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Background Mutations involving BRAF and TERT are important predictors of disease severity in thyroid cancer, but molecular testing is limited by cost and lack of adequate tissue sample. This study aimed to assess the utility of BRAFV600E and TERT testing using droplet digital PCR (ddPCR) as a diagnostic and prognostic tool for thyroid fine needle aspirate biopsy (FNAB). Methods Patients with thyroid nodules were prospectively enrolled from March 2015 to September 2018. Pre-operative FNAB was collected for standard cytology and molecular testing. BRAFV600E and TERT levels were analyzed by ddPCR. Cytology (Bethesda system) and ddPCR results were correlated to surgical pathology. Results A total of 222 patients were enrolled, of which 124 received thyroid surgery. Pre-operative cytology alone with Bethesda ≥5 was 100% specific and 70% sensitive for malignancy on final surgical pathology. BRAFV600E positivity or TERT overexpression was 100% specific and 60.0% sensitive. Combining cytology (Bethesda ≥5) with BRAFV600E and TERT testing increased the sensitivity of a malignant diagnosis to 80.0%. High TERT levels and/or BRAFV600E was associated with aggressive or advanced stage pathology. Conclusions Combining cytology with ddPCR analysis of BRAFV600E and TERT can improve the diagnostic accuracy of thyroid FNAB, and help predict aggressive pathology.

Objective The total oral tongue (anterior 2/3 glossectomy) defect is seldom addressed in the literature. This is the first series to describe a consistent technique for its reconstruction. The aim of the study is to describe the use of the beavertail modified radial forearm free flap (BTRFFF) to reconstruct a total oral tongue defect and the functional and quality of life outcomes associated with it. Study design Retrospective review of prospectively collected data from 2000 to 2010. Methods All patients at the University of Alberta undergoing head and neck free flap surgery are enrolled in a prospective functional outcomes program. Pre-operatively and at set post-operative time points patients complete videofluoroscopic swallowing studies (VFSS), speech evaluations and quality of life questionnaires (EORTC H&N-35). Peri-operative outcomes were also measured. Results 17 consecutive patients were included. All were gastrostomy tube free at 12 months post-operatively and tolerating a full soft diet with aspiration scores of 0. Swallowing transit times increased by a mean of 0.4 s (p = 0.32). Speech intelligibility remained high with mean sentence intelligibility at 75% and single word intelligibility at 62%. Quality of life scores returned to baseline and remained satisfactory. Complications related to the BTRFFF were limited to scarring. Conclusions The BTRFFF provides a robust reconstructive option for the total oral tongue defect with excellent long term functional outcomes and quality of life.

Background The role of molecular biomarkers in oropharyngeal squamous cell carcinoma (OPSCC) has recently been increasingly recognized. There is conflicting evidence in the literature with regards to the prognostic value of p53 and Bcl-xL. Objective The purpose of this study was to investigate the association between p53 and Bcl-xL expression profiles and survival outcomes in OPSCC. Methods Patients diagnosed with OPSCC and treated with curative intent between 1998 and 2009 were included in the study. Patient demographics, disease, treatment, and oncologic outcomes were collected prospectively. A tissue microarray (TMA) from patients' biopsies or surgical specimens was retrospectively constructed. The expression levels of p53, Bcl-xL, and p16 were digitally quantified and correlated to patient survival outcomes. Results One hundred and sixty-six patients were included (mean age 56.7 years; standard deviation (SD) ± 10.0; 78% male). High expression of Bcl-xL (p= 0.04) was significantly associated with nodal disease at presentation, and decreased overall survival (OS) (p= 0.04). Combined expression of low Bcl-xL and low p53 conferred a survival advantage in non-smokers (p= 0.04). Multivariate analysis supported smoking and p16 status as independent prognosticators for OS. Conclusions This study suggests that biomarker profiling using Bcl-xL and p53 levels may be of prognostic value in select patients with OPSCC.

Background RAAPID (Referral, Access, Advice, Placement, Information, and Destination) is a 24-h call center in Alberta, Canada, facilitating urgent telephone consultations between physicians and specialists. We evaluated the extent to which RAAPID calls to Otolaryngology-Head and Neck Surgery (OHNS) reduced visits to the emergency department and specialty clinics. Methods This was a cross-sectional study evaluating all telephone consultations to OHNS from physicians in northern Alberta between 2013 and 2014 (T1) (where consultations by residents occurred) and 2015 to 2017 (T2) (where consultations were done by consultants during office hours and residents during after hours). Outcomes of the calls included medical advice, specialty clinic referrals, and emergency department (ED) referrals. Differences in the reduction of ED visits and costs, overall as well as in T1 and T2, were assessed using multivariate logistic regression. Results Overall, 62.3% (1064/1709) of telephone consultations reduced ED visits consisting of advice being provided (n = 884; 83.1%) and referral to specialty clinics (n = 180; 16.9%). The adjusted odds ratio of calls reducing emergency visits in T2 as compared to T1 was 2.47 (95% CI 1.99 to 3.08). The adjusted odds ratio of reducing ED visits during office hours compared to after-hours 2.54 (95% CI 1.77–3.64). The estimated direct costs avoided from ED visits in T1 and T2 were $42,224.22 and $114,393.86, respectively. Conclusion RAAPID telephone consultations to OHNS were effective in reducing ED visits and healthcare costs. This model should be considered in other areas to improve efficiencies within the health system.

IMPORTANCE: Incorporation of patient perspectives, or patient-reported outcomes, in functional outcome measures has been gaining prominence in the literature on reconstructive surgery. OBJECTIVE: To create and validate an instrument for measuring the main functional areas of concern for patients with head and neck cancer. DESIGN, SETTING, AND PARTICIPANTS: This 4-phase mixed-methods qualitative study was conducted from July 1, 2013, to June 30, 2016, in a quaternary head and neck oncology center in Edmonton, Alberta, Canada. Patients were recruited from 3 Head and Neck Research Network sites: University of Alberta (Edmonton, Canada), Mount Sinai Health Network (New York, New York), and University of Turku Hospital (Turku, Finland). The inclusion criteria included 18 years of age or older, diagnosis of squamous cell carcinoma involving the subsites of the head and neck (ie, oral cavity, oropharynx, hypopharynx, and larynx), and at least 1 year since treatment completion. Those patients who were undergoing additional active treatment or with evidence of disease recurrence were excluded. Data were analyzed from July 1, 2013, to June 30, 2016. MAIN OUTCOMES AND MEASURES: The primary outcome measures were the clinical correlation of the Edmonton-33 instrument scores with swallowing, speech, dry mouth, and chewing assessment outcomes. RESULTS: In total, 10 patients with head and neck cancer (mean age, 59.6 years; 6 men [60%]) were included in phase 1 of the study, 5 patients (mean age, 55.2 years) were included in phase 2, 10 patients were included in phase 3, and 25 patients with head and neck cancer (mean age, 62.6 years; 14 men [56%]) participated in the phase 4 validation. The Edmonton-33 instrument scores correlated strongly with the swallowing scores of the MD Anderson Dysphagia Inventory (r = 0.77; 95% CI, 0.49-1.0), the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire–Head and Neck 35 (EORTC QLQ–H&N35) (r = –0.73; 95% CI, –1.0 to –0.44), and the modified barium swallow test (r = –0.60; 95% CI, –0.94 to –0.25). The instrument scores were also strongly correlated with the Speech Handicap Index scores (r = –0.64; 95% CI, –0.97 to –0.31), word intelligibility scores (r = 0.61; 95% CI, 0.27-0.95), and sentence intelligibility scores (r = 0.55; 95% CI, 0.19-0.91). A moderate to strong correlation was observed between the Edmonton-33 instrument and the EORTC QLQ–H&N35 scores in the dry mouth (r = –0.54; 95% CI, –0.91 to –0.18) and chewing (r = –0.45; 95% CI, –0.84 to –0.06) domains. The factor loading values for the domains of swallowing, speech, dry mouth, and chewing were all greater than 0.3. The mean factor loading values for the items related to swallowing were 0.71 (95% CI, 0.62-0.80) and for the items related to speech were 0.76 (95% CI, 0.72-0.80). The mean factor loading values for the items related to dry mouth were 0.71 (95% CI, 0.59-0.83) and for those related to chewing were 0.77 (95% CI, 0.69-0.85). CONCLUSIONS AND RELEVANCE: The Edmonton-33 appears to be a validated instrument that will allow patients with head and neck cancer to assess and report their own functional outcomes. It could serve as a single comprehensive measure for functional outcomes.

