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BACKGROUND: Follicular thyroid carcinoma (FTC) and Hurthle cell carcinoma (HCC) are rare and aggressive thyroid cancers with limited published data comparing their outcomes or regarding their subtypes. The aim of this study was to describe clinicopathological features and compare clinical outcomes of patients with FTC and HCC based on the 2017 World Health Organization definition and extent of vascular invasion (VI). METHODS: We retrospectively studied 190 patients with HCC and FTC primarily treated with surgery at Memorial Sloan Kettering Cancer Center between 1986 and 2015. Patients were classified as minimally invasive (MI), encapsulated angioinvasive with focal VI (EA-FVI), encapsulated angioinvasive with extensive VI (EA-EVI), and as widely invasive (WI). To compare clinical outcomes, patients were grouped as follows: group 1 = FTC-MI and FTC EA-FVI, group 2 = FTC EA-EVI and FTC-WI, group 3 = HCC-MI and HCC EA-FVI, group 4 = HCC EA-EVI and HCC-WI. Outcomes of interest were overall survival (OS), disease-specific survival (DSS), recurrence-free survival (RFS), locoregional recurrence-free survival (LRRFS), and distant recurrence-free survival (DRFS). Outcomes were determined using the Kaplan–Meier method and compared with log-rank test. RESULTS: Patients with HCC (n = 111) were more likely to be older than 55 years old (59% vs. 27%, p

Although infections are a significant potential complication among patients undergoing left ventricular assist device (LVAD) implantation, standardized surgical infection prophylaxis (SIP) regimens are not well defined. At Montefiore Medical Center, a 4-drug SIP regimen containing fluconazole, ciprofloxacin, rifampin, and vancomycin was previously utilized. In January 2020, the antimicrobial stewardship program implemented a 2-drug SIP regimen of vancomycin and cefazolin to limit exposure to broad-spectrum antibiotics. This study evaluated LVAD-associated infection rates prior to and following the SIP revision.A retrospective review of patients who underwent LVAD implantation from 1/2018 to 4/2021 was performed. Infections were classified using the International Society for Heart and Lung Transplantation definitions. Infection rates at 2 weeks, 30 days, and 90 days post-implantation in the 4-drug SIP regimen (1/2018-12/2019) and the 2-drug SIP regimen (1/2020 to 4/2021) were compared.A total of 71 patients were included. The number of patients with LVAD-associated infections (including surgical site infections) was not significantly different in either SIP group at 2 weeks (9% vs. 4%, p = .64), 30 days (9% vs. 11%, p = .99), or 90 days (19% vs. 14%, p = .75). There was no statistically significant difference in 30 or 90-day mortality. LVAD-associated gram-negative (7% vs. 7%; p .99) and fungal (5% vs. 0%; p = .51) infections were uncommon. The most common organism isolated was Staphylococcus aureus, and the most common type of infection was pneumonia in both SIP groups.No significant difference in LVAD-associated infections or infection-related mortality was observed with de-escalation of perioperative antibiotics. Additional studies with larger sample sizes are needed to endorse the findings of this study.

Epidemiology of the US coronavirus disease 2019 (COVID-19) outbreak focuses on individuals’ biology and behaviors, despite centrality of occupational environments in the viral spread. This demonstrates collusion between epidemiology and racial capitalism because it obscures structural influences, absolving industries of responsibility for worker safety. In an empirical example, we analyzed economic implications of race-based metrics widely used in occupational epidemiology. In the United States, White adults have better average lung function and worse hearing than Black adults. Impaired lung function and impaired hearing are both criteria for workers’ compensation claims, which are ultimately paid by industry. Compensation for respiratory injury is determined using a race-specific algorithm. For hearing, there is no race adjustment. Selective use of race-specific algorithms for workers’ compensation reduces industries’ liability for worker health, illustrating racial capitalism operating within public health. Widespread and unexamined belief in inherent physiological inferiority of Black Americans perpetuates systems that limit industry payouts for workplace injuries. We see a parallel in the epidemiology of COVID-19 disparities. We tell stories of industries implicated in the outbreak and review how they exemplify racial capitalism. We call on public health professionals to critically evaluate who is served and neglected by data analysis and to center structural determinants of health in etiological evaluation.

