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Objectives: Self-inflicted facial gunshot wounds (GSWs) result in complex but consistent injuries that are often survivable. We suggest a novel method for rapid stratification into groups that may ...

Background Pelvic fractures cause significant morbidity in the trauma population. Many factors influence time to fracture fixation. No previous study has determined the optimal time window for pelvic fixation. Methods A retrospective review of trauma patients with pelvic fractures from 2016 to 2020 was performed. Patients were stratified into EARLY and LATE groups, by time to fixation within 3 days or greater than 3 days whether from admission or from completion of a life-saving procedure. Unpaired Student’s t-test and Fisher’s exact test were performed with multiple linear regression for variables with P < .2 on univariate analysis. Results 287 patients were identified with a median fixation time of 3 days. There was no significant difference in demographics, incidence of preceding life-saving procedure, angioembolization, or mechanism of injury in the 2 groups ( P > .05). Length of stay in the EARLY group was significantly reduced at 11.9 +/− .7 days compared to 18.0 +/−1.2 days in the LATE group ( P < .001). There was no significant difference in rates of ventilator-associated pneumonia, deep vein thrombosis, pulmonary embolism (PE), acute kidney injury (AKI), pressure ulcer, or acute respiratory distress syndrome (ARDS) ( P > .05). There were significantly more SSIs (surgical site infections) in the LATE group. After multiple linear regression adjusting for covariates of age and ISS, the difference in hospital LOS was 5.5 days (95% CI −8.0 to −3.1, P < .001). Discussion Fixation of traumatic pelvic fractures within 3 days reduced LOS. Prospective multi-center studies will help identify additional factors to decrease time to surgery and improve patient outcomes.

Private higher education has become increasingly important in China which has the largest numbers of students enrolled in private universities in the world. The Chinese government, in an attempt to regulate the sector, issued legislation in 2016 which required private universities to classify and register themselves as either for-profit or not-for-profit. However, implementation of the policy is slow and the majority of private universities so far have not re-registered their legal status. This study reports on an empirical investigation of the factors that have affected implementation of the policy through interviews with stakeholders involved in Chinese private HE, and an examination of policy documents. It fills a gap in the English language study of the classification management as for-profit or not-for-profit of private universities. As such, it provides insight into practice for policymakers and academics in the field of governance of private universities.

Aims Debate remains whether the patella should be resurfaced during total knee replacement (TKR). For non-resurfaced TKRs, we estimated what the revision rate would have been if the patella had been resurfaced, and examined the risk of re-revision following secondary patellar resurfacing. Methods A retrospective observational study of the National Joint Registry (NJR) was performed. All primary TKRs for osteoarthritis alone performed between 1 April 2003 and 31 December 2016 were eligible (n = 842,072). Patellar resurfacing during TKR was performed in 36% (n = 305,844). The primary outcome was all-cause revision surgery. Secondary outcomes were the number of excess all-cause revisions associated with using TKRs without (versus with) patellar resurfacing, and the risk of re-revision after secondary patellar resurfacing. Results The cumulative risk of all-cause revision at ten years was higher (p < 0.001) in primary TKRs without patellar resurfacing (3.54% (95% confidence interval (CI) 3.47 to 3.62)) compared to those with resurfacing (3.00% (95% CI 2.91 to 3.11)). Using flexible parametric survival modelling, we estimated one ‘excess’ revision per 189 cases performed where the patella was not resurfaced by ten years (equivalent to 2,842 excess revisions in our cohort). The risk of all-cause re-revision following secondary patellar resurfacing was 4.6 times higher than the risk of revision after primary TKR with patellar resurfacing (at five years from secondary patellar resurfacing, 8.8% vs 1.9%). Conclusion Performing TKR without patellar resurfacing was associated with an increased risk of revision. Secondary patellar resurfacing led to a high risk of re-revision. This represents a potential substantial healthcare burden that should be considered when forming treatment guidelines and commissioning services. Cite this article: Bone Joint J 2021;103-B(5):864–871.

Introduction The ability of rescuers to maintain contact with incident command (IC) and each other is a critical component of search and rescue (SAR) operations. When rescuers lose radio communication with operation leaders, the effectiveness of operations may be substantially affected. This often occurs owing to the limitations of standard communications equipment in difficult terrain or when victims are beyond line-of-sight. This study investigates the viability of using an aerial drone-repeater system configuration to restore and maintain radio communications between IC and deployed rescuers. Methods SAR operators in Southern Utah identified 10 areas where radio communication is compromised during live rescue operations. Trained SAR personnel were deployed to these areas in a mock exercise. After confirmed loss of communication, a repeater-equipped aerial drone was piloted 122 m above IC to restore communication. Once restored, communication was assessed at regular intervals for the duration of the mock deployment. Results In all 10 areas tested, communication was successfully restored. In all cases, once communication was restored, no additional loss of radio contact occurred. The time between communication loss and restoration across the 10 scenarios was 6.5±1.1 (4.4–9.3) min (mean±SD with range). Conclusions This method of restoring radio communication among SAR personnel could drastically improve the ability to assist victims and help mitigate the risks faced by rescuers. SAR leaders should be made aware of the useful applications of drones during SAR operations, especially in instances where communication is compromised.

Internists frequently care for patients who suffer from breathlessness in both the inpatient and the outpatient settings. Patients may experience chronic refractory breathlessness despite thorough evaluation and management of their underlying medical illnesses. Left unmanaged, chronic breathlessness is associated with worsened quality of life, more frequent visits to the emergency room, and decreased activity levels, as well as increased levels of depression and anxiety. This narrative review summarizes recent research on interventions for the relief of breathlessness, including both non-pharmacologic and pharmacologic options.

The coronavirus disease 2019 (COVID-19) pandemic is a slow-moving global disaster with unique challenges for maintaining trauma center operations. University Medical Center New Orleans is the only level 1 trauma center in New Orleans, LA, which became an early hotspot for COVID-19. Intensive care unit surge capacity, addressing components including space, staff, stuff, and structure, is important in maintaining trauma center operability during a high resource-strain event like a pandemic. We report management of the trauma center’s surge capacity to maintain trauma center operations while assisting in the care of critically ill COVID-19 patients. Lessons learned and recommendations are provided to assist trauma centers in planning for the influx of COVID-19 patients at their centers.

As the Coronavirus disease 2019 (COVID-19) pandemic spread to the US, so too did descriptions of an associated coagulopathy and thrombotic complications. Hospitals created institutional protocols for inpatient management of COVID-19 coagulopathy and thrombosis in response to this developing data. We collected and analyzed protocols from 21 US academic medical centers developed between January and May 2020. We found greatest consensus on recommendations for heparin-based pharmacologic venous thromboembolism (VTE) prophylaxis in COVID-19 patients without contraindications. Protocols differed regarding incorporation of D-dimer tests, dosing of VTE prophylaxis, indications for post-discharge pharmacologic VTE prophylaxis, how to evaluate for VTE, and the use of empiric therapeutic anticoagulation. These findings support ongoing efforts to establish international, evidence-based guidelines., Highlights • COVID-19 protocols agreed on heparin-based venous thromboembolism prophylaxis. • Disagreement on thrombosis risk and diagnosis, D-dimer, empiric anticoagulation • Cumulative incidence of COVID-19 did not correlate with specific recommendations. • Framework for frontline providers and hospitals to evaluate practices and outcomes

Food and power are inseparable. This essay analyzes a significant moment in transnational food history. Soviet Premier Nikita Khrushchev’s Cold War era 1959 visit to the United States has been reco...

