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A systematic review and meta-analysis was conducted to evaluate the occult contralateral nodal metastases (OCM) in patients undergoing bilateral neck dissection for surgically treated oropharyngeal squamous cell carcinoma (OPSCC). Following PRISMA guidelines, MEDLINE, Embase and Cochrane Controlled Register of Trials databases were searched for observational and experimental studies until March 2021. Search yielded 175 articles, of which 13 were included. Overall, OCM were seen in 9.8% of patients (95% CI: [5.7, 16.4], 839 patients, 12 studies, I 2 65%). For ipsilateral cN0 necks, the OCM rate was 1.7% (95% CI: [0.1, 22.4], 150 patients, 8 studies, I 2 0%) and for cN + necks the OCM rate was 9.8% (95% CI: [4.4, 20.3], 429 patients, 8 studies, I 2 72%). Occult contralateral nodal metastases are uncommon in OPSCC patients with clinico-radiologically negative ipsilateral necks. Occult rates are higher in the contralateral neck when the ipsilateral neck is clinico-radiologically node positive. [ABSTRACT FROM AUTHOR]

We investigated the quality of life (QoL), functional, and oncological outcomes after robotic-assisted transoral or combined cervical-transoral salvage surgery for oropharyngeal carcinoma following radiotherapy. We performed a single tertiary referral center, prospective, observational cohort study of all consecutive patients who underwent salvage robotic-assisted surgery for oropharyngeal carcinoma between 2015 and 2021. The primary outcomes were quality of life assessments using the MDADI, EORTC-QLQC30, and EORTC-QLQH&N35. Secondary endpoints were the functional and oncological outcomes based on overall survival, disease-free survival, and local control. A consecutive cohort of 53 patients were included. The median Charlson comorbidity index was 5. The p16 status was negative in 87%, and 22.6% were T3-4. A flap reconstruction was performed in 90.6%, with a free flap in 67.9%. Margins were negative in 81.1%. The preoperative, 1-year, and 2-year MDADI total scores were 71.4, 64.3, and 57.5, respectively. The preoperative, 1-year, and 2-year QLQ-C30 global scores were 61.2, 59.4, and 80.6, respectively. Decannulation was possible in 97.1% of the tracheotomized patients. The two-year enteral tube dependence was 23.1%. The two-year overall survival, disease-free survival, and local control rates were 59%, 46.1%, and 80.9%, respectively. Robotic-assisted salvage surgery for oropharyngeal carcinoma following radiotherapy demonstrated a very satisfactory quality of life, good functional sequelae, and good oncological outcomes compared to historical approaches. [ABSTRACT FROM AUTHOR]

Nonsurgical primary treatment of early and advanced laryngeal squamous cell carcinoma, employing radiotherapy with or without chemotherapy, is considered a standard of care in many centers throughout the world. When patients have persistent or recurrent disease after non-surgical treatment, salvage surgery is frequently the only remaining potentially curative treatment. Depending on the extent of the residual/recurrent disease, different surgical salvage options are at the surgeon's disposal. In selected cases with limited local disease, salvage transoral laser microsurgery, transoral robotic surgery and open partial laryngectomies can be employed to achieve cure while preserving laryngeal function. For more advanced cases total laryngectomy is necessary. Identifying situations with unacceptable results from surgical salvage may guide future therapies. [ABSTRACT FROM AUTHOR]

Trans-oral robotic surgery (TORS) was approved by the FDA in 2009 and over the past decade head and neck surgeons have adopted the technology for the benefit of their patients. Whilst the surgical methods have evolved, there has been little consideration about the pathological assessment of the specimens and a lack of understanding around the oncological principles that underpin minimally invasive surgical techniques in the head and neck region. This article will highlight the issues encountered during the reporting of TORS specimens. The challenges include identifying anatomical boundaries, block selection, assessment of resection margins, the use of intra-operative frozen sections, the assessment of tongue base mucosectomies for patients with head and neck cancer of unknown primary, and TORS for recurrent disease. The article will conclude with emerging innovations, including i-Knife, narrow band imaging and the potential of step serial sections to identify sub-clinical HPV-related oropharyngeal squamous cell carcinomas. [ABSTRACT FROM AUTHOR]