Introduction Evidence-based interventions for tobacco control in the US workplace can reach a large audience. The purpose of our study was to explore the prevalence and determinants of type of tobacco use (ie, cigarettes only, e-cigarettes only, or dual use) among adult employees in the United States and to examine type of use by state. Methods We used data from the 2017 Behavioral Risk Factor Surveillance System to examine the prevalence of cigarette use, e-cigarette use, dual use, and quit attempts. We used multinomial logistic regression to examine the relationships between sociodemographic characteristics and type of tobacco product used, and we estimated adjusted prevalence. Results Approximately 17% of respondents were current smokers, 5% were current e-cigarette users, and 2% were dual users. E-cigarette-only and dual use were generally highest among young (aged 18-24), male, and less-educated respondents and lower for respondents who identified as black, Asian/Native Hawaiian/Pacific Islander, or Hispanic than for white respondents. Cigarette-only and dual use were higher for respondents who did not have health care coverage. Prevalence by state of e-cigarette use only ranged from 1.2% (Vermont) to 3.9% (Arkansas), whereas the prevalence of dual use ranged from 0.6% (District of Columbia) to 4.0% (Oklahoma). Conclusion Prevalence of cigarette, e-cigarette, and dual use varied by sociodemographic characteristics and by state. These findings can support targeting of specific populations when designing and implementing evidence-based interventions for tobacco control in workplace settings.

Purpose: To construct a wellness committee (WC) implementation index and determine whether this index was associated with evidence-based intervention implementation in a workplace health promotion program. Design: Secondary data analysis of the HealthLinks randomized controlled trial. Setting: Small businesses assigned to the HealthLinks plus WC study arm. Sample: Small businesses (20-200 employees, n = 23) from 6 low-wage industries in King County, Washington. Measures: Wellness committee implementation index (0%-100%) and evidence-based intervention implementation (0%-100%). Analysis: We used descriptive and bivariate statistics to describe worksites’ organizational characteristics. For the primary analyses, we used generalized estimating equations with robust standard errors to assess the association between WC implementation index and evidence-based intervention implementation over time. Results: Average WC implementation index scores were 60% at 15 months and 38% at 24 months. Evidence-based intervention scores among worksites with WCs were 27% points higher at 15 months (64% vs 37%, P < .001) and 36% points higher at 24 months (55% vs 18%, P < .001). Higher WC implementation index scores were positively associated with evidence-based intervention implementation scores over time ( P < .001). Conclusion: Wellness committees may play an essential role in supporting evidence-based intervention implementation among small businesses. Furthermore, the degree to which these WCs are engaged and have leadership support, a set plan or goals, and multilevel participation may influence evidence-based intervention implementation and maintenance over time.

Background Recent guidelines for the management of thyroid nodules incorporate mutation testing as an adjunct for surgical decision-making, however current tests are costly with limited accuracy. Droplet digital PCR (ddPCR) is an ultrasensitive method of nucleic acid detection that is particularly useful for identifying gene mutations. This study aimed to assess the analytic and clinical validity of RAS and BRAF ddPCR mutational testing as a diagnostic tool for thyroid fine needle aspirate biopsy (FNAB). Methods Patients with thyroid nodules meeting indication for FNAB were prospectively enrolled from March 2015 to September 2017. In addition to clinical protocol, an additional FNAB was obtained for ddPCR. Optimized ddPCR probes were used to detect mutations including HRASG12 V, HRASQ61K, HRASQ61R, NRASQ61R, NRASQ61K and BRAFV600E. The diagnostic performance of BRAF and RAS mutations was assessed individually or in combination with Bethesda classification against final surgical pathology. Results A total of 208 patients underwent FNAB and mutational testing with the following Bethesda cytologic classification: 26.9% non-diagnostic, 55.2% benign, 5.3% FLUS/AUS, 2.9% FN/SPN, 2.4% SFM and 7.2% malignant. Adequate RNA was obtained from 91.3% (190) FNABs from which mutations were identified in 21.1% of HRAS, 11.5% of NRAS and 7.4% of BRAF. Malignant cytology or BRAFV600E was 100% specific for malignancy. Combining cytology with ddPCR BRAF600E mutations testing increased the sensitivity of Bethesda classification from 41.7 to 75%. Combined BRAFV600E and Bethesda results had a positive predictive value (PPV) of 100% and negative predictive value (NPV) of 89.7% for thyroid malignancy in our cohort. Conclusions DdPCR offers a novel and ultrasensitive method of detecting RAS and BRAF mutations from thyroid FNABs. BRAFV600E mutation testing by ddPCR may serve as a useful adjunct to increase sensitivity and specificity of thyroid FNAB.

The aim of this study was to identify alignments between wellness offerings low socioeconomic status (SES) employees need and those large companies can provide.Focus groups (employees); telephone interviews (large companies). Employees were low-SES, insured through their employers, and employed by large Washington State companies. Focus groups covered perceived barriers to healthy behaviors at work and potential support from companies. Interviews focused on priorities for employee health and challenges reaching low-SES employees.Seventy-seven employees participated in eight focus groups; 12 companies completed interviews. Employees identified facilitators and barriers to healthier work environments; companies expressed care for employees, concerns about employee obesity, and reluctance to discuss SES.Our findings combine low-SES employee and large company perspectives and indicate three ways workplaces could most effectively support low-SES employee health: create healthier workplace food environments; prioritize onsite physical activity facilities; use clearer health communications.

Purpose: The purpose of this study is to evaluate managers’ barriers and facilitators to supporting employee participation in the Washington State Wellness program. Design: Exploratory sequential mixed methods. Setting: Four Washington State agencies located in Olympia and Tumwater, Washington. Participants: State employees in management positions (executive, middle, and line), whose job includes supervision of subordinates and responsibility for the performance and conduct of a subunit or group. Methods: We interviewed 23 managers and then used the results to create a survey that was fielded to all managers at the 4 agencies. The survey response rate was 65% (n = 607/935). Analysis: We used qualitative coding techniques to analyze interview transcripts and descriptive statistics to summarize survey data. We used the Total Worker Health framework to organize our findings and conclusions. Results: Managers support the wellness program, but they also face challenges with accommodating employees’ participation due to workload, scheduling inflexibility, and self-efficacy to discuss wellness with direct reports. About half the managers receive support from the manager above them, and most have not received training on the wellness program. Conclusion: Our findings point to several strategies that can strengthen managers’ role in supporting the wellness program: the provision of training, targeted messages, formal expectations, and encouragement (from the manager above) to support employees’ participation.

With the changing landscape of postgraduate surgical education to competency-based curricula, there emerges a need for alternative forms of training. Video teaching modules have been shown to be effective tools in surgical education, complementing traditional postgraduate curricula. There is a lack of validated modules described in the literature, specifically for teaching thyroidectomy. The primary objective of this study was to develop and validate a high definition video-based teaching module instructing thyroidectomy surgery to Otolaryngology-Head and Neck Surgery trainees.This prospective study included intermediate to senior Otolaryngology-Head and Neck Surgery residents. Each participant first performed a thyroid lobectomy, serving as the initial assessment. After a washout period of at least 3 weeks, each participant was given the teaching module. The 15-minute module was developed using a 3-camera system and detailed a step-by-step approach to the surgery. After exposure to the module, each trainee performed the same procedure. Recordings of both procedures were deidentified and reviewed by a blinded, independent evaluator. Scoring was done using the Observational Clinical Human Reliability Assessment (OCHRA) system.University of Alberta Hospital and Royal Alexandra Hospital, Edmonton, Alberta, Canada.A total of 6 intermediate to senior Otolaryngology-Head and Neck Surgery residents entered and completed the study.The mean error rate was 8.8 errors per procedure before module exposure and 4.5 errors per procedure after exposure, representing a 49% decrease in error occurrence (p0.05). The mean staff takeover event rate was 10.5 takeovers per procedure prior to module exposure and 5.0 takeovers per procedure after exposure, representing a 52% decrease in error occurrence (p0.05).High-definition video teaching modules are a useful complement to traditional surgical training. In a climate where new innovations for teaching thyroid surgery are needed, properly constructed and validated video teaching modules can serve as important tools in supplementing traditional surgical training.