Background Helicopter transport (HT) is an efficient, but costly, means for injured patients to receive life-saving, definitive trauma care. Identifying the characteristics of inappropriate HT presents an opportunity to improve the utilization of this finite medical resource. Methods Trauma registry records of all HT for a 3-year period (2016-2018) to an urban Level I trauma center were reviewed. HT was defined as inappropriate for patients who were discharged home from the emergency department or had a hospital length of stay Results There were 713 patients who received HT during the study period. One-hundred and forty-eight (20.8%) patients met the criteria as an inappropriate HT. In univariate analysis, Glasgow Coma Scale >8, Shock Index 55 was found to be associated with an appropriate HT. The average Injury Severity Score of the inappropriate HT group was 3.86 (±3.85) compared with 16.80 (±11.23) ( P = .0001, Student’s t-test). Discussion Our findings suggest that there are evidence-based predictors of patients receiving inappropriate HT. Triage of HT using these predictors has the potential to decrease unnecessary deployments and reduce health care costs.

Objective: To consider the association of injuries with transition periods in the dance year, i.e., when dancers return at the start of the year, and when they transition from rehearsal to performance periods. Methods: Six electronic databases were searched to November 2019. All English language peer-reviewed studies, of any study design investigating ballet and contemporary pre-professional and professional dance populations were included. Only those studies reporting on the timing of injury were included. Results: Fifteen cohort and two case-series studies were included. A meta-analysis of seven studies revealed the rate of injuries to be significantly higher for the second and third months (1.52; 95% confidence interval [CI]:1.11–2.08; 1.26; 95%CI:1.07–1.48 respectively) after the return to dance. Two further studies report more injuries up to Week 13 of the year. One study showed an increase in injured dancers at three and four weeks after transition from rehearsals to a performance season. Four studies show an increase in injuries at performance times. Conclusions: Meta-analyses of seven studies shows the second and third months after returning to dance have a significantly higher rate of injuries. More research is needed to quantify training loads in dance. Practitioners should be cognisant of the higher injury rates during periods of transition and consider modifying load, as it is a potential contributing factor.

BACKGROUND Limited data exist regarding which head and head and neck cancer (HNC) survivors will suffer from long-term dysphagia. METHODS From a population-based cohort of 1901 Utah residents with HNC and ≥3 years follow-up, we determined hazard ratio for dysphagia, aspiration pneumonia, or gastrostomy associated with various risk factors. We tested prediction models with combinations of factors and then assessed discrimination of our final model. RESULTS Cancer site in the hypopharynx, advanced tumor classification, chemoradiation, preexisting dysphagia, stroke, dementia, esophagitis, esophageal spasm, esophageal stricture, gastroesophageal reflux, thrush, or chronic obstructive pulmonary disease were associated with increased risk of long-term dysphagia. Our final prediction tool gives personalized risk calculation for diagnosis of dysphagia, aspiration pneumonia, or gastrostomy tube placement at 5, 10, and 15 years after HNC based on 18 factors. CONCLUSION We developed a clinically useful risk prediction tool to identify HNC survivors most at risk for dysphagia.

Background and AimsPatients with differentiated thyroid cancer are often advised to follow a low iodine diet (LID) one to two weeks before radioiodine remnant ablation (RRA). We describe treatment practices and ablation success rates in centres (C1, C2, C3) in the UK with different approaches to LID advice.MethodsHistoric cohort of patients with differentiated thyroid cancer treated with RRA in 2015/16 in C1 (n=50, 1-week LID), C2 (n=59, 2-week LID) and C3 (n=108, no LID advice). Response to RRA was stratified as excellent, indeterminate, or incomplete by the adapted American Thyroid Association Dynamic Risk Stratification Score.ResultsThere was little difference in age, sex and staging between centres, but the percentage receiving 1.1GBq vs higher administered activities differed (C1:22%, C2:44%, C3:15%, pConclusionsThere was no evidence that advising a LID for 2-weeks before RRA improves outcomes compared to 1-week. For definitive recommendations on LIDs prior to RRA, a prospective multi-centre study with a more homogenous approach to patient management or, randomised controlled trial, is needed.

Background Mortality and hospital readmission rates may reflect the quality of acute and postacute stroke care. Our aim was to investigate if, compared with usual care (UC), the COMPASS‐TC (Comprehensive Post‐Acute Stroke Services Transitional Care) intervention (INV) resulted in lower all‐cause and stroke‐specific readmissions and mortality among patients with minor stroke and transient ischemic attack discharged from 40 diverse North Carolina hospitals from 2016 to 2018. Methods and Results Using Medicare fee‐for‐service claims linked with COMPASS cluster‐randomized trial data, we performed intention‐to‐treat analyses for 30‐day, 90‐day, and 1‐year unplanned all‐cause and stroke‐specific readmissions and all‐cause mortality between INV and UC groups, with 90‐day unplanned all‐cause readmissions as the primary outcome. Effect estimates were determined via mixed logistic or Cox proportional hazards regression models adjusted for age, sex, race, stroke severity, stroke diagnosis, and documented history of stroke. The final analysis cohort included 1069 INV and 1193 UC patients (median age 74 years, 80% White, 52% women, 40% with transient ischemic attack) with median length of hospital stay of 2 days. The risk of unplanned all‐cause readmission was similar between INV versus UC at 30 (9.9% versus 8.7%) and 90 days (19.9% versus 18.9%), respectively. No significant differences between randomization groups were seen in 1‐year all‐cause readmissions, stroke‐specific readmissions, or mortality. Conclusions In this pragmatic trial of patients with complex minor stroke/transient ischemic attack, there was no difference in the risk of readmission or mortality with COMPASS‐TC relative to UC. Our study could not conclusively determine the reason for the lack of effectiveness of the INV. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02588664.

BackgroundOver the past three decades there have been numerous molecular biology developments that have led to an explosion in the number of gene expression studies being performed. Many of these gene expression studies publish their data to the public database GEO, making them freely available. By analysing gene expression datasets, researchers can identify genes that are differentially expressed between two groups. This can provide insights that lead to the development of new tests and treatments for diseases. Despite the wide availability of gene expression datasets, analysing them is difficult for several reasons. These reasons include the fact that most methods for performing gene expression analysis require programming proficiency.ResultsWe developed the GEOexplorer software package to overcome several of the difficulties in performing gene expression analysis. GEOexplorer was therefore developed as a web application, that can perform interactive and reproducible microarray gene expression analysis, while producing a wealth of interactive visualisations to facilitate result exploration. GEOexplorer is implemented in R using the Shiny framework and is fully integrated with the existing core structures of the Bioconductor project. Users can perform the essential steps of exploratory data analysis and differential gene expression analysis intuitively and generate a broad spectrum of publication ready outputs.ConclusionGEOexplorer is distributed as an R package in the Bioconductor project (http://bioconductor.org/packages/GEOexplorer/). GEOexplorer provides a solution for performing interactive and reproducible analyses of microarray gene expression data, empowering life scientists to perform exploratory data analysis and differential gene expression analysis on GEO microarray datasets.