Clinical staff who work in healthcare settings experience work-related stress which can lead to emotional and physical burnout, anxiety, depression, and poorer mental wellbeing. In the general population, exercise and physical activity are associated with greater mental wellbeing, reduced incidence of depression, improvements in mood and sleep quality, and reductions in stress. The aim of this systematic review was to investigate the effects of exercise and physical activity interventions, delivered both in the workplace and outside of work, on mental wellbeing, stress, burnout, depression, anxiety, and sleep in healthcare professionals. Major databases were searched from inception to June 2023 for intervention studies investigating aerobic, non-aerobic exercise and resistance training, or interventions designed to increase physical activity amongst healthcare workers. Study quality was assessed using Cochrane and Effective Public Health Practice Project (EPHPP) checklists. The search retrieved 16 intervention studies, including 11 randomised controlled trials (RCTs). There was consistent evidence of a reduction in psychological stress (3/3, 100% of RCTs) and improvement of sleep quality (3/4, 75%) following exercise compared to non-active controls. There was inconclusive evidence regarding the effects of exercise and physical activity on mental wellbeing, depression severity, burnout, traumatic stress, and fatigue. Neither exercise nor physical activity appeared to reduce symptoms of anxiety. Exercise and interventions to increase physical activity may be a viable and effective intervention to improve some aspects of mental wellbeing in healthcare professionals, although more large-scale, high-quality trials are needed to establish the full range of benefits. • Physical activity can be successfully implemented for healthcare staff. • Physical activity may improve perceived stress amongst healthcare staff. • More research is needed to determine the full range of benefits for staff. [ABSTRACT FROM AUTHOR]

Background Rural patients with atherosclerotic cardiovascular disease (ASCVD) experience greater cardiovascular morbidity and mortality than their urban counterparts. Statin therapy is a key component of ASCVD treatment. The extent to which there may be regional differences in long-term adherence to statins is unknown. Objective To assess long-term rates of adherence to statins in a high-risk ASCVD cohort, and whether regional differences exist between rural and urban patients. Methods Follow-up was conducted in patients who underwent coronary angiography at a single tertiary center between 2009 and 2013. Adherence was defined as consumption of prescribed statin ≥6 days per week. Patients were divided into remoteness areas (RAs), classified as RA1 (major city), RA2 (inner regional), and RA3 (outer regional) based on the Australian Standard Geographical Classification. Results Five hundred twenty-five patients (69% male, mean age 64 ± 11 years) were followed-up after a median of 5.3 years. Baseline characteristics were similar between RAs. Overall adherence was 83%; however, rural patients were significantly more adherent to their statin therapy (80% in RA1, 83% in RA2, and 93% in RA3, P =.04). Living in RA3 independently predicted greater statin adherence than living in RA1 (odds ratio: 2.75, 95% CI: 1.1–7.8, P =.03). All-cause mortality was significantly higher in RA3 than other regional areas (6% RA1, 12% RA2, and 18% RA3, P =.01). Conclusions Despite higher all-cause mortality, rural patients with ASCVD demonstrate significantly greater long-term adherence to statins than urban patients. Other factors, such as reduced access to health care and delayed diagnosis may explain the gap in outcomes between rural and urban patients. Highlights • Long-term statin adherence is suboptimal in patients at high atherosclerotic risk. • Rural patients are significantly more adherent than urban patients. • Despite greater adherence, all-cause mortality is greater in rural populations. • Poorer access to health services and delayed diagnosis are likely contributory. [ABSTRACT FROM AUTHOR]

Our aim was to examine the clinicopathological features of squamous cell carcinoma (SCC) of the oral cavity and oropharynx in a group of young patients who were dignosed during a 15-year period (2000–2014). Patients’ clinical details, risk factors, and survival were obtained from medical records. Formalin-fixed, paraffin-embedded, tissue was tested for high-risk human papillomavirus (HPV). The results were compared with those of a matching group of older patients. We identified 91 patients who were younger than 45 years old, and the 50 youngest patients were studied in detail. The male:female ratio was 2:1, with more tumours located in the oral cavity than in the oropharynx (35 compared with 15). HPV-related SCC was restricted to the oropharynx. When matched for site, stage and HPV status, five-year overall survival was similar in young and matched older patients (log-rank test, p = 0.515). Our findings suggest that young patients with oral SCC have a disease profile similar to that of older patients with the condition. It is plausible that prognostic information generally available for oral cancers is applicable to young patients with the disease. [ABSTRACT FROM AUTHOR]