Objectives. To determine whether (1) participating in HealthLinks, and (2) adding wellness committees to HealthLinks increases worksites’ evidence-based intervention (EBI) implementation. Methods. We developed HealthLinks to disseminate EBIs to small, low-wage worksites. From 2014 to 2017, we conducted a site-randomized trial in King County, Washington, with 68 small worksites (20–200 employees). We assigned worksites to 1 of 3 arms: HealthLinks, HealthLinks plus wellness committee (HealthLinks+), or delayed control. At baseline, 15 months, and 24 months, we assessed worksites’ EBI implementation on a 0% to 100% scale and employees’ perceived support for their health behaviors. Results. Postintervention EBI scores in both intervention arms (HealthLinks and HealthLinks+) were significantly higher than in the control arm at 15 months (51%, 51%, and 23%, respectively) and at 24 months (33%, 37%, and 24%, respectively; P Conclusions. HealthLinks is an effective strategy for disseminating EBIs to small worksites in low-wage industries. Public Health Implications. Future research should focus on scaling up HealthLinks, improving EBI maintenance, and measuring impact of these on health behavior.

Background Donor site complications secondary to radial forearm free flap (RFFF) reconstruction can limit recovery. Optimizing hand and wrist function in the post-operative period may allow more efficient self-care and return to activities of daily living. Negative pressure wound dressings (NPD) may increase blood flow and perfusion as compared to static pressure dressings (SPD) designed to minimize shear forces during the healing period. This study aims to compare subjective and objective hand and wrist functional outcomes following RFFF reconstruction with split thickness skin grafts (STSG) in patients treated with NPD and SPD. Methods Adult patients undergoing RFFF with STSG were identified preoperatively and randomized to receive NPD or SPD following their RFFF reconstruction. NPD involved a single-use, portable device capable of applying 80 mmHg of negative pressure to the forearm donor site. SPD involved a volar splint. Dressings were left in place for seven days with subjective and objective function assessed at seven days, one month and three months postoperatively. The primary outcome was self-reported hand function as measured with the function subscale of the Michigan Hand Questionnaire (MHQ). Secondary outcomes included hand and wrist strength, range of motion, sensation, scar aesthetics, and skin graft complications. Results Twenty-four patients undergoing RFFF were randomized to NPD or SPD. Patients treated with NPD had improved MHQ self-reported functional scores as compared to those treated with SPD at seven days postoperatively (P = 0.016). Flexion at seven days was improved in NPD group (P = 0.031); however, all other strength and range of motion outcomes were similar between groups. There were no differences in rates of graft complications, scar aesthetics, or sensation. Conclusions In the immediate post-operative period, NPD was associated with improved patient-reported hand and wrist function. Wound care to optimize hand and wrist function could allow for improved patient outcomes in the immediate postoperative period.

Objective The aim of this study was to assess whether tobacco policy, program, and communication evidence-based practice implementation is associated with employee tobacco outcomes [current smoking; quit attempt; smokeless tobacco (SLT) use; and perceived worksite support for cessation] at small low-wage worksites. Methods We analyzed data from a randomized controlled trial testing an intervention to increase implementation of evidence-based health promotion practices. We used generalized estimating equations to examine relationships between practice implementation and tobacco outcomes. Results Communication practice implementation was associated with better perceived worksite support for cessation (P = 0.027). Policy and program implementation were associated with increased odds of being a current SLT user; these findings should be interpreted with caution given small sample sizes. Conclusion Tobacco communication evidence-based practice implementation was associated with favorable perceptions of worksite support for cessation; more may be needed to change tobacco use behavior.

Objectives/hypothesis The free flap reconstructive protocols of the jaws have been refined over the years and presently are based on bone-driven approaches that generally use the lower border of the mandible or the anterior surface of the maxilla as the templates for reconstruction because these contours are deemed important to the eventual cosmetic outcomes of patients. The ultimate goal of functional jaw reconstruction, however, is the reconstruction of the dental occlusion and oral rehabilitation. The purpose of the present study was to evaluate the Alberta reconstructive technique (ART), which is a new approach of occlusion-driven jaw reconstruction with digitally planned immediate osseointegrated implant installation. Study design Prospective cohort study. Methods This research study considers the ART's safety, effectiveness, accuracy, timeliness of reconstruction, aesthetic appeal, and cost-effectiveness in comparison with the standard bone-driven and delayed osseointegrated implant installation (BDD) protocol. Results The ART procedures were as safe and more effective at achieving full occlusal reconstruction and oral rehabilitation. The ART cohort of patients achieved oral rehabilitation in 21.4 month as compared to 73.1 months for the BDD cohort. There were no differences in the aesthetic appeal the two groups. The ART cost an average of $22,004 less than BDD and we calculated the quality adjusted life years gain to be between 2.14 and 4.04 in favour of ART. Conclusions The ART is a good option for patients with jaw defects. It provides a safe, effective, accurate, aesthetic, and cost-effective reconstruction that restores form and function in a timely manner. Level of evidence 2b Laryngoscope, 129:S1-S14, 2019.

Purpose The incidence of hypothyroidism after radiation therapy for head and neck cancer (HNC) has been found to be ≤53%. Medical treatment of hypothyroidism can be costly and difficult to titrate. The aim of the present study was to assess the feasibility of free thyroid transfer as a strategy for the prevention of radiation-induced damage to the thyroid gland during radiation therapy for HNC. Methods and Materials A prospective feasibility study was performed involving 10 patients with a new diagnosis of advanced HNC undergoing ablative surgery, radial forearm free-tissue transfer reconstruction, and postoperative adjuvant radiation therapy. During the neck dissection, hemithyroid dissection was completed with preservation of the thyroid arterial and venous supply for implantation into the donor forearm site. All patients underwent a diagnostic thyroid technetium scan 6 weeks and 12 months postoperatively to examine the functional integrity of the transferred thyroid tissue. Results Free thyroid transfer was executed in 9 of the 10 recruited patients with advanced HNC. The postoperative technetium scans demonstrated strong uptake of technetium at the forearm donor site at 6 weeks and 12 months for all 9 of the transplanted patients. Conclusions The thyroid gland can be transferred as a microvascular free transfer with maintenance of function. This technique could represent a novel strategy for maintenance of thyroid function after head and neck irradiation.

This study examines whether paid sick leave and hours worked per week are associated with receipt of recommended well-child visits, preventive dental care, influenza vaccines, obesity screening, and vision screening among U.S. children aged 0 to 17 years whose mothers were employed using data from the Medical Expenditure Panel Survey. Residual inclusion instrumental variables methods were used to address unobserved confounding related to maternal employment and child health care use. Instruments were the industry-specific mean of paid leave and hours worked. Fewer than half of children received the recommended number of well-child visits and dental care; only 14% of children received an influenza vaccine in the past year. Paid sick leave was associated with increased adherence to recommended well-child visits (marginal probability, 0.12; 95% confidence interval [CI] = 0.23, 0.01), preventive dental care (marginal probability, 0.28; 95% CI = 0.34, 0.33), and receipt of the influenza vaccine (marginal probability, 0.09; 95% CI = 0.13, 0.05 ).