The complex web of political-economic relations that constitutes biotechnology coupled with a contentious history of public resistance, illustrates the power of perceptions of credibility in mediat...

Pulmonary manifestations of inflammatory bowel disease are increasingly recognized in patients with ulcerative colitis and Crohn's disease. Most commonly, incidental abnormalities are noted on chest imaging or pulmonary function tests. Although clinically significant pulmonary disease is less common, it can carry significant morbidity for patients. We review the presenting symptoms, workup, and management for several of the more common forms of inflammatory bowel disease-related pulmonary disease. Increased awareness of the spectrum of extraintestinal inflammatory bowel disease will help providers more readily recognize this phenomenon in their own patients and more comprehensively address the protean sequelae of inflammatory bowel disease.

Objective: Differentiated thyroid cancer patients uncommonly present with bone metastasis as the initial manifestation. Their molecular profile is largely unknown. The aim of this study was to evaluate the histopathology, molecular profiles, and response to radioactive iodine therapy in these patients. Methods: Eight patients presented with symptomatic bone metastasis from an unknown primary tumor. We identified these patients by performing a retrospective chart review. Pathology slides were reviewed and the molecular analysis of 112 thyroid cancer-related genes was performed on bone metastasis specimens using targeted next-generation sequencing. Results: These patients presented with long bone fractures, spinal cord compression, or intractable bone pain. Histopathologic analysis of the bone and thyroid tumor specimens revealed follicular variant of papillary carcinoma in 7 patients and tall cell variant papillary carcinoma in 1 patient. Primary tumor size ranged from 0.4 to 7.5 cm. All patients received high dose radioiodine therapy following thyroidectomy. Molecular analysis revealed telomerase reverse transcriptase (TERT) mutations in 7 (88%) tumors, 4 (50%) contained co-occurring TERT and RAS GTPase gene (RAS) mutations, 2 had isolated TERT mutations, and 1 had TERT and proto-oncogene B-Raf (BRAF) V600E mutations, respectively. Tumors carrying RAS, TERT, or a combination of these mutations were radioiodine-avid, with predictable tumor response and reduction in serum thyroglobulin levels. One patient with radioiodine-refractory disease harbored BRAF and TERT mutations. Conclusion: These results demonstrate that differentiated thyroid cancers presenting with bone metastasis independent of the primary tumor size have a high prevalence of TERT mutations, frequently coexisting with RAS mutations. This molecular signature may predict a favorable response to radioiodine therapy. Abbreviations: BRAF = proto-oncogene B-Raf; DNA = deoxyribonucleic acid; DTC = differentiated thyroid cancer; FV = follicular variant; PTC = papillary thyroid carcinoma; RAI = radioactive iodine; RAS = Ras GTPase gene; TERT = telomerase reverse transcriptase; TG = thyroglobulin

Objective: To carry out a UK national clinical audit of orthognathic acceptance criteria and information provided to orthognathic patients before treatment. Design: National clinical audit. Setting: Data collected using Bristol Online Surveys. Participants: Sixty-nine UK hospital orthodontic departments submitted data. Methods: Data were collected at two time points using Bristol Online Surveys over a period of 12 months. These were before treatment at the first multidisciplinary clinic (MDT) and immediately after surgery. The data collected included: Index of Orthognathic Functional Treatment Need (IOFTN); Index of Orthodontic Treatment Need (IOTN); age; previous orthodontic treatment; attendance at an MDT; treatment times; and information provision. Results: Eighty-five units agreed to take part in the audit with 69 submitting data, giving a response rate of 81%. The data from 3404 patients were uploaded, 2263 before treatment and 1141 immediately after surgery. Of patients, 91.07% had an IOFTN score of 4 or 5 and 88.73% had an IOTN score of 4 or 5. The mean age at the first MDT was 22 years in the first cohort and 21 years and 4 months in the second immediate post-surgery cohort. Of patients, 37.93% had undergone some form of previous orthodontic treatment, but only 0.28% had undergone previous orthognathic treatment; 96.93% had an MDT confirm that orthodontic treatment by itself was insufficient to adequately correct their functional symptoms. The average treatment time from bond up to surgery was 2 years and 6 months. With respect to information provision, patients received information from a number of sources, principally the British Orthodontic Society (BOS) patient information leaflets and the BOS website Your Jaw Surgery. Conclusions: In the UK, the majority of orthognathic cases fulfil the criteria for acceptance for NHS-funded orthognathic treatment, as outlined by the Chief Dental Officer’s interim guidance on orthognathic treatment. This suggests any prior approval process would not be a good use of NHS resources in the commissioning of orthognathic treatment.

Unmanned aircraft systems, also known as unmanned aerial vehicles or drones, are becoming increasingly common consumer products; their potential applications to search and rescue operations are becoming ever more apparent. A consumer drone was used to locate a mountaineer after he and his climbing partner were separated while summiting Broad Peak in the Karakoram Mountains of northeastern Pakistan, the world's 12th highest summit. The use of a commercial drone in the search for the missing climber allowed for a quick rescue mission, eliminating the need for a fully mobilized rescue party while significantly reducing the risk to the climbers charged with rescuing him. Without the drone, the rescue party would have faced immense challenges, including a vast search area and altitudes near the limits of human physiologic function. With real-time imagery and global positioning system capabilities, drones may become an invaluable tool in search and rescue operations, helping to reduce response time and maintain the safety of responders at high altitude and in many other types of difficult terrain.

Jugular foramen cavernous hemangiomas are extremely rare vascular malformations, and, to the best of the authors’ knowledge, their occurrence as multifocal lesions involving both intra- and extracranial compartments has never been reported before. Here, the authors describe the case of a 60-year-old woman with a complex multifocal jugular foramen cavernous hemangioma. The patient presented with signs and symptoms concerning for jugular foramen syndrome, as well as a right neck mass. Surgical extirpation of the lesion was achieved by a multidisciplinary team via a right infratemporal fossa approach (Fisch type A) with concurrent high neck dissection and a closure buttressed with an autologous fat graft and a temporoparietal fascial flap. Although rare, cavernous hemangiomas should be included in the differential diagnosis of jugular foramen masses.