Morbidity and mortality associated with increasingly radical doses of chemoradiotherapy have led many to question the current standard of care in head and neck cancer. Recently, surgeons have developed minimally invasive, transoral techniques which have demonstrated excellent survival and favourable functional outcomes. Transoral robotic surgery (TORS) is the most recent, cutting edge in the evolution of transoral techniques; TORS allows surgeons unprecedented access to and visualisation of the upper aerodigestive tract. Early reports of TORS in the head and neck are favourable in both primary and recurrent disease. TORS has a role in the assessment of the patient with unknown primary and in the de-intensification of therapy in patients with cancers secondary to human papilloma virus. In this review we discuss the practical set up and technical features of TORS surgery and the application of TORS in primary and recurrent disease, and carcinoma of unknown primary. We outline the current ongoing research into the use of this technique and set out the vision for the future of this surgical modality. Surgical care for upper aerodigestive tract cancers has changed dramatically over the last three decades with technological advances in tumour imaging and resection. Recent advances in mechanical instrumentation and energy devices allow surgeons to remove head and neck cancers transorally; it is only rarely that the extrinsic muscles of the neck and the tongue are involved and the transoral route leads to reduced disruption of the external musculature, quicker recovery and a better functional outcome. In this review we will focus exclusively on the advances in transoral robotic surgery which have transformed the shape of resective head and neck cancer surgery. [ABSTRACT FROM AUTHOR]

Our aim was to identify the set of referral criteria that will offer optimal diagnostic efficacy in patients suspected to have head and neck cancer (HNC) in the primary care setting. We analysed the referral criteria and outcomes from two tertiary care cancer centres in the United Kingdom. Between 2007 and 2010, 4715 patients were referred via the fast track system with a suspected HNC. The main outcome measures were the parameters of diagnostic efficacy, a multivariate regression model to calculate estimated probability of HNC and the area under the receiver operating characteristic curve (AUROC). We found that the majority of referring symptoms had a positive predictive value higher than the 3% cut-off point stated to be significant for HNC detection in the 2015 NICE recommendations. Nevertheless, our multivariate analysis identified 9 symptoms to be linked with HNC. Of these, only 4 are included in the latest NICE guidelines. The best fit predictive model for this dataset included the following symptoms: hoarseness>3 weeks, dysphagia>3 weeks, odynophagia, unexplained neck mass, oral swelling >3 weeks, oral ulcer >3weeks, prolonged otalgia with normal otoscopy, presence of blood in mouth with concurrent sensation of lump in throat, and presence of otalgia with concurrent lump in throat sensation. Intermittent hoarseness and sensation of lump in throat were negatively associated with HNC. The AUROC demonstrated that our model had a higher predictive value (0.77) compared to those generated using the NICE 2005 (0.69) and 2015 (0.68) referral criteria (p<0.0001). An online risk calculator based on this study is available at http://www.orlhealth.com/risk-calculator.html . This paper presents a significantly refined version of referral guidelines which demonstrate greater diagnostic efficacy than the current NICE guidelines. We recommend that further iterative refinements of referral criteria be considered when referring patients with suspected HNC. [ABSTRACT FROM AUTHOR]

Summary: Introduction: The superficial circumflex iliac artery perforator (SCIP) flap is a modification of the groin flap using perforators of the superficial circumflex iliac artery (SCIA). It has mainly been used in lower-limb reconstruction with no descriptions in the literature of its use in intra-oral soft-tissue head and neck reconstruction. This article reports the initial Newcastle experience. Methods: Data were gathered prospectively for the first five head and neck patients with SCIP flap reconstruction. All patients had a speech and swallowing assessment as part of their post-operative follow-up. Results: An SCIP flap was used following the resection for four intra-oral squamous cell carcinomas (SCCs) and one pharyngeal SCC. There was no flap compromise and excellent functional outcome at 6 months. The donor-site morbidity was minimal with direct closure achieved in each case leaving a scar easily concealed in the groin crease. Conclusions: Overall, the results at both the primary and donor sites in our first five cases have been aesthetically and functionally excellent. The flap pedicle easily reached the common recipient vessels in the neck. The vessels can be of smaller calibre but well within the scope of the microsurgeon. The SCIP flap appears to offer a thin, pliable, reliable flap with an excellent donor site. [Copyright &y& Elsevier]