The mainstay of treatment of well-differentiated thyroid cancer (WDTC) is surgery followed by adjuvant radioactive iodine therapy. Postoperative radiation therapy (PORT) is rarely used.The aim of our study was to report our experience of patients with WDTC who were selected to receive PORT.After Institutional Review Board approval, patients who received PORT were identified from a departmental database of 6259 patients with WDTC treated with primary surgery from 1986 to 2015. We carried out propensity matching to compare outcomes with a cohort of patients who did not receive PORT. The main outcome of interest was central neck recurrence-free probability (CNRFP), while secondary outcomes were lateral neck recurrence-free probability (LNRFP), disease-specific survival (DSS), and overall survival (OS).From 6259 patients, 32 (0.5%) patients with a median age of 65.2 years received PORT. Tall-cell variant papillary thyroid carcinoma was the most common pathology (45%). Patients who received PORT had no difference in CNRFP compared with patients treated without PORT (10-year CNRFP 88% vs. 73%; p = 0.18). Furthermore, patients who received PORT had superior LNRFP (10-year LNRFP 100% vs. 62%; p = 0.001) compared with the no-PORT cohort. Despite this, patients who received PORT had similar DSS (71% PORT vs. 75% no-PORT) and OS (65% PORT vs. 58% no-PORT group) as the no-PORT cohort.Our data show that select patients who received PORT had improved locoregional recurrence-free probability; however, this did not translate into improved DSS and OS. At our institution, we recommend the use of PORT only in highly selected patients with locally advanced primary tumors who are deemed to have a high risk of central neck recurrence for which salvage surgery would result in unacceptable risk to the airway.

Cardiac sarcoidosis (CS) is a widely underdiagnosed yet clinically significant form of granulomatous myocarditis associated with significant morbidity and mortality. Clinical presentation ranges from silent cardiac involvement detected on imaging to cardiomyopathy or sudden cardiac death. Diagnosis of CS remains challenging due to the lack of sensitivity and specificity of any single diagnostic method, underscoring the importance of elevated clinical suspicion and the use of multimodality imaging to guide diagnosis and treatment. In this review, we discuss the epidemiology, pathogenesis, clinical features, and diagnosis of this clinically evading and enigmatic disease.

Transitions of care is one of the most complex, and often one of the most problematic, aspects of healthcare systems, leading to errors and negative outcomes when not done effectively. Transitions of care, however, is rarely taught in undergraduate medical education, and when it is, it is typically relegated to the classroom setting. The authors describe a new elective experience that not only holds educational value for students but also entails a value-added component for patient care and teamwork., Objectives Health care in the United States is costly, fragmented, and often ineffective. Transitions of care (TOC), particularly from the inpatient to the outpatient setting, is an especially complicated time and one that is potentially fraught with errors that contribute to negative outcomes. The coronavirus 2019 pandemic exacerbated many of these challenges. In particular, vulnerable patient populations have experienced more barriers to successful care transitions. Effective care transitions should include interprofessional teamwork, robust patient education, and seamless communication among the various healthcare team members. Increasingly, medical schools are working toward graduating systems-ready physicians who demonstrate competency in the health system sciences and are able to operate effectively within the healthcare system, including being able to navigate complex transitions of care issues. Undergraduate medical education, however, continues to provide experiential learning in the traditional silos of inpatient versus outpatient medicine, so that learners do not have the opportunity to directly participate in transitions of care. Although transitions of care is a pivotal part of patient care, it is rarely taught at the undergraduate level, and when it is, it is typically relegated to the classroom setting. Methods We used the disruption of the coronavirus 2019 pandemic to develop a TOC elective. The aim was to fulfill an acute educational need and to develop competencies around care transitions for students while concurrently providing support for patient care and teamwork. The elective was offered to second-, third- and fourth-year medical students. Our educational innovation was initiated within our safety-net hospital where we care for a high percentage of uninsured patients, with a high language discordance. In addition, our city has multiple care systems without a single or connected electronic health record system, further complicating patient care transitions. The work of the TOC elective crossed inpatient and outpatient silos, with close collaboration with our local federally qualified health centers. This remotely conducted elective includes three main pillars: participation in team activities, including virtual participation in interdisciplinary rounds and care coordination; discharge planning; and communication, including goals of care and end of life communication. Results Medical students successfully integrated into team structures to directly counsel families, facilitate goals of care conversations, and engage a multidisciplinary team for discharge planning. Students found this experience valuable in their reflections. In addition, there was a value-added component from a patient care and teamwork perspective. Conclusions Participation of students in TOC is a valuable educational experience and contributes a value-added component to patient care and interprofessional teamwork. Moreover, an appreciation of the failures of the current system is pivotal as learners start to reimagine, explore, and design improved patient-centered systems in the future.