OBJECTIVE: To estimate long-term prevalence of new dysphagia-related diagnoses in in a large cohort of head and neck cancer survivors. STUDY DESIGN: Retrospective cohort SETTING: Population-based SUBJECTS AND METHODS: 1901 adults diagnosed with head and neck cancer between 1997 and 2012 with at least 3 years of follow up were compared with 7,796 controls matched for age, sex and birth state. Prevalence of new dysphagia-related diagnoses and procedures and hazard ratio compared to controls were evaluated in patients 2–5 years and 5 years and beyond after diagnosis. Risk factors for the development of these diagnoses were analyzed. RESULTS: Prevalence of new diagnosis and hazard ratio compared to controls remained elevated for all diagnoses throughout the time periods investigated. The rate of aspiration pneumonia was 3.13% at 2–5 years increasing to 6.75% at 5 or more years, with hazard ratios of 9.53 (95% CI 5.08 −17.87) and 12.57 (7.17–22.04) respectively. Rate of gastrostomy tube placement increased from 2.82% to 3.32% with hazard ratio remaining elevated from 51.51 (13.45 – 197.33) to 35.2 (7.81–158.72) over the same time period. The rate of any dysphagia-related diagnosis or procedure increased from 14.9% to 26% with hazard ratio remaining elevated from 3.32 (2.50–4.42) to 2.12 (1.63–2.75). Treatment with radiation therapy and age over 65 were associated with increased hazard ratio for dysphagia-related diagnoses. CONCLUSION: Our data supports our hypothesis that new dysphagia-related diagnoses continue to occur at clinically meaningful levels in long-term head and neck cancer survivors beyond 5 years after diagnosis.

Introduction Expanding or fragmenting bullets have been known to cause extensive injuries since they became available in the late 19th century. Although these bullets are now banned from international warfare, their use by civilians and law enforcement is still legal in the US. In this case report, we describe the complex injuries and subsequent complicated hospital course of a civilian trauma patient who was shot with a newly-designed fragmenting bullet, known as a Radically Invasive Projectile (RIP) bullet. Case report A 22-year-old man presented as a trauma activation after a gunshot wound to his left chest. He subsequently underwent chest tube placement, an emergent thoracotomy, and an exploratory laparotomy. In the operating room, the patient had multiple ballistic fragments lodged within his left thoracic cavity and left upper abdomen. These fragments caused multiple penetrating injuries resulting in an 18 day hospital stay with numerous complications. He underwent 4 emergency operations, 2 separate admissions to the intensive care unit (ICU), and the placement of 4 chest tubes. He was ultimately discharged home in stable condition. Conclusion Expanding or fragmenting bullets are designed to inflict significantly more tissue damage than non-deformable bullets. This type of ammunition is prohibited in international warfare on the basis that it does not serve a military advantage but can result in excessive wounding and unnecessary suffering. There is no such ban for handgun ammunition for domestic use in most countries including the United States. Ammunition manufacturers have recently released a fragmenting bullet that is designed to inflict a maximum amount of tissue damage. In this case report, we described the devestating effects of this bullet on a civilian trauma patient.

Background Breast cancer, historically a disease of more affluent women, has increased in incidence for women from areas of greater social deprivation, yet prognosis is worse for these women. This study identifies differences in presentation, treatment and prognostic factors between the socioeconomic groups. Methods Patient data obtained from the prospectively maintained Welsh national Cancer Network Information System Cymru, for an 11-year period, were categorised according to Welsh Index of Multiple Deprivation quintiles. Quintiles were compared for differences in variables relating to patient characteristics, detection of cancer, tumour biology and treatment. Results 1570 patients were included. Analysis showed that in the more socially deprived quintiles, there are proportionally fewer women being diagnosed through the NHS breast cancer screening programme and as a consequence greater numbers of women from poorer areas being diagnosed outwith the screening age parameters. Screen detection is strongly associated with better prognosis in terms of Nottingham Prognostic Index. Similarly, increasing levels of social deprivation are associated with higher incidence of oestrogen receptor negative and triple negative tumours, both features associated with a shorter disease free and overall survival. Other variables of tumour biology, rates and type of surgical and adjuvant treatment were similar across social deprivation quintiles. Conclusion There is a trend of reduced early detection of breast cancer in South East Wales in those patients living in areas of higher social deprivation. Given that there is equity in access to treatment within NHS, which is free for patients at the point of care, further study is warranted to address this existing disparity. Population cancer surveillance will need to inform both public health and NHS service responses, to continue to achieve improvements. Health trends may yet alter depending on current and future shifts in governmental health policy.

Purpose There is limited information on how the COVID-19 pandemic has changed health behaviors among cancer patients. We examined the impact of the pandemic on changes in exercise behaviors and identified characteristics associated with these changes among cancer patients. Methods Cancer patients (n = 1,361) completed a survey from August-September 2020 to assess COVID-19 pandemic-related changes in health behaviors and psychosocial factors. Patients were categorized into 3 groups: exercising less, exercising did not change, and exercising more. Patient characteristics were compared by exercise groups. Results One-third of the patients reported a decreased amount of regular exercise, while 11% reported exercising more during the pandemic. Patients who exercised less were more likely to be unemployed/retired, undergoing active treatment, and had increased pandemic-related alcohol consumption and psychosocial stressors such as loneliness and financial stress (all p p p

Radiation therapy–mediated salivary gland destruction is characterized by increased inflammatory cell infiltration and fibrosis, both of which ultimately lead to salivary gland hypofunction. However, current treatments (e.g., artificial saliva and sialagogues) only promote temporary relief of symptoms. As such, developing alternative measures against radiation damage is critical for restoring salivary gland structure and function. One promising option for managing radiation therapy–mediated damage in salivary glands is by activation of specialized proresolving lipid mediator receptors due to their demonstrated role in resolution of inflammation and fibrosis in many tissues. Nonetheless, little is known about the presence and function of these receptors in healthy and/or irradiated salivary glands. Therefore, the goal of this study was to detect whether these specialized proresolving lipid mediator receptors are expressed in healthy salivary glands and, if so, if they are maintained after radiation therapy–mediated damage. Our results indicate that specialized proresolving lipid mediator receptors are heterogeneously expressed in inflammatory as well as in acinar and ductal cells within human submandibular glands and that their expression persists after radiation therapy. These findings suggest that epithelial cells as well as resident immune cells represent potential targets for modulation of resolution of inflammation and fibrosis in irradiated salivary glands.

PURPOSE: In vivo measurement of the spatial distribution of neurofibrillary tangle pathology is critical for early diagnosis and disease monitoring in Alzheimer’s disease (AD). METHODS: Forty-nine participants were scanned with (18)F-PI-2620 PET to examine the distribution of this novel PET ligand throughout the course of AD: 36 older healthy controls (HC) (age range 61 to 86), 11 beta-amyloid+ (Aβ+) participants with cognitive impairment (CI; clinical diagnosis of either mild cognitive impairment or AD dementia, age range 57 to 86), and 2 participants with semantic variant primary progressive aphasia (svPPA, age 66 and 78). Group differences in brain regions relevant in AD (medial temporal lobe, posterior cingulate cortex, and lateral parietal cortex) were examined using standardized uptake value ratios (SUVRs) normalized to the inferior gray matter of the cerebellum. RESULTS: SUVRs in target regions were relatively stable 60 to 90 minutes post-injection, with the exception of very high binders who continued to show increases over time. Robust elevations in (18)F-PI-2620 were observed between HC and Aβ+ CI across all AD regions. Within the HC group, older age was associated with subtle elevations in target regions. Mildly elevated focal uptake was observed in the anterior temporal pole in one svPPA patient. CONCLUSION: Preliminary results suggest strong differences in the medial temporal lobe and cortical regions known to be impacted in AD using (18)F-PI-2620 in patients along the AD trajectory. This work confirms that (18)F-PI-2620 holds promise as a tool to visualize Tau aggregations in AD.