BACKGROUND: Different modalities of treatment in early laryngeal cancer lead to equivalent oncological outcomes. Hence this systematic review was undertaken to synthesise the key oncological outcomes following primary open partial laryngectomy for laryngeal cancer. METHODS: A systematic review of the English literature with statistical pooling of outcomes, the main outcome measure being local control at 24months. RESULTS: A total of 53 articles satisfied inclusion criteria and were included in the review. The pooled local control rate at 24months from 5061 patients was 89.8% (95% CI 88.3-91.2), pooled overall survival was 79.7% (n=3967; 95% CI 76.5-782.8) and pooled mean disease free survival was 84.8% (n=2344; 95% CI 80.6-88.7). The pooled mean operative mortality, laryngectomy for function, tracheostomy decannulation and permanent gastrostomy rates were 0.7%, 1.7%, 96.3%, and 2.0%, respectively. CONCLUSIONS: Open conservation laryngectomy is a good option in selected primary laryngeal cancers with excellent oncological outcomes. [ABSTRACT FROM AUTHOR]

Summary: Comorbidity, the presence of additional illnesses unrelated to the tumor, has a significant impact on the prognosis of patients with head and neck cancer. In these patients, tobacco and alcohol abuse contributes greatly to comorbidity. Several instruments have been used to quantify comorbidity including Adult Comorbidity Evaluation 27 (ACE 27), Charlson Index (CI) and Cumulative Illness Rating Scale. The ACE 27 and CI are the most frequently used indices. Information on comorbidity at the time of diagnosis can be abstracted from patient records. Self-reporting is less reliable than record review. Functional status is not a reliable substitute for comorbidity evaluation as a prognostic measure. Severity as well as the presence of a condition is required for a good predictive instrument. Comorbidity increases mortality in patients with head and neck cancer, and this effect is greater in the early years following treatment. In addition to reducing overall survival, many studies have shown that comorbidity influences disease-specific survival negatively, most likely because patients with high comorbidity tend to have delay in diagnosis, often presenting with advanced stage tumors, and the comorbidity may also prompt less aggressive treatment. The impact of comorbidity on survival is greater in younger than in older patients, although it affects both. For specific tumor sites, comorbidity has been shown to negatively influence prognosis in oral, oropharyngeal, laryngeal and salivary gland tumors. Several studies have reported higher incidence and increased severity of treatment complications in patients with high comorbidity burden. Studies have demonstrated a negative impact of comorbidity on quality of life, and increased cost of treatment with higher degree of comorbidity. Our review of the literature suggests that routine collection of comorbidity data will be important in the analysis of survival, quality of life and functional outcomes after treatment as comorbidity has an impact on all of the above. These data should be integrated with tumor-specific staging systems in order to develop better instruments for prognostication, as well as comparing results of different treatment regimens and institutions. [Copyright &y& Elsevier]

Introduction: Resection of head and neck cancer with positive margins is a crucial prognostic factor, yet no reliable intraoperative diagnostic adjuncts exist. Rapid Evaporative Ionisation Mass Spectrometry (REIMS/iKnife) can analyse smoke generated by dissection with electrocautery to provide near instant tissue classification. However, REIMS has never been investigated in head and neck cancer in vivo. We designed an IDEAL stage 2a developmental study, aiming to evaluate the validity of our diagnostic model, and develop a feasible protocol for a subsequent clinical trial. Methods: Previously-irradiated patients undergoing transoral robotic surgery at the Royal Marsden for recurrence were prospectively recruited (REC: 14/EE/0024). Intraoperative REIMS data was captured and synchronised with the video feed. The surgeon was blinded to REIMS data throughout the procedure. Univariate and multivariate analyses were conducted using AMX, R and Python. Results: 7 patients have been recruited to date (target 20). All were male. Median age was 63 (range 58-74). 4/7 had HPV-positive disease. REIMS signal was successfully acquired in 100% of cases, but was less reliable during deeper dissection. Tumour signals were successfully classified, as were normal tissue types such as muscle and mucosa, in over 95% of captured signal. Metabolic species potentially contributing to classification were identified, including phospholipids, glycerophospholipids and ceramides previously associated with carcinogenesis. Conclusions: REIMS near-instantaneously distinguishes head and neck cancer from normal tissue intraoperatively. We are iteratively developing engineering solutions to optimise signal collection. Recruitment is ongoing. An optimised protocol will allow design of a clinical trial to evaluate the impact of REIMS on survival outcomes. [ABSTRACT FROM AUTHOR]