In 2017 Ontario experienced the largest mumps outbreak in the province in 8 years, at a time when multiple outbreaks were occurring across North America. Of 259 reported cases, 143 occurred in Toronto, primarily among young adults. Routine genotyping of the small hydrophobic gene indicated that the outbreak was due to mumps virus genotype G. We performed a retrospective study of whole genome sequencing of 26 mumps virus isolates from early in the outbreak, using a tiling amplicon method. Results indicated that two of the cases were genetically divergent, with the remaining 24 cases belonging to two major clades and one minor clade. Phylogeographic analysis confirmed circulation of virus from each clade between Toronto and other regions in Ontario. Comparison with other genotype G strains from North America suggested that the presence of co-circulating major clades may have been due to separate importation events from outbreaks in the United States. A transmission network analysis performed with the software program TransPhylo was compared with previously collected epidemiological data. The transmission tree correlated with known epidemiological links between nine patients and identified new potential clusters with no known epidemiological links.

Survival from malignant mesothelioma, particularly pleural mesothelioma, is very poor. For patients with breast, ovarian, or prostate cancers, overall survival is associated with increased sensitivity to platinum chemotherapy due to loss-of-function mutations in DNA repair genes. The goal of this project was to evaluate, in patients with malignant mesothelioma, the relationship between inherited loss-of-function mutations in DNA repair and other tumor suppressor genes and overall survival following platinum chemotherapy. Patients with histologically confirmed malignant mesothelioma were evaluated for inherited mutations in tumor suppressor genes. Survival was evaluated with respect to genotype and site of mesothelioma. Among 385 patients treated with platinum chemotherapy, median overall survival was significantly longer for patients with loss-of-function mutations in any of the targeted genes compared with patients with no such mutation (P = 0.0006). The effect of genotype was highly significant for patients with pleural mesothelioma (median survival 7.9 y versus 2.4 y, P = 0.0012), but not for patients with peritoneal mesothelioma (median survival 8.2 y versus 5.4 y, P = 0.47). Effect of patient genotype on overall survival, measured at 3 y, remained independently significant after adjusting for gender and age at diagnosis, two other known prognostic factors. Patients with pleural mesothelioma with inherited mutations in DNA repair and other tumor suppressor genes appear to particularly benefit from platinum chemotherapy compared with patients without inherited mutations. These patients may also benefit from other DNA repair targeted therapies such as poly-ADP ribose polymerase (PARP) inhibitors.

IMPLEMENTATION INSIGHTS.

CASE Extensive and multiple symptomatic chondral lesions in the knee of a professional athlete presents unique challenges when considering optimal management. We present the case of a professional National Basketball Association player with symptomatic and extensive patellofemoral chondral lesions, who failed 24 months of nonoperative management and was treated surgically with bipolar patellofemoral osteochondral allograft transplantation (OCA) consisting of 3 large grafts to the patella, medial trochlea, and lateral trochlea. The player was able to return to his preinjury level of play 10 months postoperatively and remains asymptomatic at same level of play 3 years after surgery. Postoperative magnetic resonance imaging at 16 months demonstrated good restoration of the articular architecture of the patellofemoral joint. CONCLUSIONS Bipolar OCA treatment for extensive chondral patellofemoral injury may be considered in high-level, high-demand athletes who wish to return to play professionally.

Objective: To review inferior vena cava (IVC) filter retrieval practice at our institution, the Royal London Hospital, and measure changes following a quality improvement intervention. IVC filters are a preventive treatment for pulmonary embolism when anticoagulation is ineffective/contraindicated. Unless permanent filtration is required, all filters should undergo attempted retrieval within manufacturer’s recommendations with a success rate of ≥80 %. Methods: Retrospective audit of filters inserted between 2011 and 2014, followed by a quality improvement intervention and a second audit between 2015 and 2017. Clinical–radiological data were analysed using the Picture Archiving and Communication System and electronic patient records. Results: During the first audit, filter retrieval was attempted in 92% of cases, of which 82% underwent the procedure within manufacturer's recommendations and 86% were successful. During the second audit, an improvement across indicators was seen. Retrieval increased by 3% and was attempted in 95% of cases (92% of which were within manufacturer’s guidelines). Rate of retrievals within manufacturer’s guidelines increased by 10%. Filter retrieval success rate increased by 11% - to 97%. Conclusions: IVC filter retrieval practice at a single institution can be improved by implementing a simple audit intervention. Advances in knowledge: Filter retrieval practice has clinical and medicolegal implications. A simple quality intervention can substantially improve overall practice.

