cells correlated with clinical responses. Delivery of GM-CSF and/or IFN-α2b had no effects on the frequency or differentiation of CD8+tet+, CD8+ or CD4+ T cells. Phenotypic analyses of CD8+tet+ T cells did not correlate with clinical responses to the vaccine, indicating that functional assessments of peptide-specific T cells are preferable for monitoring of anti-tumor vaccines. [ABSTRACT FROM AUTHOR]

The article discusses the use of robot-assisted surgery in treatment of head, neck and skull base tumors. These surgeries are gaining a lot of popularity due to various reason including minimally invasive approaches, reduction in surgery duration and recovery time, overall low risks. Transoral robotic surgery may prove to be a more accurate way to treat head, neck and skull base cancer, while allowing for decreased levels of morbidity and decreased levels of adjuvant radiation and chemotherapy.

Objectives/Hypothesis: The purpose of this study was to determine the regional recurrence rate of node-positive oropharyngeal squamous cell carcinoma (OPSCC) in patients undergoing transoral robotic surgery (TORS) and selective neck dissection (SND) followed by observation, radiation, or concurrent chemoradiation. Study Design: A prospective, phase I, single-arm study was conducted. All OPSCC patients who voluntarily participated in a surgical trial with TORS and SND at an academic tertiary referral center from May 2005 to July 2007 were included. Methods: Thirty-one patients with previously untreated OPSCC undergoing TORS and SND (29 unilateral and two bilateral) were included. There were 29 males and two females, with ages ranging from 36 to 76 years (median = 55 years) with one palate, one lateral wall, 17 tonsil, 11 base of tongue, and one vallecula primary tumor classified as follows: T1 (n = 9, 29%), T2 (n = 15, 48.4%), T3 (n = 7, 22.6%), N0 (n = 6, 19.4%), N1 (n = 15, 48.4%), N2b (n = 10, 32.3%), and N2c (n = 1, 3.2%). There were three stage I (9.7%), two stage II (6.5%), 15 stage III (48.4%) and 11 stage IVa (35.5%) patients. Twenty-two patients were treated postoperatively with adjuvant therapy (12 radiation alone and 12 combined radiation and chemotherapy). Primary outcome measured was regional recurrence rate. Results: There was one regional recurrence on the contralateral, non-operated neck and one distant recurrence among the 31 patients who underwent SND. Conclusions: SND after TORS resection of primary OPSCC enables the use of selective and deintensified adjuvant therapy to reduce regional recurrence rates. Laryngoscope, 2010 [ABSTRACT FROM AUTHOR]

Objective: 1) Investigate a novel technology called narrow band imaging (NBI) in the detection of laryngopharyngeal reflux (LPR). 2) Compare mucosal abnormalities using NBI to conventional fiberoptic white‐light laryngoscopy. Method: A prospective case‐control pilot study on the usage of NBI to identify mucosal abnormalities in patients with LPR at a tertiary referral center from July 2010 to February 2011. RFS scores were calculated using white‐light endoscopy. NBI was used to characterize endoscopic findings. Video images were reviewed by two blinded laryngologists. Results: Twelve adult patients with LPR based on RSI scores and 11 normal adult controls were included. Reflux symptom index (RSI) greater than 13 and reflux finding score (RFS) greater than 11 were significantly correlated. NBI findings were graded on 2 vascular patterns and number of laryngeal sites involved. NBI was scored on a scale of 0 to 2 based on degree of color compared with background. Subsites were graded as 1 for 1 subsite and 2 for 2 or more subsites. Higher RFS were associated with lacey and punctuate patterns, as well as increased number of laryngeal sites involved. Conclusion: This pilot study has demonstrated various vascularity and morphologic patterns in mucosa visualized on NBI examination of patients with LPR. Preliminary results indicate that NBI may be a useful aid in the diagnosis of LPR, but a larger study size and standardized methods of quantification of LPR changes are recommended. [ABSTRACT FROM AUTHOR]

Objective: 1) To describe a new technique for prefabricating a fasciomucosal flap on the forearm. 2) To report initial outcomes of reconstruction using this technique for small oral defects. 3) To learn how to apply and customize the prelaminated radial forearm fasciomucosal flap for reconstruction of the head and neck. Method: This is a case series of 3 patients who underwent reconstruction with a prelaminated radial forearm fasciomucosal flap for small lip or oropharyngeal defects at a tertiary referral center from September 2011 to December 2011. Initial clinical outcomes are described and patient photographs are shown. Results: We prelaminated and successfully transferred 3 flaps in 3 male patients ranging in age from 46 to 53 years. These patients required reconstruction of a lip (n = 1) or oropharyngeal (n = 2) defect after removal of a head and neck arteriovenous malformation (n = 2) or cancer (n = 1). All flaps were prelaminated utilizing morcelized buccal mucosa grafts. Second stage transfer typically occurred approximately 2 to 3 weeks after prelamination. There were no intraoperative complications and no postoperative bleeding, infection, or flap failures. Reconstruction was stable and satisfactory at a range of 2‐5 months following surgery. Conclusion: The prelaminated radial forearm fasciomucosal flap using morcelized buccal mucosa for aerodigestive defects minimizes donor site morbidity and allows for mucosal restoration. A larger multisite study will provide more information on clinical outcomes. [ABSTRACT FROM AUTHOR]