Summary Background Despite the promise of metabolic tumor volume (MTV) as a risk-stratifying marker, the retrospective design of the initial study limits its generalizability. Therefore, this study sought to validate MTV as a prognostic factor for oral cavity squamous cell carcinoma (OCSCC) treated with primary surgery within an independent data set. Methods The validation data set consisted of 42 patients diagnosed with OCSCC between 2008 and 2012. The original cohort consisted of 80 patients. MTV and SUVmax were calculated for the primary tumor and nodal metastasis separately, as well as combined. Before statistical analysis, MTV and SUVmax values were divided into intertertile thirds to allow for intergroup survival analysis. Validation analysis was conducted on the validation data set alone. Data from both cohorts were then combined ( n = 122) to increase statistical power. Results An increase in combined MTV of 17.5 cm 3 was associated with statistically significant increase in risk of disease recurrence (HR = 19.2, p p p > 0.05) and disease-free survival (HR = 1.0, p > 0.05). Increase in the MTV of the primary tumor was associated with an increase in the risk of disease recurrence (HR = 21.7, p = 0.0001) and risk of death (HR = 7.0, p = 0.0001), while increase in the MTV of the locoregional neck metastasis was not ( p > 0.05). An MTV cutoff value of greater than 10.2 cm 3 was found to significantly affect survival. Conclusion Due to the reproducibility of MTV findings, this study validates MTV as an independent prognostic factor for OCSCC treated with primary surgery.

Background and purpose Declines in strength, flexibility, and balance in older adults can lead to injuries and loss of independence and are particularly common in those of greater age and in worse health. EnhanceFitness (EF) is a nationally disseminated, evidence-based group exercise program for older adults that has been shown to improve function through cardiovascular, strength, flexibility, and balance exercises. This article examines changes in, and predictors of, participant physical function from baseline through 2 program cycles of EF as measured by 3 physical function tests: arm curls, chair stands, and 8-foot up-and-go. Methods We analyzed data on participants who attended at least 2 consecutive 16-week program cycles between January 2005 and June 2016. We ran 3 random-effects linear regression models, 1 for each physical function test, and accounted for missing data and clustering by class site. Independent variables included attendance, demographics, and health status. Results and discussion A total of 7483 participants completed baseline and 2 sets of follow-up physical function tests. For all 3 physical function tests, participants showed some degree of improved physical function at each follow-up, and greater program attendance predicted clinically significant improvements. Some participants had less improvement: females, those less active at baseline, older than 75 years, not married or partnered, or in fair or poor health, those who had experienced at least 1 fall, and those with a disability. Conclusion EnhanceFitness program providers may need to implement additional measures to support the participants who could benefit most from EF, such as targeting messaging, coordinating with referring providers to emphasize attendance and general activity in specific participants, and offering additional support to groups who show less improvement during classes. The evidence presented here may inform clinical decision making for older adult patients and increase health care provider confidence in EF and similar exercise programs, thereby providing a mechanism to maintain and continue functional gains made in clinical or rehabilitation settings.

Background. HealthLinks is a workplace health promotion program developed in partnership with the American Cancer Society. It delivers a package of evidence-based interventions and implementation support to small worksites in low-wage industries. As part of a randomized, controlled trial of HealthLinks, we studied approaches to recruiting these worksites. Aims. This study aims to guide future recruitment for community-based worksite health promotion interventions by comparing three approaches, including leveraging relationships with community partners. Method. We recruited 78 small, low-wage worksites in King County, Washington, to participate in the trial via three approaches: phone calls to companies on a purchased list (“cold”), phone calls to a list of eligible companies provided by a health insurer (“lukewarm”), and personal referrals from local health insurers and brokers (“warm”). Eligible and interested worksites received an in-person visit from researchers and completed additional steps to enroll. Results. Of the worksites screened and deemed eligible, 32% of the “cold” worksites enrolled in HealthLinks, as did 48% and 60%, respectively, of the “lukewarm” and “warm” worksites. Compared with “warm” worksites, “cold” worksites were twice as likely to be ineligible. Discussion. Two distinct factors help explain why “warmer” worksites were more likely to enroll in HealthLinks. First, eligibility was significantly higher among warmer referrals. Second, most of the warm-referred worksites eligible for the study agreed to meet in person with the project team to hear more about the project. Conclusions. “Warmer” recruitment approaches yielded higher recruitment. Leveraging relationships with community partners can help researchers identify and successfully recruit small, low-wage worksites.

Background Defects following resection of tumors in the head and neck region are complex; more detailed and defect-specific reconstruction would likely result in better functional and cosmetic outcomes. The objectives of our study were: 1) to improve the understanding of the two- and three-dimensional nature of oral cavity and oropharyngeal defects following oncological resection and 2) to assess the geometric dimensions and the shapes of fasciocutaneous free flaps and locoregional tissue flaps required for reconstruction of these defects. Methods This study was an anatomic cadaveric study which involved creating defects in the oral cavity and oropharynx in two cadaveric specimens. Specifically, partial and total glossectomies, floor of mouth excisions, and base of tongue excisions were carried out. These subsites were subsequently geometrically analyzed and their volumes measured. The two-dimensional (2D) assessment of these three-dimensional (3D) structures included measures of surface area and assessment of tissue contours and shapes. Results The resected specimens all demonstrated unique dimensional geometry for the various anatomic sites. Using 2D analysis, hemiglossectomy defects revealed right triangle geometry, whereas total glossectomy geometry was a square. Finally, the base of tongue defects exhibited a trapezoid shape. Conclusions Customizing the geometry and dimensions of fasciocutaneous free flaps so that they are specific to the confronted head and neck defects will likely result in better functional and cosmetic outcomes.

Background There is a paucity of studies reporting long-term survival outcomes for HPV/p16 positive oropharyngeal squamous cell carcinoma (OPSCC). This study aims to compare long-term outcomes of advanced stage p16 positive and negative OPSCCs, treated by surgical and non-surgical modalities. Methods OPSCC patients from 1998 to 2012 were identified through a prospectively collected cancer registry. P16 immunohistochemistry was used as a surrogate marker for HPV-OPSCC. Overall survival (OS) and aspiration free survival (AFS) comparisons were made between patients treated with chemoradiation (CRT) versus primary surgery and radiation/chemoradiation (S+RT/CRT) at 5, 10 and 15 years post-treatment. Results A total of 319 patients were included. P16 positive patients and non-smokers had significantly higher long-term (5, 10 and 15-year) OS. Smokers and p16 negative patients treated with S+RT/CRT had improved long-term OS compared to patients who received CRT. Smokers and p16 negative patients had lower long-term AFS. Multivariate analysis showed improved OS was associated with p16 positivity (HR 0.42, 0.28–0.61) and surgery (HR 0.47, 0.32–0.69), whereas lower OS was associated with ECOG ≥ 2 (HR 2.46, 1.61–3.77), smoking (HR 2.37, 1.41–3.99) and higher stage (HR 1.68, 1.05–2.68). Conclusions In smokers and p16-negative OPSCC patients, primary surgery may be associated with improved long-term survival and dysphagia-related outcomes.

To assess the survival outcomes of oral cavity squamous cell carcinoma (OCSCC) by differing geographical location.Demographic, pathologic, treatment, and survival data was obtained from OCSCC patients from 1998-2010 in Alberta, Canada. 554 patients were included from 660 OCSCC patients. Overall, disease-specific, and disease-free survivals were estimated with Kaplan-Meier and Cox regression analyses. Patients were grouped by geographic locations.Patients from urban locations had improved overall, disease-specific, and disease-free survival compared to rural locations (p0.05). Two and five year estimates of overall survival were significantly higher in the urban cohort at 84% and 78%, versus rural with 48% and 44%, respectively (p0.05). Disease-specific and disease-free survival rates were also superior in the urban group (p0.05). Diagnosis to treatment time for all 3 geographical groups was not found to be statistically significant (p0.05).This study shows that patients with OCSCC living in urban settings have improved survival compared to rural groups.