There has been increasing use of a novel combined femoral venous sheath, catheter and retrievable self-expanding and collapsible diamond-shaped IVC filter (Angel

Hurricanes Irene and Sandy heavily impacted New Jersey. Investigating EMS dispatch trends during these storms may allow us to prepare for future disasters.Our objectives to characterize the types of EMS dispatches immediately before, during, and after landfall compared to a control period.This retrospective study was conducted at a large EMS dispatch center that provides first responders, Basic Life Support (BLS), Advanced Life Support (ALS), and critical care transport services to an area with approximately 20 receiving hospitals including a Level I Trauma Center. At peak staffing, there are 8-10 ALS vehicles, 25 BLS vehicles, and 3 critical care transport vehicles deployed. We included of the day of landfall and seven days before and after. We compared dispatch data to a control period in 2010 that mirrored Hurricane Sandy the dates of. Descriptive statistics and two way ANOVA were used to assess dispatch, gender and age differences.We found Hurricane Sandy dispatches peaked 2 days after landfall. Both ALS and BLS had an increase in age in the post-Sandy period compared to the pre-Sandy (ALS 58.5 to 64.2, p = 0.005, ANOVA p = 0.078; BLS 47.4 to 56.3, p0.001, ANOVA p = 0.001). There were 17 "hurricane related" (loss of power related issues, oxygen supply depleted, evacuation) and 15 carbon monoxide dispatches in the post-Sandy period and none in the others, including peri-Irene. The average age of cardiac arrest dispatches was lower in the post-Irene group compared to pre-Irene (74.3 to 47.8, p = 0.023). There were no critical care requests before or after Hurricane Sandy, but there were 14 around Hurricane Irene and 10 surrounding the control period.Dispatch data can inform natural disaster planning. Education efforts can focus on geriatric patients, as well as resource distribution planning for an increase in geriatric populations. However, pattern variability between storms shows further study is needed to clarify exactly which resources should be utilized in order to maintain an ideal response to a natural disaster.

BACKGROUND: Care coordination between adult hospitalists and primary care providers (PCPs) is a critical component of successful transitions of care from hospital to home, yet one that is not well understood. OBJECTIVE: The purpose of this study was to understand the challenges in coordination of care, as well as potential solutions, from the perspective of hospitalists and PCPs in North Carolina. DESIGN AND PARTICIPANTS: We conducted an exploratory qualitative study with 58 clinicians in four hospitalist focus groups (n = 32), three PCP focus groups (n = 19), and one hybrid group with both hospitalists and PCPs (n = 7). APPROACH: Interview guides included questions about care coordination, information exchange, follow-up care, accountability, and medication management. Focus group sessions were recorded, transcribed verbatim, and analyzed in ATLAS.ti. The constant comparative method was used to evaluate differences between hospitalists and PCPs. KEY RESULTS: Hospitalists and PCPs were found to encounter similar care coordination challenges, including (1) lack of time, (2) difficulty reaching other clinicians, (3) lack of personal relationships with other clinicians, (4) lack of information feedback loops, (5) medication list discrepancies, and (6) lack of clarity regarding accountability for pending tests and home health. Hospitalists additionally noted difficulty obtaining timely follow-up appointments for after-hours or weekend discharges. PCPs additionally noted (1) not knowing when patients were hospitalized, (2) not having hospital records for post-hospitalization appointments, (3) difficulty locating important information in discharge summaries, and (4) feeling undervalued when hospitalists made medication changes without involving PCPs. Hospitalists and PCPs identified common themes of successful care coordination as (1) greater efforts to coordinate care for "high-risk" patients, (2) improved direct telephone access to each other, (3) improved information exchange through shared electronic medical records, (4) enhanced interpersonal relationships, and (5) clearly defined accountability. CONCLUSIONS: Hospitalists and PCPs encounter similar challenges in care coordination, yet have important experiential differences related to sending and receiving roles for hospital discharges. Efforts to improve coordination of care between hospitalists and PCPs should aim to understand perspectives of clinicians in each setting.

The purpose of this study was for us to present our evaluation of the effectiveness of positron emission tomography (PET)/CT imaging in postoperative patients with oral cavity squamous cell carcinoma (SCC) before initiating adjuvant radiation therapy.Treatment planning PET/CT scans were obtained in 44 patients with oral cavity SCC receiving adjuvant radiation. We identified target areas harboring macroscopic disease requiring higher radiation doses or additional surgery.Fourteen PET/CT scans were abnormal. Thirteen patients underwent surgery and/or biopsy, increased radiation dose, and/or addition of chemotherapy. Eleven patients received higher radiation doses. Patients undergoing imaging8 weeks were more likely to have abnormal results (p = .01). One-year distant metastases-free survival was significantly worse in patients with positive PET/CT scans (61.5% vs 92.7%; p = .01). The estimated positive predictive value (PPV) was 38% for postoperative PET/CT scanning.We demonstrated that 32% of patients have abnormal PET/CT scans resulting in management changes. Patients may benefit from postoperative PET/CT imaging to optimize adjuvant radiation treatment planning. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1285-E1293, 2016.