Objective: 1) Describe a novel operative technique using a posteriorly pedicled nasoseptal flap (NSF) for reconstruction of secondary palatal defects. 2) Report initial outcomes of patients with secondary palatal defects who underwent NSF palatal reconstruction. Method: Case series of 5 patients who underwent NSF for repair of secondary palatal defects at a tertiary referral center from October 2008 to October 2010. A NSF pedicled on the posterior nasoseptal artery was used for coverage of palatal defects. Clinical outcomes and images will be presented. Results: Two patients had secondary palatal defects from prior tumor resection, 1 patient had a traumatic injury, 1 patient had granulomatous disease, and 1 patient had a palatal defect after Le Fort I advancement. Area of defects ranged from 0.5 to 7cm2. Initial outcomes reveal that all defects less than 1cm in width (n = 3) closed successfully and defects larger than 2cm in width (n = 2) did not completely close. There were no intraoperative complications. All patients had complete intranasal healing by 6 weeks postoperatively. There were no postoperative bleeding, infectious, or wound complications, as well as no cerebrospinal fluid leaks. Conclusion: Secondary palatal defects are challenging and reconstruction with vascularized tissue is desirable. A posteriorly pedicled nasoseptal flap offers a novel option to repair palatal defects. The success rate for small defects is promising with minimal donor site morbidity. [ABSTRACT FROM AUTHOR]

Introduction: Rosai-Dorfman disease (RDD) is a rare benign lymphocytic disorder characterized by idiopathic histiocytic proliferation affecting lymph nodes. RDD in the central nervous system (CNS) without nodal disease is exceedingly uncommon. We describe a rare case of extensive multifocal RDD involving the CNS, skull base, and paranasal sinuses. We review the literature and propose a surgical strategy to manage extensive multifocal disease. Methods: This 39 year-old-male with known RDD and multiple previous surgeries for intracranial and spinal RDD lesions presented with worsening spasticity, gait dysfunction, left facial pain and numbness, and mild dysphagia. Neuroimaging demonstrated multifocal enhancing dural-based lesions in the brain including right frontal, right temporal, right cerebellopontine angle, left clinoidal, left petroclival and bilateral Meckel's cave lesions. There was progressive growth of the left petroclival lesion causing symptomatic brainstem compression. The patient also had obstructive sleep apnea due to RDD occupying the entire nasal and paranasal sinuses. Results: The patient underwent a left-sided retrolabyrinthine transpetrosal-transtentorial approach to remove the left petroclival tumor and decompress the brainstem. The mass was carefully dissected off of cranial nerves IV through XI with excellent decompression of the brainstem. Endoscopic resection of the paranasal sinus mass was performed at a later date. Histologically, both masses were consistent with RDD. Conclusions: Extensive multifocal RDD involving the brain, spine, and paranasal sinuses is exceedingly rare and often mimic meningiomas on imaging. Surgical management can be challenging. We recommend a conservative approach with close observation and reserve surgical treatment for enlarging symptomatic lesions. [ABSTRACT FROM AUTHOR]

The presence of frontal cells poses unique challenges when using endoscopic approaches. This study describes the use of a balloon dilation system as an aid for functional endoscopic sinus surgery (FESS) to access the frontal sinus in cases that would traditionally require open approaches. We present a case series of four patients with chronic rhinosinusitis refractive to medical management who underwent FESS with the aid of a balloon dilation system at a tertiary referral center. All patients had variant forms of frontal sinus anatomy. Surgical techniques will be described and use of the balloon system will be reviewed. All patients (aged 13-68 years) successfully underwent fontal sinusotomies with the assistance of a balloon dilation system, which was used in a variety of ways: to dilate the narrow infundibulum of a high intersinus septal cell, to remove an anteriorly located type III frontal sinus cell, to expand the natural frontal ostium in the presence of excessive agger nasi pneumatization, and to remove a type IV frontal sinus cell. All patients were spared an osteoplastic flap or trephination, and there were no intraoperative complications. No postoperative bleeding, infection, or cerebral spinal fluid leaks were reported. Balloon dilation in combination with standard frontal sinus dissection techniques may be beneficial for a select group of patients with complex frontal anatomy. In this series of patients, the balloon dilation system was used as a tool during FESS and eliminated the need for open approaches.