Background The locations of subsequent fractures after initial fracture in postmenopausal women are poorly characterized. Methods We conducted a prospective analysis of subsequent fractures after initial fracture in Women's Health Initiative (1993–2018) participants who provided follow-up (mean 15.4 years, SD 6.2 years) data (n = 157,282 participants; baseline age 50–79; 47,458 participants with incident fracture). Cox proportional hazards models were adjusted for age, race/ethnicity, body mass index, and other covariates. Findings The risk of each type of subsequent fracture was increased after each type of initial fracture. Incident lower arm/wrist fracture was associated with significantly elevated risks of subsequent fractures at the upper arm/shoulder, upper leg, knee, lower leg/ankle, hip/pelvis, and spine (adjusted hazard ratios [aHRs] ranging 2·63–5·68). The risk of hip fracture was increased after initial lower arm or wrist fracture (aHR 4·80, 95% CI 4·29–5·36), initial upper arm or shoulder fracture (aHR 5·06, 95% CI 4·39–5·82), initial upper leg fracture (aHR 5·11, 95% CI 3·91–6·67), initial knee fracture (aHR 5·03, 95% CI 4·20–6·03), initial lower leg/ankle fracture (aHR 4·10, 95% CI 3·58–4·68), and initial spine fracture (aHR 6·69, 95% CI 5·95–7·53). Associations were significant in all age groups, even women aged 50–59 years. Risks of subsequent fracture were more pronounced among non-Hispanic Black, Hispanic/Latina, and Asian/Pacific Islander than among non-Hispanic White women. Interpretation Increased risk of subsequent fracture is observed for all fracture types across all ages. Women who experience any of these fractures should be targeted for interventions to prevent subsequent fractures. Funding National Institutes of Health HHSN268201600018C,HHSN268201600001C, HHSN268201600002C, HHSN268201600003C, and HHSN268201600004C.

Introduction The COVID-19 pandemic has exacerbated many social conditions associated with violence. The objective of this systematic review was to examine trends in hospital reported violent trauma associated with the pandemic. Methods Databases were searched in using terms “trauma” or “violence” and “COVID-19,” yielding 4,473 records (2,194 de-duplicated). Exclusion criteria included non-hospital based studies and studies not reporting on violent trauma. 44 studies were included in the final review. Results Most studies reported no change in violent trauma incidence. Studies predominately assessed trends with violent trauma as a proportion of all trauma. All studies demonstrating an increase in violent trauma were located in the United States. Conclusions A disproportionate rise in violence has been reported within the US. However, most studies examined violent trauma as a proportion of all trauma; results may reflect relative changes from lockdowns. Future studies should examine rates of violent trauma to provide additional context.

Background International guidelines on the treatment of differentiated thyroid cancers promote low iodine diets (LID) before radioiodine remnant ablation. Evidence that the LID ultimately improves treatment success is inconsistent. This study aimed to determine if there is a difference in ablation success rates according to provision of advice to follow a LID.Methods Retrospective study of patients with differentiated thyroid cancer treated with total thyroidectomy and radioiodine remnant ablation between 01/01/2015 and 31/12/2016 in 3 centres advising: no LID (C1: n=108); LID for 1-week before (C2: n=50); LID for 2-weeks before and 48 hours (C3: n=59) after RRA. Response to treatment was determined by adapted American Thyroid Association Dynamic Risk Stratification Score, stratified as excellent, indeterminate, or incomplete response.Results In total, 217 patients were included in the analysis. We found differences in preparation for radioiodine remnant ablation and in the assessment of outcomes between centres. Furthermore, although there was little difference in staging between centres there was a difference in the percentage of patients receiving 1.1GBq vs higher administered activities (15% in C1, 22% in C2 and 44% in C3, pConclusions We found no evidence that advice to follow a low iodine diet for 1 or 2 weeks before radioiodine remnant ablation impacts on ablation success but differences between centres means the results should be regarded as exploratory. There is no immediate need to change practice regarding the LID, but a prospective multi-centre study with a more homogenous approach to patient management or a randomised controlled trial will provide more definitive recommendations.

To interpret the open-ended phrase “undue hardship,” courts must look not just to the goals of the nondischargeability provision in isolation, but also to the broader purposes of Title IV of the Higher Education Act (HEA), the statutory scheme governing federal student loans. Over 90 percent of outstanding student loans were made under Title IV programs, nondischargeability was originally adopted as an amendment to the HEA, and the Brunner test itself purports to be based on the “purposes of the guaranteed student loan program.” In re Brunner, 46 B.R. 752, 756 (S.D.N.Y. 1985), aff’d, 831 F.2d 395 (2d Cir. 1987). Overly stingy application of the undue-hardship provision undermines the expressly articulated overarching goals of the federal student loan programs. Fear of debt and student debt itself deter students, particularly low-income students, from starting and completing higher education. Unmanageable debt discourages borrowers from using their education for the economic benefit of society because their earnings simply go to creditors. Fear of financial distress distorts students’ career choices. Many student loans are harmful to borrowers, who would have been better off never borrowing for higher education. By denying borrowers escape from debts they cannot repay, nondischargeability exacerbates all these effects, each of which undermines a goal of Title IV. The Brunner decision imagines a harsh “quid pro quo” in which the federal government “exacts” a price of near-total nondischargeability in exchange for making student loans. Brunner, 46 B.R. at 756. Although the Brunner opinion asserts that this arrangement advances the purposes of the student loan programs, it cites no evidence of the programs’ aims and ignores their true goals. The same is true of the Fifth Circuit’s decisions adopting and applying Brunner. These decisions are thus fundamentally flawed. To be sure, Congress did limit the dischargeability of student loans, despite the tension between nondischargeability and the goals of the student loan programs. It thought doing so would combat abuse and enhance repayment. But the limit on dischargeability contains an “undue hardship” exception of uncertain scope. In applying that exception, courts should act not just to fight abuse and recover money but also to advance the education-promoting goals of the overall statutory scheme.