We propose a new algorithm for partial redundancy elimination based on the new concepts of safe partial availability and safe partial anticipability. These new concepts are derived by the integration of the notion of safety into the definitions of partial availability and partial anticipability. The algorithm works on flow graphs whose nodes are basic blocks. It is both computationally and lifetime optimal and requires four unidirectional analyses. The most important feature of the algorithm is its simplicity; the algorithm evolves naturally from the new concept of safe partial availability. [Copyright &y& Elsevier]

This study targets the value-added engineering applications of Distillers' dried grains with solubles (DDGS), a co-product from corn ethanol industry in lightweight biocomposites. The DDGS derived carbonaceous materials produced through torrefaction and pyrolysis were used as fillers for the manufacture of polypropylene (PP) based biocomposites. A systematic study was conducted for the first time in scientific literature in which the DDGS was heat treated from 100 to 1000 °C (torrefaction; 200–300 °C and pyrolysis; 400–1000 °C) and used in the biocomposites with a fixed 30 wt % content. With increase in temperature of pyrolysis, the functional groups of the filler were removed, and the ash content was increased. The biocomposites showed their best performance in terms of stiffness-toughness balance with biocarbon pyrolyzed at 700 °C, because of its non-polarity compared to the DDGS_400 °C, and lower ash content and particle size than the DDGS_1000 °C. Comparatively improved compatibility between the DDGS_700 °C and PP resulted in higher complex viscosity and storage modulus than the rest of biocomposites. Overall, this study shows the importance of understanding and optimizing the heat treatment temperature for the production of biocarbon used as a filler in biocomposites based on the specific properties, application, yield, and hence cost effectiveness of the filler. [Display omitted] • This study targets the value-added engineering applications of Distillers' grains with solubles (DDGS), a co-product from corn ethanol industry in light-weight biocomposites. • The torrefaction/pyrolysis temperature of DDGS affected the functionality, ash content and modulus of newly engineered sustainable filler for biocomposites uses. • This is the 1st ever publication in dissipating new knowledge how the tuning of heat temperature of biomass can affect the performance of the resulting biocomposites. • Improved compatibility between the pyrolyzed DDGS and polypropylene matrix resulted in higher complex viscosity and storage modulus of the biocomposites. • Utilizing a single source of DDGS biomass, different types of biocomposites were engineered. [ABSTRACT FROM AUTHOR]

Abstract: There is controversy as to whether IIb should be dissected in the node negative neck. The aim of this survey was to ascertain how often head and neck surgical oncologists performed a level IIb neck dissection for node negative T2 and T4 tumours of the oral cavity, oropharynx and larynx, and to gauge how many might be willing to take part in a RCT of sparing IIb. A convenience sample of 110 MFU colleagues and 125 members of the ENTUK head and neck group were questioned. Response rate for the MFU was 62% and ENT 30%. A clear majority from MFU had a strong preference for including IIb in all clinical scenarios apart from laryngeal T2 tumours whilst ENT included IIb with oral cavity T4, oropharyngeal T2 and oropharyngeal T4 tumours. This survey would support the need for a multicentre study with 53 responders interested in taking part. [Copyright &y& Elsevier]