Background While aggressive treatment for oral cancer may optimize survival, decrements in speech and swallowing function and quality of life often result. This exploratory study investigated how patients recover their communicative function, swallowing ability, and quality of life after primary surgery [with or without adjuvant (chemo)radiation therapy] for tongue cancer over the course of the first year post-operation. Methods Patients treated for oral cancer at three institutions (University of Alberta Hospital, Mount Sinai Beth Israel Medical Center, and Turku University Hospital) were administered patient-reported outcomes assessing speech [Speech Handicap Index (SHI)], swallowing [(M.D. Anderson Dysphagia Inventory (MDADI)] and quality of life [European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Head and Neck Module (EORTC-H&N35)]. Outcome measures were completed pre-operatively and at 1-, 6-, and 12-months post-operatively. Results One hundred and seventeen patients undergoing partial glossectomy with reconstruction participated in this study. Results indicated no significant differences in swallowing function (MDADI and EORTC-H&N35 subscales) between baseline and 6 months post-surgery and no significant differences in speech function (SHI subscales) between baseline and 1 year post-surgery. Most quality of life domains (EORTC-H&N35 subscales) returned to baseline levels by 1 year post-operation, while difficulties with dry mouth and sticky saliva persisted. A clear time trend of adjuvant (chemo)radiation therapy negatively affecting dry mouth scores over time was identified in this study, while negative independent effects of chemoradiation on MDADI swallowing, and EORTC-H&N35 swallowing, eating, and opening mouth subscales were found. Conclusions Assessment time influenced patient-reported speech, swallowing, and quality of life outcomes, while treatment (by time) effects were found for only swallowing and quality of life outcomes. Results of the present study will help guide clinical care and will be useful for patient counseling on expected short and long-term functional and quality of life outcomes of surgical and adjuvant treatment for oral cavity cancer.

Background The resection of large oropharyngeal tumors traditionally involves a lip-splitting mandibulotomy for adequate margin visualization and free flap reconstruction of the surgical defect. Transoral robotic surgery (TORS) has emerged as a technique that can resect large and complex oropharyngeal tumors, avoiding a lip-splitting approach. The aim of this study is to compare the lip-splitting mandibulotomy approach versus TORS for the management of advanced stage oropharyngeal carcinomas. Methods Prospectively collected data from 18 patients with advanced stage oropharyngeal squamous cell carcinoma (OPSCC) who received TORS with radial forearm free flap reconstruction (RFFF) was compared to a matched cohort of 39 patients who received a lip-splitting mandibulotomy and RFFF. Patients were matched for stage, p16 positivity, smoking, age and gender. Length of hospital stay (LOHS), tracheostomy decanulation time, operative time, surgical margin status, and post-operative complications were compared between groups. Results Patients who received TORS with RFFF had a significantly lower mean LOHS, compared to patients who were treated by lip-splitting mandibulotomy and RFFF (14.4 vs 19.7 days, p = 0.03). No significant differences were seen between groups in terms of operative time, tracheostomy decannulation time, margin positivity and post-operative complications. Conclusion TORS with radial forearm free flap reconstruction is a safe, effective and cost-saving alternative to the lip-splitting mandibulotomy approach for the treatment of advanced stage OPSCC.

Background The incidence of oropharyngeal squamous cell carcinoma (OPSCC) caused by oncogenic human papillomavirus (HPV) is rising worldwide. HPV-OPSCC is commonly diagnosed by RT-qPCR of HPV E6 and E7 oncoproteins or by p16 immunohistochemistry (IHC). Droplet digital PCR (ddPCR) has been recently reported as an ultra-sensitive and highly precise method of nucleic acid quantification for biomarker analysis. To validate the use of a minimally invasive assay for detection of oncogenic HPV based on oropharyngeal swabs using ddPCR. Secondary objectives were to compare the accuracy of ddPCR swabs to fresh tissue p16 IHC and RT-qPCR, and to compare the cost of ddPCR with p16 IHC. Methods We prospectively included patients with p16+ oral cavity/oropharyngeal cancer (OC/OPSCC), and two control groups: p16− OC/OPSCC patients, and healthy controls undergoing tonsillectomy. All underwent an oropharyngeal swab with ddPCR for quantitative detection of E6 and E7 mRNA. Surgical specimens had p16 IHC performed. Agreement between ddPCR and p16 IHC was determined for patients with p16 positive and negative OC/OPSCC as well as for healthy control patients. The sensitivity and specificity of ddPCR of oropharyngeal swabs were calculated against p16 IHC for OPSCC. Results 122 patients were included: 36 patients with p16+OPSCC, 16 patients with p16−OPSCC, 4 patients with p16+OCSCC, 41 patients with p16−OCSCC, and 25 healthy controls. The sensitivity and specificity of ddPCR of oropharyngeal swabs against p16 IHC were 92 and 98% respectively, using 20–50 times less RNA than that required for conventional RT-qPCR. Overall agreement between ddPCR of tissue swabs and p16 of tumor tissue was high at ĸ = 0.826 [0.662-0.989]. Conclusion Oropharyngeal swabs analyzed by ddPCR is a quantitative, rapid, and effective method for minimally invasive oncogenic HPV detection. This assay represents the most sensitive and accurate mode of HPV detection in OPSCC without a tissue biopsy in the available literature. Electronic supplementary material The online version of this article (doi:10.1186/s40463-016-0177-8) contains supplementary material, which is available to authorized users.

As the Affordable Care Act unfolds, federally qualified health centers (FQHCs) will likely experience an influx of newly insured, low-income patients at disparate risk for cancer. Cancer-focused organizations are seeking to collaborate with FQHCs and the Primary Care Associations (PCAs) that serve them, to prevent cancer and reduce disparities. To guide this collaboration, we conducted 21 interviews with representatives from PCAs and FQHCs across four western states. We asked about: FQHC priorities, barriers and facilitators to cancer prevention, the PCA–FQHC relationship, and collaboration opportunities for external organizations. FQHC priorities include medical home transformation, electronic health records, and clinical care; prevention efforts must integrate with these. Barriers to cancer prevention include competing priorities, inadequate patient insurance, and lack of reimbursement, while facilitators are the presence of patient navigators and cancer-related performance measures. Collaboration opportunities for external organizations include dissemination of culturally appropriate educational materials and support for patient navigators.

Purpose. To develop a theory-based questionnaire to assess readiness for change in small workplaces adopting wellness programs. Design. In developing our scale, we first tested items via “think-aloud” interviews. We tested the revised items in a cross-sectional quantitative telephone survey. Setting. The study setting comprised small workplaces (20–250 employees) in low-wage industries. Subjects. Decision-makers representing small workplaces in King County, Washington (think-aloud interviews, n = 9), and the United States (telephone survey, n = 201) served as study subjects. Measures. We generated items for each construct in Weiner’s theory of organizational readiness for change. We also measured workplace characteristics and current implementation of workplace wellness programs. Analysis. We assessed reliability by coefficient alpha for each of the readiness questionnaire subscales. We tested the association of all subscales with employers’ current implementation of wellness policies, programs, and communications, and conducted a path analysis to test the associations in the theory of organizational readiness to change. Results. Each of the readiness subscales exhibited acceptable internal reliability (coefficient alpha range, .75–.88) and was positively associated with wellness program implementation ( p < .05). The path analysis was consistent with the theory of organizational readiness to change, except change efficacy did not predict change-related effort. Conclusion. We developed a new questionnaire to assess small workplaces’ readiness to adopt and implement evidence-based wellness programs. Our findings also provide empirical validation of Weiner’s theory of readiness for change.