International audience; The Extreme Universe Space Observatory on a Super Pressure Balloon 1 (EUSO-SPB1) instrument was launched out of Wanaka, New Zealand, by NASA in April, 2017 as a mission of opportunity. The detector was developed as part of the Joint Experimental Missions for the Extreme Universe Space Observatory (JEM-EUSO) program toward a space-based ultra-high energy cosmic ray (UHECR) telescope with the main objective to make the first observation of UHECRs via the fluorescence technique from suborbital space. The EUSO-SPB1 instrument is a refractive telescope consisting of two 1m$^{2}$ Fresnel lenses with a high-speed UV camera at the focal plane. The camera has 2304 individual pixels capable of single photoelectron counting with a time resolution of 2.5μ s. A detailed performance study including calibration was done on ground. We separately evaluated the properties of the Photo Detector Module (PDM) and the optical system in the laboratory. An end-to-end test of the instrument was performed during a field campaign in the West Desert in Utah, USA at the Telescope Array (TA) site in September 2016. The campaign lasted for 8 nights. In this article we present the results of the preflight laboratory and field tests. Based on the tests performed in the field, it was determined that EUSO-SPB1 has a field of view of 11.1$^{∘}$ and an absolute photo-detection efficiency of 10%. We also measured the light flux necessary to obtain a 50% trigger efficiency using laser beams. These measurements were crucial for us to perform an accurate post flight event rate calculation to validate our cosmic ray search. Laser beams were also used to estimated the reconstruction angular resolution. Finally, we performed a flat field measurement in flight configuration at the launch site prior to the launch providing a uniformity of the focal surface better than 6%.

There is an urgent need for new pain-relieving therapies. We have previously shown using mouse models of persistent pain that a single intrathecal injection of substance P conjugated to the light chain of botulinum toxin (SP-BOT) silenced neurons in the dorsal horn of the spinal cord and alleviated mechanical hypersensitivity. The SP-BOT construct selectively silenced neurokinin 1 receptor positive (NK1R+) neurons in the superficial dorsal horn of the spinal cord. A subset of these NK1R+ neurons are nociceptive projection neurons and convey injury-related information to the brainstem, initiating and maintaining programmes of escape and recovery essential for healing. Previously, we observed a reduction in mechanical hypersensitivity in a spared nerve injury (SNI) model of neuropathic pain state after intrathecal injection of SP-BOT over the lumbar spinal cord and lasting for up to 40 days. In this latest study, we have extended these observations and now show that thermal and affective measures of pain behaviour were also alleviated by a single intrathecal injection of SP-BOT. By introducing SNI 30 days, 60 days, 90 days or 120 days after injection of SP-BOT we have established that NK1R+ spinal neurons in the superficial lamina of the dorsal horn were silenced for up to 120 days following a single intrathecal injection of the botulinum construct. We also show that behavioural alleviation of neuropathic pain symptoms could be reinstated by a second injection of SP-BOT at 120 days. Taken together this research demonstrates that this recently developed botulinum toxin conjugate provides a powerful new way of providing long term pain relief without toxicity following a single injection and also has a therapeutic potential for repeated dosing when pain begins to return.

Background: Using meta-regression, this article aims at establishing the minimum change in BMI-standard deviation score (SDS) needed to improve lipid profiles and blood pressure in children and adolescents with obesity, to aid future trials and guidelines. Methods: Studies with participants involved in lifestyle interventions, aged 4–19 years, with a diagnosis of obesity according to defined BMI thresholds, were considered for inclusion in a large systematic review. Interventions had to report pre- and post-intervention (or mean change in) BMI-SDS, plus either systolic blood pressure (SBP), high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, and/or triglycerides (TGs). Random-effects meta-regression quantified the relationship between mean change in BMI-SDS and mean change in cardiovascular outcomes. Results: Seventy-one papers reported various cardiovascular measurements and mean change in BMI-SDS. Fifty-four, 59, 46, and 54 studies were analyzed, reporting a change in SBP, HDL, LDL, and TG, respectively. Reduction in mean BMI-SDS was significantly related to improvements in SBP, LDL, TG, and HDL (p 1, >1.2, or >0.7 are likely to reduce SBP, LDL, and TG, respectively. Further studies are needed to clarify the optimal duration, intensity, and setting for interventions. Consistency is required regarding derived BMI values to facilitate future systematic reviews and meta-analyses.

Background Total hip replacement (THR) is clinically and cost-effective. The surgical approach employed influences the outcome; however, there is little generalisable and robust evidence to guide practice. Methods A total of 723,904 primary THRs captured in the National Joint Registry, linked to hospital inpatient, mortality and patient-reported outcome measures (PROMs) data with up to 13.75 years follow-up, were analysed. There were seven surgical approach groups: conventional posterior, lateral, anterior and trans-trochanteric groups and minimally invasive posterior, lateral and anterior. Survival methods were used to compare revision rates and 90-day mortality. Groups were compared using Cox proportional hazards and Flexible Parametric Survival Modelling (FPM). Confounders included age at surgery, sex, risk group (indications additional to osteoarthritis), American Society of Anesthesiologists grade, THR fixation, thromboprophylaxis, anaesthetic, body mass index (BMI) and deprivation. PROMs were analysed with regression modelling or non-parametric methods. Results Unadjusted analysis showed a higher revision risk than the referent conventional posterior for the conventional lateral, minimally invasive lateral, minimally invasive anterior and trans-trochanteric groups. This persisted with all adjusted FPM and adjusted Cox models, except in the Cox model including BMI where the higher revision rate only persisted for the conventional lateral approach (hazard rate ratio (HRR) 1.12 [95% CI 1.06,1.17] P P = 0.003). PROMs demonstrated statistically, but not clinically, significant differences. Self-reported complications were more frequent with the conventional lateral approach, and the risk of 90-day mortality was higher (HRR 1.15 [95%CI 1.01–1.30] P = 0.029). Conclusions Lateral approaches for THR are associated with worse outcomes, including more deaths and revisions, than the posterior approach. We recommend the posterior approach should be considered the current standard approach for THR. Large well-designed studies are needed to assess any potential benefits from using minimally invasive posterior approaches and the conventional anterior approach.

ObjectiveTo determine whether memory tasks with demonstrated sensitivity to hippocampal function can detect variance related to preclinical Alzheimer disease (AD) biomarkers, we examined associations between performance in 3 memory tasks and CSF β-amyloid (Aβ)42/Aβ40 and phosopho-tau181 (p-tau181) in cognitively unimpaired older adults (CU).MethodsCU enrolled in the Stanford Aging and Memory Study (n = 153; age 68.78 ± 5.81 years; 94 female) completed a lumbar puncture and memory assessments. CSF Aβ42, Aβ40, and p-tau181 were measured with the automated Lumipulse G system in a single-batch analysis. Episodic memory was assayed using a standardized delayed recall composite, paired associate (word–picture) cued recall, and a mnemonic discrimination task that involves discrimination between studied “target” objects, novel “foil” objects, and perceptually similar “lure” objects. Analyses examined cross-sectional relationships among memory performance, age, and CSF measures, controlling for sex and education.ResultsAge and lower Aβ42/Aβ40 were independently associated with elevated p-tau181. Age, Aβ42/Aβ40, and p-tau181 were each associated with (1) poorer associative memory and (2) diminished improvement in mnemonic discrimination performance across levels of decreased task difficulty (i.e., target–lure similarity). P-tau mediated the effect of Aβ42/Aβ40 on memory. Relationships between CSF proteins and delayed recall were similar but nonsignificant. CSF Aβ42 was not significantly associated with p-tau181 or memory.ConclusionsTests designed to tax hippocampal function are sensitive to subtle individual differences in memory among CU and correlate with early AD-associated biomarker changes in CSF. These tests may offer utility for identifying CU with preclinical AD pathology.