Evidence suggests that early oral feeding following laryngectomy does not increase the rate of pharyngocutaneous fistulae (PCF). These interviews aimed to gain opinions on oral feeding to assess the feasibility of a multi-centre randomised control trial of early oral feeding. One-to-one semi-structured interviews were performed with eight head and neck consultants, working in the North of England and were analyzed using qualitative methods. Consultants conceded that there was no 'scientific basis' or 'objective evidence' to the current practice of oral feeding. Three suggested they would consider feeding patients earlier, three intimated that they might do and two suggested they would not. The consultant's age did seem associated with this view. Half of the consultants felt that earlier feeding might reduce in hospital stay. Standard practice and attitudes towards feeding regimes varies amongst consultants. Six of the eight consultants may be interested in contributing patients towards a trial. Such interest and attitudes demonstrates that a multi-centre randomised controlled trial of early feeding is feasible. [ABSTRACT FROM AUTHOR]

Summary: Evidence suggests that early oral feeding following laryngectomy does not increase the rate of pharyngocutaneous fistulae (PCF). These interviews aimed to gain opinions on oral feeding to assess the feasibility of a multi-centre randomised control trial of early oral feeding. One-to-one semi-structured interviews were performed with eight head and neck consultants, working in the North of England and were analyzed using qualitative methods. Consultants conceded that there was no “scientific basis” or “objective evidence” to the current practice of oral feeding. Three suggested they would consider feeding patients earlier, three intimated that they might do and two suggested they would not. The consultant’s age did seem associated with this view. Half of the consultants felt that earlier feeding might reduce in hospital stay. Standard practice and attitudes towards feeding regimes varies amongst consultants. Six of the eight consultants may be interested in contributing patients towards a trial. Such interest and attitudes demonstrates that a multi-centre randomised controlled trial of early feeding is feasible. [Copyright &y& Elsevier]

Context: Mobile health (mHealth) provides an opportunity to use internet coverage in low- and middle-income countries to improve palliative care access and quality.Objectives: This study aimed to design a mobile phone application (app) to enable or improve communication between family caregivers, community caregivers, and palliative care teams; to evaluate its acceptability, processes, and mechanisms of action; and to propose refinements.Methods: A codesign process entailed collaboration between a Project Advisory Group and collaborators in India, Uganda, and Zimbabwe. We then trained community and family caregivers to use an app to communicate patient-reported outcomes to their palliative care providers each week on a data dashboard. App activity was monitored, and qualitative in-depth interviews explored experience with the app and its mechanisms and impact.Results: N = 149 caregivers participated and uploaded n = 837 assessments of patient-reported outcomes. These data were displayed to the palliative care team on an outcomes dashboard on n = 355 occasions. Qualitative data identified: 1) high acceptability and data usage; 2) improved understanding by team members of patient symptoms and concerns; 3) a need for better feedback to caregivers, for better prioritisation of patients according to need, for enhanced training and support to use the app, and for user-led recommendations for ongoing improvement.Conclusion: An outcomes-focused app and data dashboard are acceptable to caregivers and health-care professionals. They are beneficial in identifying, monitoring, and communicating patient outcomes and in allocating staff resource to those most in need. [ABSTRACT FROM AUTHOR]

Background: Although the concept of maintaining a period of 'nil by mouth' following head and neck reconstruction is commonly held ideas on delaying function have changed dramatically since the introduction of peri-operative care recovery programmes. This study sought to evaluate the outcomes of early feeding on patients undergoing free flap reconstruction of oral defects with particular emphasis on post-operative complications and length of stay.Methods: Data was gathered prospectively on two cohorts of patients treated in a tertiary referral centre comparing those undergoing a five-day post-operative period of 'nil by mouth' with a second group in which the aim was to start fluids and soft diet on the day following surgery. Complications and length of stay were evaluated.Results: Both early and late feeding groups comprised of 200 patients. No significant differences were observed in terms of age, gender, smoking and alcohol use or tumour T and N stages between the two groups. 8% of patients had complications at the recipient site but no difference was observed in the rates of flap dehiscence or fistula formation between the two groups. Early feeding was associated with a statistically reduced length of hospital stay (mean 11.6 days vs 20.6 days, p < 0.01).Conclusions: Early oral feeding following head and neck free flap reconstruction is not associated with an increase incidence of peri-operative complications but reduces hospital stay. The latter may have far-reaching implications for patients' physical and psychological well-being in addition to health care resources. [ABSTRACT FROM AUTHOR]