A 34-year-old woman presented to the surgical assessment unit with severe right loin to groin pain. An ultrasound scan of the abdomen revealed a complex cyst in the right iliac fossa and a subsequent CT scan revealed a 7.5 cm retroperitoneal cystic lesion below the lower pole of the right kidney. The patient also had MRI of the kidneys, which confirmed the finding. The image showed the cyst was not attached to the kidneys and was clearly separate. She underwent a laparoscopic excision of the cyst. Histopathology revealed a cyst lined by a single layer of mucinous epithelium of endocervical type with foci of calcification and hyalinisation on the wall. The cyst was thought to be a benign cyst of Mullerian origin.

We hypothesized that pathological N1 (pN1) and N2a (pN2a) nodal disease portend a similar prognosis in patients with oral cancer.An international multicenter study of 739 oral squamous cell carcinoma (SCC) patients with pN1 or pN2a stage disease was conducted. Multivariable analyses were performed using Cox proportional hazard models to compare locoregional failure, disease-specific survival (DSS), and overall survival (OS). Institutional heterogeneity was assessed using 2-stage random effects meta-analysis techniques.Univariate analysis revealed no difference in locoregional failure (p = .184), DSS (p = .761), or OS (p = .475). Similar results were obtained in adjusted multivariable models and no evidence of institutional heterogeneity was demonstrated.The prognosis of pN2a and pN1 disease is similar in oral SCC suggesting these categories could be combined in future revisions of the nodal staging system to enhance prognostic accuracy. However, these results may reflect more aggressive treatment of N2a disease; hence, we caution against using these data to deintensify treatment.

The role of protein phosphatase-2A (PP-2A) in regulating the motility and adhesion of human head and neck squamous cell carcinomas (HNSCC) was investigated. Immunofluorescent staining of these HNSCC cells showed PP-2A can co-localize with microtubules. That the PP-2A influences motility was shown by the increase in HNSCC cell migration through laminin and vitronectin when PP-2A was selectively inhibited with low dose okadaic acid, and by the reduction in invasion through these same matrix components by elevators of PP-2A activity. Motility of HNSCC cells through collagen I or fibronectin was not modulated by PP-2A. The reduction in HNSCC migration through vitronectin or laminin that resulted from treatment with PP-2A elevators was associated with an increase in cellular adhesiveness to these same ECM components. These studies show the association of PP-2A with the cellular cytoskeleton and its role in restricting the invasiveness of tumor cells through select extracellular matrix components.

Adenoid cystic carcinoma (ACC) is a locally aggressive tumor with a high prevalence of distant metastases. The purpose of this study was to identify independent predictors of outcome and to characterize the patterns of failure.An international retrospective review was conducted of 489 patients with ACC treated between 1985 and 2011 in 9 cancer centers worldwide.Five-year overall-survival (OS), disease-specific survival (DSS), and disease-free survival (DFS) were 76%, 80%, and 68%, respectively. Independent predictors of OS and DSS were: age, site, N classification, and presence of distant metastases. N classification, age, and bone invasion were associated with DFS on multivariate analysis. Age, tumor site, orbital invasion, and N classification were independent predictors of distant metastases.The clinical course of ACC is slow but persistent. Paranasal sinus origin is associated with the lowest distant metastases rate but with the poorest outcome. These prognostic estimates should be considered when tailoring treatment for patients with ACC.

Complement system activation plays an important role in both innate and acquired immunity. Activation of the complement and the subsequent formation of C5b-9 channels (the membrane attack complex) on the cell membranes lead to cell death. However, when the number of channels assembled on the surface of nucleated cells is limited, sublytic C5b-9 can induce cell cycle progression by activating signal transduction pathways and transcription factors and inhibiting apoptosis. This induction by C5b-9 is dependent upon the activation of the phosphatidylinositol 3-kinase/Akt/FOXO1 and ERK1 pathways in a Gi protein-dependent manner. C5b-9 induces sequential activation of CDK4 and CDK2, enabling the G1/S-phase transition and cellular proliferation. In addition, it induces RGC-32, a novel gene that plays a role in cell cycle activation by interacting with Akt and the cyclin B1-CDC2 complex. C5b-9 also inhibits apoptosis by inducing the phosphorylation of Bad and blocking the activation of FLIP, caspase-8, and Bid cleavage. Thus, sublytic C5b-9 plays an important role in cell activation, proliferation, and differentiation, thereby contributing to the maintenance of cell and tissue homeostasis.