Although we know a great deal about the phenotype and function of haematopoietic stem/progenitor cells, a major challenge has been mapping their dynamic behaviour within living systems. Here we describe a strategy to image cells in vivo with high spatial and temporal resolution, and quantify their interactions using a high-throughput computational approach. Using these tools, and a new Msi2 reporter model, we show that haematopoietic stem/progenitor cells display preferential spatial affinity for contacting the vascular niche, and a temporal affinity for making stable associations with these cells. These preferences are markedly diminished as cells mature, suggesting that programs that control differentiation state are key determinants of spatiotemporal behaviour, and thus dictate the signals a cell receives from specific microenvironmental domains. These collectively demonstrate that high-resolution imaging coupled with computational analysis can provide new biological insight, and may in the long term enable creation of a dynamic atlas of cells within their native microenvironment., It is difficult to image haematopoietic stem cells (HSC) in their niche. Here, the authors present a new high-throughput computational approach to visualise HSCs in vivo at a high spatial and temporal resolution and also use a Msi2-reporter to label endogenous HSCs and progenitors, enabling cell tracking

The treatment for most advanced head and neck cancers (stage III and IV) usually includes radiation, and the most common side effect of this treatment modality is a permanent decrease in salivary production. Xerostomia is a devastating complication that significantly affects patients' quality of life by interfering with functions of taste, mastication, deglutition, and speech production. Treatment of xerostomia is varied, but one of the strategies developed by our group was to preserve one submandibular gland by surgically transferring it to the submental space and shielding it from the full dose of radiation. This procedure is proven to reduce the rate of radiation-induced xerostomia, but its main disadvantage is that it is contraindicated in oral cavity cancer. This study describes and evaluates a modification of the submandibular gland transfer (SGT) procedure, where the submandibular gland contralateral to the disease process is relocated to the parotid region. This modification has the potential of expanding the benefits of submandibular gland transfer procedures to patients with oral cavity cancers.Prospective feasibility study.This study involved nine patients with a new diagnosis of advanced head and neck cancer undergoing major head and neck cancer resection with postoperative adjuvant radiation therapy. The new modified salivary gland transfer procedure was performed on all nine patients, and the glands total dose received with radiation therapy was assessed.All the modified SGT procedures were successful with no post-operative complications. The radiation oncology team has been able to successfully localize the transferred submandibular glands and shield them from the radiation beam postoperatively.We have successfully demonstrated that surgical transfer of a submandibular salivary gland to the parotid region is feasible, surgically viable, oncologically sound, and does not interfere with radiation therapy.4 Laryngoscope, 126:2492-2496, 2016.

Purpose. Study goals were to (1) describe stakeholder perceptions of workplace health promotion (WHP) appropriateness, (2) describe barriers and facilitators to implementing WHP, (3) learn the extent to which WHP programs are offered to workers' spouses and partners and assess attitudes toward including partners in WHP programs, and (4) describe willingness to collaborate with nonprofit agencies to offer WHP. Design. Five 1.5-hour focus groups. Setting. The focus groups were conducted with representatives of midsized (100–999 workers) workplaces in the Seattle metropolitan area, Washington state. Subjects. Thirty-four human resources professionals in charge of WHP programs and policies from five low-wage industries: accommodation/food services, manufacturing, health care/social assistance, education, and retail trade. Measures. A semistructured discussion guide. Analysis. Qualitative analysis of focus group transcripts using grounded theory to identify themes. Results. Most participants viewed WHP as appropriate, but many expressed reservations about intruding in workers' personal lives. Barriers to implementing WHP included cost, time, logistical challenges, and unsupportive culture. Participants saw value in extending WHP programs to workers' partners, but were unsure how to do so. Most were willing to work with nonprofit agencies to offer WHP. Conclusion. Midsized, low-wage employers face significant barriers to implementing WHP; to reach these employers and their workers, nonprofit agencies and WHP vendors need to offer WHP programs that are inexpensive, turnkey, and easy to adapt.

Objective: Advanced tongue cancer is a devastating diagnosis with potential for significant morbidity after treatment. This is especially true for patients undergoing total glossectomy with laryngeal preservation (TGLP), free flap reconstruction and adjuvant radiotherapy. The goals of this study were to: 1) determine long-term objective functional and quality of life outcomes, 2) investigate the influence of rehabilitation on functional recovery and 3) determine swallowing ability in patients with TGLP. Study Design: Prospective cohort study and systematic review of the literature. Methods: Functional outcomes data were collected from 2000–2010. Outcomes were measured pre- and 12 months post-surgery and included: gastrostomy-tube (G-Tube) rates, swallowing transit times on video fluoroscopic swallowing studies, speech intelligibility and EORTC-H&N 35 quality of life scores. A systematic review of the literature was conducted to determine comprehensive long term G-Tube rates. Results: Twelve patients were included and eight were still living at 12 months post-surgery. Fifty percent of patients in this study and 24% with systematic review used G-Tubes at 1 year post-surgery. Patients who could swallow did not aspirate, but more than doubled swallowing transit times. Spoken sentence intelligibility averaged 66% and mean quality of life scores improved 8.9 points 12 months post-surgery. Patients who attended >80% of swallowing and speech rehabilitation sessions demonstrated superior swallowing and speech functional outcomes. Conclusions: Although a potentially morbid treatment, TGLP and free flap reconstruction can provide good swallowing and speech outcomes as well as meaningful long-term quality of life. Regular attendance of rehabilitation sessions is imperative to optimize functional outcomes. Laryngoscope, 2013

The reconstructive surgeon is often faced with the dilemma of offering free flap reconstruction to the elderly after surgical extirpation in the head and neck due to the perception that this population tolerates these procedures poorly.A 42-month retrospective review of all microvascular free flap reconstruction cases from a large head and neck oncology program was reviewed. A series of 278 patients met inclusion criteria and were stratified into 2 age groups: 45 to 64.9 years (n = 177) and ≥65 years (n = 101).There was no significant difference in primary outcomes, anastomotic compromise (p = .36), unsalvageable flaps (p = .46), secondary outcomes, complicated recoveries (p = .29), or deaths within 30 days of surgery (p = .14) between the 2 groups. However, the length of postoperative recovery was increased in the elderly cohort (p = .029).Given that outcomes were similar between young and elderly patients, surgeons should not restrict the use of free flaps based on their patients' age.

Purpose of the Study: To examine the components of cost that drive increased total costs after a medical fall over time, stratified by injury severity. DESIGN AND METHODS: We used 2004-2007 cost and utilization data for persons enrolled in an integrated care delivery system. We used a longitudinal cohort study design, where each individual provides 2-3 years of administrative data grouped into 3-month intervals relative to an index date. We identified 8,969 medical fallers through International Classification of Diseases, 9th Revision, codes and E-Codes and used 8,956 nonfaller controls, identified through age and gender frequency matching. Total costs were partitioned into 7 components: inpatient, outpatient, emergency, radiology, pharmacy, postacute care, and "other." RESULTS: The large increase in costs after a hospitalized fall is mainly associated with inpatient and postacute care components. The spike in costs after a nonhospitalized fall is attributable to outpatient and "other" (e.g., ambulatory surgery or community health services) components. Hospitalized fallers' inpatient, emergency, postacute care, outpatient, and radiology costs are not always greater than those for nonhospitalized fallers. IMPLICATIONS: Components associated with increased costs after a medical fall vary over time and by injury severity. Future studies should compare if delivering certain acute and postacute health services improve health and reduce cost trajectories after a medical fall more than others. Additionally, since the older adult population and the problem of falls are growing, health care delivery systems should develop standardized methodology to monitor medical fall rates. Language: en

The objective was to determine the extent of informed decision making for prostate cancer screening in a defined population. A state-wide population based survey of men aged 50 and above (Behavioral Risk Factor Surveillance System, 2004, Washington state) and a simple random sample of primary care physicians, were conducted in the same geographic area. We examined prostate cancer screening rates among the men (defined as either PSA or digital rectal examination within the past year) and prostate cancer screening practices among the physicians. Screening rates were 56% at ages 50-64, 68% at ages 65-79 and 64% among men age 80 and older. Adjusted analyses indicated that age, income, marital status, possessing health insurance and a personal health care provider, and talking with a provider about prostate cancer screening tests were all positively associated with screening status. In the physician survey, most physicians recommend screening to their average-risk male patients. Three-fourths (74%) of physicians discussed benefits and risks of PSA testing with their patients; but few used educational tools. Only 35% discussed the side effects of prostate cancer treatment with their patients. The rates of screening reported by men were relatively high, given that current recommendations promote informed decision making rather than universal screening. The majority of physicians recommend prostate cancer screening to their patients, with few decision-making tools used. All relevant information may not be provided in the discussion. These results point to the need for increasing informed decision making about prostate cancer screening.