Background and aims: The home parenteral nutrition population (HPN) face many challenges, especially with respect to fluid balance management. A low urinary sodium concentration of Methods: Patients on HPN were asked to collect urine samples at 5 specific times points (day 0,7,14, 21 and 28) to send to the laboratory for formal electrolyte analysis. The participant and a member of laboratory staff tested these samples with the Quantab dipstick to estimate urinary chloride concentration. Participants were instructed to complete a QOL questionnaire at each of the 5 time-points in addition to a baseline demographic questionnaire and an end-of-study questionnaire. Six participants completed an interview at the end of the study period. The relationship between participant-derived and laboratory-derived data was assessed using rank correlation coefficients. QOL assessment was correlated with urine dipstick measurements. Results: 10 patients on HPN completed the study. Data on chloride concentration as estimated by the dipstick (assessed by participants and by the laboratory) and sodium concentration from the laboratory were available for 47 urine samples. There was a positive relationship between participant dipstick estimated chloride concentration and laboratory sodium (Kendall’s τ=0.45; PConclusions: Patients on HPN are able to collect urine specimens, complete QOL questionnaires, and are capable of using the Quantab dipstick to estimate urinary chloride concentration. The Quantab dipstick correlates with laboratory measured sodium and chloride concentrations. Further work is required to fully establish whether this point-of-care test could be used to guide fluid balance management in the HPN population.

Background: Prosthetic implants used in total hip replacements (THR) have a range of bearing surface combinations (metal-on-polyethylene, ceramic-on-polyethylene, ceramic-on-ceramic, and metal-on-metal), head sizes (small [

Adult head and neck (HN) sarcomas are a rare malignancy with limited data delineating the role of postoperative radiotherapy (PORT), particularly for a positive surgical margin. There are no randomized trials supporting the use of PORT, therefore treatment trends vary between institutions. A positive margin predicts recurrence and poor survival outcomes. This study uses the National Cancer Database (NCDB) to investigate whether PORT improves overall survival (OS) in adult HN sarcomas with a positive margin and how utilization has changed.Patients (n = 1142) in the NCDB from 2004-2013 with adult HN sarcomas who underwent resection and had a positive margin.Factors significantly associated with increased utilization of PORT were: having insurance, salivary gland primary site, high-risk histology, poor differentiation, and a macroscopic positive margin. Treatment with PORT was associated with improved 5-year OS for all patients with a positive margin (57% vs 48%; P = .002), both microscopic (57% vs 49%; P = .010) and macroscopic (57% vs 41%; P = .036). Improved OS was significant after controlling for other known covariates on multivariate analysis (HR: 0.76; [0.64-0.90]; P = .002). Treatment at a community-based facility was an independent predictor for reduced OS (HR: 1.37; [1.15-1.64]; P .001). The percentage utilization (53%) of PORT for these patients did not change significantly over time.PORT provides a significant survival benefit for adult HN sarcoma patients with either a microscopic or macroscopic positive margin; however, PORT is underutilized. Treatment at academic/research cancer programs was associated with increased utilization of PORT and improved survival outcomes.

Background To determine unicompartmental (UKR) and total knee replacement (TKR) revision rates, compare UKR revision rates with what they would have been had they received TKR instead, and assess subsequent re-revision and 90-day mortality rates. Methods Using National Joint Registry data, we estimated UKR and TKR revision and mortality rates. Flexible parametric survival modeling (FPM) was used to model failure in TKR and make estimates for UKR. Kaplan-Meier estimates were used to compare cumulative re-revision for revised UKRs and TKRs. Results Ten-year UKR revision rates were 2.5 times higher than expected from TKR, equivalent to 70 excess revisions/1000 cases within 10 years (5861 excess revisions in this cohort). Revision rates were 2.5 times higher for the highest quartile volume UKR surgeons compared to the same quartile for TKR and 3.9 times higher for the lowest quartiles respectively. Re-revision rates of revised TKRs (10 years = 17.5%, 95% confidence interval [CI] 16.4-18.7) were similar to revised UKRs (15.2%, 95% CI 13.4-17.1) and higher than revision rates following primary TKR (3.3%, 95% CI 3.1-3.5). Ninety-day mortality rates were lower after UKR compared with TKR (0.08% vs 0.33%) and lower than predicted had UKR patients received a TKR (0.18%), equivalent to 1 fewer death per 1000 cases. Conclusion UKR revision rates were substantially higher than TKR even when demographics and caseload differences were accounted for; however, fewer deaths occur after UKR. This should be considered when forming treatment guidelines and commissioning services. Re-revision rates were similar between revised UKRs and TKRs, but considerably higher than for primary TKR, therefore UKR cannot be considered an intermediate procedure.

BACKGROUND: The influence of obesity on outcomes following total hip replacement is unclear. Restriction of total hip replacement on the basis of body mass index (BMI) has been suggested. The purpose of this study was to assess the influence of BMI on the risk of revision and 90-day mortality. METHODS: This was a population-based, longitudinal cohort study of the National Joint Registry (NJR) for England, Wales, Northern Ireland and the Isle of Man. Using data recorded from April 2003 to December 2015, linked to Office for National Statistics data, we ascertained revision and 90-day mortality rates following primary total hip replacement by BMI category. The probability of revision was estimated using Kaplan-Meier methods. Associations of BMI with revision and mortality were explored using adjusted Cox proportional hazards regression models. RESULTS: We investigated revision and 90-day mortality among 415,598 and 413,741 primary total hip replacements, respectively. Each data set accounts for approximately 52% of the total number of recorded operations in the NJR. Thirty-eight percent of the patients were classified as obese. At 10 years, class-III obese patients had the highest cumulative probability of revision (6.7% [95% confidence interval (CI), 5.5% to 8.2%]), twice that of the underweight group (3.3% [95% CI, 2.2% to 4.9%]). When the analysis was adjusted for age, sex, American Society of Anesthesiologists [ASA] grade, year of operation, indication, and fixation type, compared with patients with normal BMI, significantly elevated hazard ratios (HRs) for revision were observed for patients in the BMI categories of class-I obese (≥30 to

The NCCN Guidelines for Thyroid Carcinoma provide recommendations for the management of different types of thyroid carcinoma, including papillary, follicular, Hurthle cell, medullary, and anaplastic carcinomas. These NCCN Guidelines Insights summarize the panel discussion behind recent updates to the guidelines, including the expanding role of molecular testing for differentiated thyroid carcinoma, implications of the new pathologic diagnosis of noninvasive follicular thyroid neoplasm with papillary-like nuclear features, and the addition of a new targeted therapy option for BRAF V600E-mutated anaplastic thyroid carcinoma.