The objective of this study was to report the authors' experience in the management of patients with early stage squamous cell cancer (SCC) of the oral tongue and determine clinicopathologic factors predictive of outcome.Two hundred sixteen patients with early stage (cT1T2N0) SCC of the oral tongue were identified from a pre-existing database of patients with oral cancer who were treated at Memorial Sloan-Kettering Cancer Center from 1985 to 2005. Patient, tumor, and treatment characteristics were recorded. Overall survival (OS), disease-specific survival (DSS), and recurrence free survival (RFS) were calculated using the Kaplan-Meier method. Predictors of outcome were identified using multivariate analysis.With a median follow-up of 80 months (range, 1-186 months), the 5-year DSS, OS, and RFS rates were 86%, 79%,and 70%, respectively. Local, neck, and distant recurrences occurred in 24 patients (11%), 40 patients (18%), and 5 patients (2%), respectively. Multivariate analysis identified occult neck metastases as the main independent predictor of OS, DSS, and RFS; patients who had occult metastases had a 5-fold increased risk of dying of disease compared with patients who did not have occult metastases (5-year DSS, 85.5% vs 48.5%; P = .001). A positive surgical margin was the main independent predictor for local RFS (91% vs 66% for a negative surgical margin; P = .0004), and depth of invasion was the main predictor for neck RFS (91% vs 73% for depth of invasion2 mm and2 mm, respectively; P = .02).In the authors' experience, patients with early stage oral tongue cancer have excellent outcomes. In the current study, the presence of occult metastases was the main predictor of survival outcome.

The effects of voluntary isocapnic hyperpnea (VIH) training (10 h over 4 weeks, 30 min/day) on ventilatory system and running performance were studied in 15 male competitive runners, 8 of whom trained twice weekly for 3 more months. Control subjects (n = 7) performed sham-VIH. Vital capacity (VC), FEV1, maximum voluntary ventilation (MVV), maximal inspiratory and expiratory mouth pressures, \({\dot{{V}}\hbox{O}_{{2{\rm max}}},}\) 4-mile run time, treadmill run time to exhaustion at 80% \({\dot{{V}}\hbox{O}_{{2 {\rm max}}},}\) serum lactate, total ventilation \({(\dot{{V}}_{\rm E}),}\) oxygen consumption \({(\dot{{V}}\hbox{O}_{2}),}\) oxygen saturation and cardiac output were measured before and after 4 weeks of VIH. Respiratory parameters and 4-mile run time were measured monthly during the 3-month maintenance period. There were no significant changes in post-VIH VC and FEV1 but MVV improved significantly (+10%). Maximal inspiratory and expiratory mouth pressures, arterial oxygen saturation and cardiac output did not change post-VIH. Respiratory and running performances were better 7- versus 1 day after VIH. Seven days post-VIH, respiratory endurance (+208%) and treadmill run time (+50%) increased significantly accompanied by significant reductions in respiratory frequency (−6%), \({\dot{{V}}_{\rm E}}\) (−7%), \({\dot{{V}}\hbox{O}_{2}}\) (−6%) and lactate (−18%) during the treadmill run. Post-VIH 4-mile run time did not improve in the control group whereas it improved in the experimental group (−4%) and remained improved over a 3 month period of reduced VIH frequency. The improvements cannot be ascribed to improved blood oxygen delivery to muscle or to psychological factors.

The current study retrospectively reviewed the cases of 68 patients who had undergone total laryngectomy and tracheoesophageal puncture (TEP) over a 16-year period. Fifty-one patients underwent primary TEP and 17 underwent secondary TEP. Nearly 80% of patients who received TEP at the time of laryngectomy achieved excellent voice quality perceptually. In contrast, only 50% of secondary TEP patients achieved excellent voice ratings. This difference was statistically robust (p = 0.03). Although both surgical and prosthesis-related complications occurred more frequently following primary TEP, statistically significant differences were not achieved. Neither pre- nor postoperative radiotherapy had any effect on voice restoration or complication rates. Based on these data, primary TEP may be preferable for several reasons, including a greater likelihood of successful voice restoration, a shorter duration of postoperative aphonia, and the elimination of the need for a second operation and interim tube feedings.