Every summer the U.S. Army Reserve Officer Training Corps (ROTC) conducts the Leader Development Assessment Course (LDAC) for several thousand upcoming senior-year cadets. This study describes respiratory illnesses at 2009 ROTC LDAC after the emergence of the novel H1N1 influenza pandemic. This retrospective cohort study examines 5,554 cadets and 1,616 cadres from 2009, and 5,180 LDAC 2008 cadets. Respiratory clinic visits for 2009 cadets were higher than 2009 cadres and 2008 cadets, at 8.7, 2.0, and 4.2 visits per 1,000 person-days available, respectively (p < 0.001). Further, respiratory illness hospitalizations and isolations were higher for 2009 cadets than cadres (p = 0.020). Although substantial efforts were made to prevent respiratory infections, there was considerable impact from respiratory illnesses, in the context of the novel H1N1 influenza pandemic, among 2009 ROTC LDAC participants. Our experience offers important lessons for future LDAC planning and for similar close quarters living...

Acoustic properties of 980 tokens of sibilants /s, z, ƒ/ produced by 17 Canadian English-speaking female and male tongue cancer patients were studied. The patients had undergone tongue resection and tongue reconstruction with a radial forearm free flap (RFFF). The spectral moments (mean, skewness) and frication duration were analysed in connected speech samples produced before the tongue resection, and 1, 6 and 12 months after the surgery. The effects of radiation therapy (RT) and inclusion of the floor of the mouth (FOM) were also studied. Acoustic changes were observed only on alveolar sibilants /s, z/ such that speech was found to improve towards normal over the 1-year period. The reduction of acoustic distinction between /s, z/ and /ƒ/ was short term. A history of RT and involvement of the FOM had no differing effects on outcomes compared with non-RT or non-FOM. Variability between individuals was found, accentuating the speaker-specific abilities for adaptation, compensation and relearning after oral reconstruction.

Purpose Controversy exists regarding physiologic outcomes related to the tongue after radial forearm free flap (RFFF) reconstruction of hemiglossectomy defects. The purpose of this study is to report swallowing and tongue mobility outcomes for patients with RFFF reconstruction of the anterior two thirds of the tongue. Materials and Methods Swallowing and tongue mobility were assessed at 4 different time points over the course of 1 year of treatment for 15 patients who underwent RFFF reconstruction of the anterior two thirds of the tongue. Preoperative swallowing function in the treatment group was compared with a patient group that had no involvement of the tongue. A comparison group of 14 patients with nasopharyngeal cancer was used to compare preintervention function in patients with and without lesions of the tongue. Results No differences existed between the experimental and comparison groups before intervention. Two significant differences were found for swallowing ability and tongue mobility in the experimental group. Some of the measures at 1 month postoperatively were significantly different from some of the preoperative measures for liquid swallows and posterior-tongue mobility. All measures returned to baseline by the study's end. Conclusion Although some minor deficits exist in swallowing and tongue mobility after RFFF reconstruction, it appears that these problems are no longer evident 12 months postoperatively.

The purpose of this study was to use acoustic analyses to describe speech outcomes over the course of 1 year after radial forearm free flap (RFFF) reconstruction of the tongue. Eighteen Canadian English-speaking females and males with reconstruction for oral cancer had speech samples recorded (pre-operative, and 1 month, 6 months, and 1 year post-operative). Acoustic characteristics of formants (F1, F2), fundamental frequency (F0), and duration of 699 vowel and diphthong tokens were analysed. Furthermore, the changes in size of the vowel space area were studied, as well as the effects of radiation therapy (RT) and inclusion of the floor of the mouth (FOM) in the reconstruction. RFFF reconstruction was found to affect several characteristics in males, and a minimal number of variables in females. General signs of reduced ability to articulate were not observed. RT and FOM had no differing effects compared to non-RT or non-FOM. There were individual differences between patients.

Our goal was to define a clinically significant population of cells by utilizing a single-step selection process to enrich hematopoietic cells capable of regenerating the retinal pigment epithelium (RPE). Utilizing intravitreal injection of bone marrow cells from a mouse with pigment (C57BL6:gfp) into albino recipient mice (C57BL6:Tyr-), we show that hematopoietic progenitor cells (HPCs) enriched for CD133 can regenerate RPE cells and improve retinal function. The chemokine CXCL12 (stromal cell-derived factor 1α) is essential for migration, incorporation, and RPE regeneration by CD133+ HPCs. Once incorporated, CD133+ HPCs become pigmented, adopt an RPE morphology, and express RPE-specific proteins, leading to partial functional recovery by electroretinogram. Human CD133+ HPCs also incorporate in the retina and assume RPE morphology in nonobese diabetic/severe combined immunodeficient mice xenografts. These data show that a clinically accessible CD133+ hematopoietic cell can home to an injured RPE layer, differentiate into cells with significant RPE morphology, and provide therapeutic functional recovery of the visual cycle.

Background Head and neck oncologists are often confronted with the difficult challenge of balancing cancer cure with the preservation of function when deciding the patient's best treatment protocol. This task is especially difficult in cancer of the base of tongue. The purpose of this manuscript is to describe the beavertail modification of the radial forearm-free flap in base of tongue reconstruction. Methods Thirty-one consecutive patients treated for base of tongue cancer with primary surgery were followed prospectively. The technique of the beavertail modification is described. Swallowing and speech function were assessed preoperatively and postoperatively. Results All the flaps survived. Thirty (97%) patients started consuming oral diet within 1 year, and all had normal speech intelligibility. Conclusions The beavertail modification of the radial forearm arm flap seems to provide the reconstructive elements that allow patients with large base of tongue extirpations to develop functional swallowing and speech production postoperatively. © 2008 Wiley Periodicals, Inc. Head Neck, 2009

Background. Xerostomia is a serious morbidity of radiation treatment in head and neck cancer. Methods. We conducted a prospective phase III multicenter randomized study comparing submandibular salivary gland transfer (SGT) procedure with pilocarpine during and for 3 months after XRT. Salivary flow (baseline, stimulated) and University of Washington Quality of Life Questionnaire (U of W QOL) scores were measured. Results. An interim intent to treat analysis (120 patients) at 6 months shows superior results in SGT arm: median baseline salivary flow for SGT (0.04 mL/minute) versus pilocarpine (0.01 mL/minute), p = .001; median stimulated salivary flow (0.18 mL/minute) for SGT versus (0.05 mL/minute) for pilocarpine, p = .003. Scores (U of W QOL) for amount (p = .017) and consistency of saliva (p = .005) in favor of SGT leading to premature closure of study. Conclusions. Submandibular SGT procedure is superior to pilocarpine in management of radiation-induced xerostomia. © 2008 Wiley Periodicals, Inc. Head Neck, 2009

Background: Historically, the prevention of functional morbidity after multimodal treatment for squamous cell carcinoma in patients with large base of tongue lesions has been challenging. The purpose of the present research is to report prospectively collected speech and swallowing outcomes for patients with disease that encompassed half or more of the base of tongue. Methods: Speech and swallowing data were gathered at 4 evaluation times that spanned the first year of treatment for 32 patients treated with surgery and adjuvant radiation therapy. Results: Speech intelligibility remained above 90% for most patients. In the early postoperative period, patients with 100% of their base of tongue resected experienced decreased intelligibility, which improved by the half-way mark of the evaluations. The majority of patients resumed normal oral feeding, with those who lacked dentition needing to puree their food. Modified barium swallow studies revealed that only 3 patients aspirated thin liquid at the final evaluation. Five patients used a feeding tube at some point over the year of evaluation. At the final evaluation, only 3 patients required enteral feeding, with 2 of these using the tube in combination with oral feeding and 1 using the tube for primary nutrition. Conclusions: The results of this study suggest that surgical reconstruction of the base of tongue using the radial forearm free flap in patients with large base of tongue lesions can lead to functional speech and swallowing results. © 2007 Wiley Periodicals, Inc. Head Neck, 2007

Tobacco use among Vietnamese adult males in the United States is higher than the general population. Less is known about the role of knowledge and attitudes of smoking in smoking status. This study describes the smoking prevalence, practices, support, knowledge, and attitudes among Vietnamese American men by smoking status. We administrated a cross-sectional in-person health questionnaire to randomly selected Vietnamese men (18-64 years of age) living in Seattle, Washington, using bilingual, bicultural Vietnamese male interviewers (N = 509). The response rate was 79%; the cooperation rate was 82%. Sixty-four percent of respondents had a history of smoking: 37% current, 27% former, and 36% never smokers. Smoking prevalence was lowest among men aged 18-29 years. Among smokers, 81% smoked 1 to 10 cigarettes per day, 69% wanted to quit, and 48% planned to do so in the next 6 months. Twelve percent of smokers reported smoking was allowed in the home. On average, respondents correctly answered six out of seven questions regarding health risks related to smoking. In logistic regression analyses, being a current smoker was negatively associated with a higher knowledge score (OR = 0.83, 95% CI 0.71-0.97). Adjusted odds of being a current smoker were 3.77 times higher among men who agreed with the attitude statement "It is appropriate for Vietnamese men to smoke when with friends." (OR = 2.15, 95% CI 1.28-3.61). The findings suggest a great need to develop appropriate tobacco-control interventions to lower smoking prevalence, improve tobacco-related health knowledge, and reduce the acceptance of smoking among Vietnamese American men.