AIM The human dentition contains many features which can be used to identify an individual from the dentition or from bite marks created and bite mark evidence may be used to link a suspect to a crime. The aim of this research was to investigate the effect of orthodontic treatment on the uniqueness of the human anterior dentition by comparison of the number of dental shape matches between pre- and post-treatment dental casts for a group of patients who have undergone orthodontic treatment (dental braces) to improve the alignment of their teeth. METHOD This comparative study utilised pre- and post-orthodontic treatment dental casts from 36 patients. The dental casts were scanned and the anterior 6 teeth landmarked with 24 landmarks in total. The dental casts were divided into 4 groups: pre-orthodontic upper jaw (maxillary) and lower jaw (mandibular) and post-orthodontic maxillary and mandibular. Partial and full Procrustes analyses were undertaken to investigate the similarity between dental casts within each group and whether any of the comparisons were similar enough to be classified as a match. A landmarking repeatability study performed on a set of digitised dental casts determined the error of the landmarking procedure and allowed a proposed match threshold to be established. RESULTS Orthodontic treatment reduced the uniqueness, and increased the similarity, between dentitions, as evidenced by a reduction in the maximum partial Procrustes distances in the post-orthodontic dental cast groups. None of the dental cast comparisons in the pre- or post-orthodontic maxillary or mandibular groups were classified as a match with the partial Procrustes analysis. However, many false positive matches (between 35 and 61) were identified within the post-orthodontic maxillary and mandibular groups using the full Procrustes analysis. CONCLUSIONS Orthodontic treatment reduced the uniqueness of the human anterior dentition between different patients. There were no matches identified with the partial Procrustes analysis, but a large number of false positive matches were identified using the full Procrustes analysis. It is therefore proposed that full Procrustes analysis is unsuitable for this type of work and that only partial Procrustes analysis should be utilised.

Objectives To investigate clinicopathologic and treatment factors associated with survival in adult head and neck sarcomas in the National Cancer Database (NCDB). To analyze whether treatment settings and therapies received influence survival outcomes and to compare trends in utilization via an aggregated national data set. Study Design Prospectively gathered data. Setting NCDB. Subjects and Methods The study comprised a total of 6944 adult patients treated for a head and neck sarcoma from January 2004 to December 2013. Overall survival (OS) was the primary outcome. Results Increased age and tumor size, nodal involvement, and poorly differentiated histology had significantly reduced OS ( P < .001). Angiosarcoma, malignant nerve sheath tumor, malignant fibrous histiocytoma, osteosarcoma, and rhabdomyosarcoma histologic subtypes had significantly reduced OS, while liposarcoma, chondrosarcoma, and chordoma had improved OS ( P < .001). Utilization of surgical therapy was associated with improved OS, while positive surgical margins were associated with treatment at a community-based cancer program and had reduced OS ( P < .001). On multivariate analysis, treatment with radiation and/or chemotherapy was not significantly associated with OS; however, primary treatment with definitive chemoradiotherapy had significantly reduced OS. Patients treated at academic/research cancer programs (n = 3874) had significantly improved 5- and 10-year OS (65% and 54%, respectively) when compared with patients treated at community-based cancer programs (n = 3027; 49% and 29%; P < .001). The percentage utilization of these programs (56% vs 44%) did not change over the study period. Conclusion For adult head and neck sarcomas, treatment at an academic/research cancer program was associated with improved survival; however, despite increasing medical specialization, the percentage utilization of these programs for this rare tumor remains constant.

Objective To investigate the effects of repeated work bouts in the heat on peak body core temperature and to explore sex-based differences in body core temperature responses. Methods Fourteen males and fifteen females performed four work bouts (two heavy and two moderate, alternating) in 32.5 °C Wet Bulb Globe Temperature (WBGT), each separated by 30-min seated rest in 28.0 °C WBGT. Participants wore a military combat uniform with body armour and helmet (10 kg load) during the work bouts, removing the vest and helmet during recovery periods. Results Body core temperature elevation over time was faster in the first compared with subsequent work bouts of each intensity. Body core temperature elevation was similar between males and females during the first heavy work bout, then remained significantly lower in females for the reminder of the trial. Conclusions Contrary to the assumed progressive elevation in strain, but in agreement with recent literature, a gradual reduction in heat storage in subsequent exercise bouts prevented a cumulative increase in heat strain in the conditions tested.

Purpose/objectives Overall non-melanoma head and neck skin cancer has a good prognosis; however, rarely patients have an aggressive variant which results in orbital invasion via perineural spread or direct extension. Despite these consequences, there are limited published studies defining this clinical entity. The main objectives of the current study are to describe orbital invasion patterns of non-melanoma head and neck skin cancers and their impact on survival. Methods Retrospective case series from a tertiary-care, academic institution performed between 2004 and 2014. Demographic and tumour characteristics are reported as well as patterns of orbital invasion, types of treatments received, and survival outcomes. Results There were 17 consecutive patients with non-melanoma skin cancer and orbital invasion who met inclusion criteria. Average age at orbital invasion diagnosis was 70.8 years old. 76% were male. Mean follow-up time was 28.5 months. Of these patients, 71% had squamous cell carcinoma and 29% had basal cell carcinoma. Brow (41%) was the most common primary sub-site followed by cheek (23%) and temple (12%). 76% of patients had a history of prior treatment. The lateral orbital wall (41%) was the most common site of invasion, followed by the medial orbital wall (29%) and antero-superior invasion (23%). Age, histology, and location of orbital invasion were associated with disease-specific and overall survival. Conclusion Orbital invasion for non-melanoma head and neck skin cancers creates a treatment dilemma and the patterns of invasion are described. In addition, the location of orbital invasion is associated with survival outcomes.

Background To assess the effectiveness and outcomes of adjuvant radiotherapy regimens for nonmelanoma skin cancers (NMSC) of the head and neck, particularly for elderly patients. Methods A retrospective review of patients with head and neck NMSC was conducted. Radiotherapy dose per fraction regimens included ≤200, 240–250, 300–400, and 500–600 cGy. Demographics, tumor characteristics, local control (LC), regional control (RC), and survival outcomes were analyzed. Results Of the 90 patients with 140 disease sites, 76.6% were squamous cell carcinoma, 15.5% were basal cell carcinoma, and 7.7% were other histologies. The mean age at diagnosis was 72.1 years old. The most common location was preauricular (20.0%), followed by temple, scalp, cheek, and forehead. The overall LC and RC rates were 88.8% and 88.8%, respectively by patients, and 92.8% and 86.4%, respectively by treatment sites. Age, primary tumor location, T classification, N classification, overall stage, perineural invasion, comorbid disease, skull base invasion, and radiotherapy subgroup were significantly associated with disease-free and overall survival (P < 0.05). LC and RC were not significantly different among the radiotherapy dose subgroups. The mean survival was longer in patients treated with 240–250 cGy/fraction (50.3 months). There was no significant difference in radiotherapy toxicity between the subgroups. Conclusion Short-term radiotherapy regimens for patients with locally or regionally advanced head and neck NMSC appear feasible and effective, particularly in elderly patients or those that cannot tolerate the length of standard regimens.