BACKGROUND Follicular carcinomas of the thyroid gland, including its oncocytic variant (so-called Hurthle cell carcinoma), are subdivided into the indolent encapsulated (“minimally invasive”) and the clinically aggressive widely invasive tumors. There are, however, cases of encapsulated follicular carcinoma that recur and metastasize. Identifying these cases at the time of diagnosis is crucial for prognostic and therapeutic considerations. Because to the authors' knowledge most studies do not focus exclusively on the encapsulated Hurthle cell carcinoma (EHC), the current study attempted to identify predictors of recurrence in EHC. METHODS A tumor was defined as EHC if it was encapsulated, macroscopically well defined with microscopic but no macroscopic evidence of vascular or capsular invasion, and composed of >75% follicular oncocytic cells. Retrospective chart review and microscopic examination identified 50 primary tumors meeting the above criteria at the Memorial Sloan-Kettering Cancer Center between 1967 and 2005. The cases were analyzed for various histologic and clinical parameters. Each parameter was correlated with recurrence-free survival (RFS). RESULTS Seven of 50 (14%) patients developed disease recurrence. All patients who developed recurrence were found to have a high number of foci of vascular invasion (≥ 4). In univariate analysis, ≥ 4 foci of vascular invasion (P 4 cm (P = .049), the presence of mitosis (P = .018), and a solid/trabecular growth pattern (P = .009) were found to be correlated with a decreased RFS. Extensive capsular invasion, gender, and age did not confer a statistically higher recurrence rate. The finding of a solid/trabecular growth and mitosis correlated with the presence of numerous foci (≥ 4) of vascular invasion (P = .01 and P = .005, respectively). CONCLUSIONS A diligent search for vascular invasion is recommended in EHC that display mitosis or a solid/trabecular growth pattern. The presence of ≥ 4 foci of vascular invasion should alert the pathologist and the clinician to a significantly higher risk of recurrence in EHC. Cancer 2006. © 2006 American Cancer Society.

This study aimed to estimate the cumulative survival rates (CSRs) of implants placed in reconstructed mandibles and to identify prognostic factors that may influence implant survival.The charts of 24 patients (10 male, 14 female) who had undergone mandibular resection and reconstruction with fibula free-flaps treated with implant-supported prostheses from April 1986 through December 2001 were reviewed. Information on demographics, surgical characteristics, treatment modalities, dentition, implant parameters, prostheses, and hyperbaric oxygen therapy (HBO) was gathered. Kaplan-Meier survival estimates were generated for the 100 implants that satisfied the inclusion criteria. Multivariate Cox proportional hazards regression models accounting for correlated implants within subjects were developed to identify prognostic factors for implant survival.Ninteen implants had been placed in native mandible (3 in irradiated bone) and 81 in fibula bone flap. Six implants failed during the follow-up period (mean 51.7 months). The overall 5- and 10-year CSRs were 97.0% and 79.9%, respectively. In the univariate analysis, variables associated with implant survival were age, gender, chemotherapy, radiation therapy, HBO, irradiated bone, implant diameter, xerostomia, trismus, opposing dentition, and type of prosthesis. At 5 years, the CSR of implants in patients with HBO was 86.7%; HBO was statistically associated with an increased risk for implant failure (P = .005, hazard ratio = 19.79, 95% CI: 2.42 to 161.71).The CSR was lower when implants were placed in a previously irradiated mandible. There is still a lack of reliable clinical evidence to support the effectiveness of HBO in these patients.A high survival rate was demonstrated for implants placed in fibula free-flap reconstructed mandibles. The finding that HBO was a risk factor can probably be attributed to the small sample size; further study is needed in this patient population.

BACKGROUND The objectives of the current study were to report the incidence of postoperative complications for salvage total laryngectomy (STL) compared with primary total laryngectomy (PTL) and to identify patient and tumor-related factors predictive of postoperative complications. METHODS A sample of 183 patients who had received a total laryngectomy were identified from an existing database of 662 patients treated for squamous cell carcinoma of the larynx. PTL and STL were performed in 113 and 70 patients, respectively. Initial therapy in the patients who required salvage surgery included radiotherapy (RT) in 32 (46%) and chemoradiotherapy (CTRT) in 38 (54%). Postoperative complications were recorded for each group and categorized into local, swallowing, airway, and systemic complications. Postoperative complication rates for STL after RT and CTRT were compared with those after PTL by univariate analysis. Patient and tumor-related predictors of complications were identified by univariate and multivariate analyses. RESULTS The overall mortality rate was 0.5%. Forty percent of all patients developed a postoperative complication after total laryngectomy. Local complications, which were the most frequent, occurred in 52 (28%) patients. Pharyngocutaneous fistula occurred in 31 (17%) patients. Statistical analysis showed that there was a greater number of patients with local wound (45% vs. 25%, P = 0.02) and fistula complications (32% vs. 12%, P = 0.012) in the STL-CTRT group compared with the primary laryngectomy group. Multivariate analysis showed that primary CTRT was an independent predictor of local complications and pharyngocutaneous fistula. CONCLUSIONS Salvage laryngectomy was more frequently associated with postoperative complications after CTRT compared with PTL. Problems related to local wound healing, especially the development of pharyngocutaneous fistula, constituted the most common postoperative complication in these patients. Multivariate analysis showed that primary CTRT was an independent predictor of local wound complications and pharyngocutaneous fistula. Cancer 2005. © 2005 American Cancer Society.