Objectives To determine the expressed needs of persons with traumatic brain injury (TBI) and their primary family caregivers. Design Semistructured interviews with content-analytic techniques to identify respondents' needs. Participants Eighty persons with TBI, with an average time since their most severe TBI of 5.8 years, and 85 primary support persons. Results Respondents described their needs via phases that paralleled transitions in settings, treatments, and responsibilities (ie, acute care, in-patient rehabilitation, return home, and living in the community). Prominent themes during in-patient phases included provider quality, emotional support, and understanding the injuries. Prominent themes during the latter 2 phases included guidance, life planning, community integration, and behavioral and emotional issues. Conclusions Participants reported insufficient education and preparation for the future. Current methods of identifying needs may not be based on these populations' perceptions, and often miss the natural divisions of needs that occur over the course of treatment and rehabilitation. To meet their needs, services must be responsive to changes in needs over time, accessible to consumers of services for as long as they are required, and designed to be directed and customized by users.

Introduction Evidence-based practices in the workplace can increase levels of healthy eating, cancer screening, physical activity, and tobacco cessation but are underused, even in large workplaces. This report summarizes an evaluation of the first year of The CEOs Challenge, a program developed by the American Cancer Society to promote implementation and maintenance of health-promoting, evidence-based workplace practices by large companies. Methods Use of 17 evidence-based practices by 17 companies in the Washington State Chapter of the American Cancer Society’s CEOs Against Cancer network was assessed via survey and scored from 0 to 100. Companies received a written report of their baseline performance, followed by at least quarterly consultations with American Cancer Society staff members trained to assist in implementation of these practices. Follow-up performance was measured at 1 year. Results At baseline, implementation scores were 54.8 for cancer screening, 46.5 for healthy eating, 59.8 for physical activity, and 68.2 for tobacco cessation. At follow-up, scores increased by 19.6 for cancer screening, 19.4 for healthy eating, 16.0 for physical activity, and 9.4 points for tobacco cessation. Conclusion The CEOs Challenge is a promising approach to chronic disease prevention via the workplace. It brings together one of the nation’s largest health-promoting voluntary agencies with the nation’s largest employers to promote evidence-based practices targeted at the most common causes of disease and death. The program increased the adoption of these practices and was well-accepted.

Small employers, especially those in low-wage industries, frequently lack the capacity and resources to implement evidence-based health promotion interventions without support and assistance. The purpose of this paper is to (a) describe the intervention design and study protocol of the HealthLinks Trial and (b) report baseline findings. This study is a three-arm randomized controlled trial testing the impact of the HealthLinks intervention on worksites' adoption and implementation of evidence-based interventions. Group 1 will receive HealthLinks, Group 2 will receive HealthLinks plus wellness committees, and Group 3 will be a delayed control group. Seventy-eight employers are participating in the study; and 3302 employees across the worksites participated in the baseline data collection. Employers and employees will participate in follow-up surveys at one and two years after baseline to measure implementation (one year) and maintenance (two years) of HealthLinks interventions. Study outcomes will determine whether HealthLinks is an effective approach to increasing evidence-based health promotion in small, low-wage worksites and whether wellness committees are a capacity-building tool that increases HealthLinks' effectiveness.

Objective To determine if rigid adherence (where medically appropriate) to an algorithm/checklist-based patient care pathway can reduce the duration of hospitalization and complication rates in patients undergoing head and neck reconstruction with free tissue transfer. Methods Study design was a retrospective case-control study of patients undergoing major head and neck cancer resections and reconstruction at a tertiary referral centre. The intervention was rigid adherence to a pre-existing care pathway including flow algorithms and multidisciplinary checklists incorporated into patient charting and care orders. 157 patients were enrolled prospectively and were compared to 99 patients in a historical cohort. Patient charts were reviewed and information related to the patient, procedure, and post-operative course was extracted. The two groups were compared for number of major and minor complications (using the Clavien-Dindo system) and length of stay in hospital. Results Comparing pre- and post-intervention groups, no significant difference was identified in duration of hospital stay (21.5 days vs. 20.5 days, p = 0.750), the rate of major complications was significantly higher in the pre-intervention cohort (25.3 % vs. 14.0 %, p = 0.031), the rate of minor complications was not significantly higher (34.3 % vs 30.8 %, p = 0.610). Conclusion Rigid adherence to our patient care pathway, and improved charting techniques including flow algorithms and multidisciplinary checklists has improved patient care by showing a significant reduction in the rate of major complications. Electronic supplementary material The online version of this article (doi:10.1186/s40463-015-0090-6) contains supplementary material, which is available to authorized users.

Introduction Restaurant workers are a large population at high risk for tobacco use, physical inactivity, and influenza. They are difficult to reach with health care interventions and may be more accessible through workplaces, yet few studies have explored the feasibility of workplace health promotion in this population. This study sought to identify barriers and facilitators to promotion of tobacco cessation, physical activity, and influenza vaccination in restaurants. Methods Moderators conducted 7 focus groups, 3 with restaurant owners and managers, 2 with English-speaking workers, and 2 with Spanish-speaking workers. All groups were recorded, and recordings were transcribed and uploaded to qualitative-analysis software. Two researchers coded each transcript independently and analyzed codes and quotations for common themes. Results Seventy people from the restaurant industry participated. Barriers to workplace health promotion included smoking-break customs, little interest in physical activity outside of work, and misinformation about influenza vaccinations. Facilitators included creating and enforcing equitable break policies and offering free, on-site influenza vaccinations. Spanish-speakers were particularly amenable to vaccination, despite their perceptions of low levels of management support for health promotion overall. Owners required a strong business case to consider investing in long-term prevention for their employees. Conclusion Tobacco cessation and influenza vaccinations are opportunities for health promotion among restaurant workers, whereas physical activity interventions face greater challenges. Promotion of equitable breaks, limited smoking-break policies, and free, on-site influenza vaccinations could improve health for restaurant workers, who often do not have health insurance. Workplace interventions may be particularly important for Hispanic workers who have additional access barriers.

Background : We formed a self-funded hypertension treatment group in a resource-poor community in rural Honduras. After training community health workers and creating protocols for standardized treatment, we used group membership fees to maintain the group, purchase generic medications in bulk on the local market, and hire a physician to manage treatment. We then assessed whether participation in the group improved treatment, medication adherence, and hypertension control. Design : This is a program evaluation using quasi-experimental design and no control group. Using data from the 86 members of the hypertension treatment group, we analyzed baseline and follow-up surveys of members, along with 30 months of clinical records of treatment, medication adherence, and blood pressure readings. Results : Our initial hypertension needs assessment revealed that at baseline, community hypertensives relied on the local Ministry of Health clinic as their source of anti-hypertensive medications and reported that irregular supply interfered with medication adherence. At baseline, hypertension group members were mainly female, overweight or obese, physically active, non-smoking, and non-drinking. After 30 months of managing the treatment group, we found a significant increase in medication adherence, from 54.8 to 76.2% ( p