The purpose of this retrospective study was to compare the functional outcomes of patients who had mandibular resection and reconstruction with and without prosthetic intervention, and to identify predictive factors that may have an impact on functional outcomes.Two hundred twenty head and neck cancer patients who had undergone mandibular resection and reconstruction with at least 6 months of postoperative convalescence formed the basis of this retrospective review. Patients who did not receive prosthetic intervention formed group I (n = 142); those who received prosthetic intervention formed group II (n = 78). Functional outcomes were measured using four individual assessments (nutritional status, swallowing, masticatory performance, and speech) and one that combined the information from these assessments, the global measure of functional outcome (GMFO). Statistical analyses were used to compare the baseline characteristics and functional outcome between groups I and II and to analyze independent predictors for GMFO.Of the 220 patients reviewed, 78 (35%) had prosthetic intervention; group II patients had better individual functional outcome measures and GMFO. Use of a prosthesis remained associated with GMFO after controlling for other significant predictors; other independent predictors were xerostomia, number of remaining mandibular teeth, number of tooth-to-tooth contacts, type of reconstruction, flap interference, and tongue defect. Patients who had fewer mandibular teeth and received a smaller prosthesis had better overall outcome than patients who received a larger prosthesis.Patients who had prosthetic intervention after mandibular reconstruction had significantly better functional outcomes than patients who did not receive prosthetic intervention, even after adjusting for confounding variables.

Bleeding is a major concern during percutaneous nephrolithotomy (PCNL), especially with the use of multiple tracts. This prospective study aimed to identify factors affecting blood loss during PCNL.Data were collected prospectively from 236 patients undergoing 301 PCNL procedures at our institute since June 2002. Blood loss was estimated by the postoperative drop in hemoglobin factored by the quantity of any blood transfusion. Various patient-related and intraoperative factors were assessed for association with total blood loss or blood transfusion requirement using stepwise multivariate regression analysis.The average hemoglobin drop was 1.68 +/- 1.23 g/dL. Stepwise multivariate regression analysis showed that the occurrence of operative complications (P0.0001), mature nephrostomy tract (P0.0001), operative time (P0.0001), method of access guidance (fluoroscopy v ultrasound) (P = 0.0001), method of tract dilatation (P = 0.0001), multiple (or =2) tracts (P = 0.003), size of the tract (P = 0.001), renal parenchymal thickness (P = 0.05), and diabetes (P = 0.05) were significant predictors of blood loss. The overall blood transfusion rate for all patients was 7.9%. Preoperative hemoglobin, multiple tracts, stone size, and total blood loss were significant in predicting perioperative blood transfusion requirement. Factors such as age, hypertension, renal insufficiency, urinary infection, the degree of hydronephrosis, stone bulk, and the function of the ipsilateral renal unit did not have any effect on the blood loss. Technical factors such as the operating surgeon and the calix of entry also did not affect the blood loss.Diabetes, multiple-tract procedures, prolonged operative time, and the occurrence of intraoperative complications are associated with significantly increased blood loss. Atrophic parenchyma and past ipsilateral intervention are associated with reduced blood loss. On the basis of this evidence, maneuvers that may reduce blood loss and transfusion rate include ultrasound-guided access, use of Amplatz or balloon dilatation systems, reducing the operative time, and staging the procedure in cases of a large stone burden or intraoperative complications. Reducing the tract size in pediatric cases, nonhydronephrotic systems and those with a narrow infundibulum, and secondary tracts in a multiple-tract procedure may also reduce blood loss during PCNL.

Background The purpose of this study was to characterize the incidence, pattern of spread, and prognostic correlation of nerve invasion in patients with adenoid cystic carcinoma (ACC). Methods Using 3 different pathological categories of perineural invasion, intraneural invasion, and perineural inflammation, we investigated the prognostic value of nerve invasion in a total of 495 ACCs from 9 international patient cohorts with median follow-up 90 months (range, 12-288 months). Results Of 239 patients (48%) with nerve invasion, 174 (73%) had perineural invasion, 65 (27%) intraneural invasion, and 37 (15%) perineural inflammation. Multivariate Cox regression analysis identified tumor site (p =.008; hazard ratio [HR] = 1.8; 95% confidence interval [CI] = 0.07-3.7) and intraneural invasion (p