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Background We aimed to study organizational aspects, case mix, and practices in Indian intensive care units (ICUs) from 2018 to 2019, following the Indian Intensive Care Case Mix and Practice Patterns Study (INDICAPS) of 2010–2011. Methods An observational, 4-day point prevalence study was performed between 2018 and 2019. ICU, patient characteristics, and interventions were recorded for 24 hours, and ICU outcomes till 30 days after the study day. Adherence to selected compliance measures was determined. Data were analyzed for 4,669 adult patients from 132 ICUs. Results On the study day, mean age, acute physiology and chronic health evaluation (APACHE II), and sequential organ failure assessment (SOFA) scores were 56.9 ± 17.41 years, 16.7 ± 9.8, and 4.4 ± 3.6, respectively. Moreover, 24% and 22.2% of patients received mechanical ventilation (MV) and vasopressors or inotropes (VIs), respectively. On the study days, 1,195 patients (25.6%) were infected and 1,368 patients (29.3%) had sepsis during their ICU stay. ICU mortality was 1,092 out of 4,669 (23.4%), including 737 deaths and 355 terminal discharges (TDs) from ICU. Compliance for process measures related to MV ranged between 62.7 and 85.3%, 11.2 and 47.4% for monitoring delirium, sedation, and analgesia, and 7.7 and 25.3% for inappropriate transfusion of blood products. Only 34.8% of ICUs routinely used capnography. Large hospitals with ≥500 beds, closed ICUs, the APACHE II and SOFA scores, medical admissions, the presence of cancer or cirrhosis of the liver, the presence of infection on the study day, and the need for MV or VIs were independent predictors of mortality. Conclusions Hospital size and closed ICUs are independently associated with worse outcomes. The proportion of TDs remains high. There is a scope for improvements in processes of care. Registered at clinicaltrials.gov (NCT03631927). How to cite this article Divatia JV, Mehta Y, Govil D, Zirpe K, Amin PR, Ramakrishnan N, et al. Intensive Care in India in 2018–2019: The Second Indian Intensive Care Case Mix and Practice Patterns Study. Indian J Crit Care Med 2021;25(10):1093–1107.

PURPOSE: The current study addressed work-related stress and burnout experienced by health care workers (HCWs) in Cairo University isolation hospital and its impact on the cognitive domain of their executive functioning. METHODS: Arabic validated questionnaires of Beverly Potter for sources of work-related burnout and Maslach Burnout Inventory Human Services Survey for evaluation of burnout degree of 81 HCWs were used. Wisconsin Card Sorting Test was used to examine the HCWs cognitive executive functioning during hospital work and 2 weeks after home isolation. RESULTS: A high degree of work-related stress was evident by a high score on Beverly questionnaire with a mean ± SD of (132.08 ± 12.573). A high degree of burnout was marked with a mean ± SD of (28.48 ± 6.622) for Emotional Exhaustion module, (31.85 ± 5.439) Personal Achievement, and (17.52 ± 6.707) Depersonalization. Health care workers experienced impairment of executive functioning in the form of increased total errors of Wisconsin Card Sorting Test during hospital shifts compared to 2 weeks after. There is a positive significant correlation between work-related stress level and Maslach Burnout Inventory and the total errors of Wisconsin Card Sorting Test results during the hospital stay (p = < 0.001), as well as 2 weeks after (p = < 0.001).This cognitive decline manifested in increased errors during HCWs' clinical work. CONCLUSIONS: Health care workers on the front line experienced a high degree of work-related stress in addition to burnout in the form of Emotional Exhaustion, Depersonalization, and reduced Personal Achievement. They also suffered from impaired cognitive executive functioning due to such stressful exposure.

Background: The combined sensory index (CSI) test is more precise in diagnosing carpal tunnel syndrome (CTS) early cases. Another useful tool for early detection of CTS is the diagnostic ultrasonography. Objective: The present study was conducted to compare between the CSI test and its sensitivity with diagnostic ultrasonography IOR (inlet outlet ratio) in suspected or early cases of carpal tunnel syndrome (CTS). Patients and methods: The presentcase-control study involved 20 subjects with signs and symptoms suggestive of early cases of CTS with duration less than 6 months, in addition to 20 apparently healthy subjects who were clinically examined and underwent EDX and US evaluation. We excluded patients with severe CTS, proximal cervical lesion, or other neurological diseases. Results: By comparison, CSI shows a higher sensitivity than IOR. Combining both tests induced elevated substantial differences between patients as well as controls (P

Objectives: To examine whether social determinants of health (SDH) factors are associated with time to diagnosis, treatment selection, and time to recurrent surgical intervention in idiopathic subglottic stenosis (iSGS) patients. Methods: Adult patients with diagnosed iSGS were recruited prospectively (2015-2017) via clinical providers as part of the North American Airway Collaborative (NoAAC) and via an online iSGS support community on Facebook. Patient-specific SDH factors included highest educational attainment (self-reported), median household income (matched from home zip code via U.S. Census data), and number of close friends (self-reported) as a measure of social support. Main outcomes of interest were time to disease diagnosis (years from symptom onset), treatment selection (endoscopic dilation [ED] vs cricotracheal resection [CTR] vs endoscopic resection with adjuvant medical therapy [ERMT]), and time to recurrent surgical intervention (number of days from initial surgical procedure) as a surrogate for disease recurrence. Results: The total 810 participants were 98.5% female, 97.2% Caucasian, and had a median age of 50 years (IQR, 43-58). The cohort had a median household income of $62 307 (IQR, $50 345-$79 773), a median of 7 close friends (IQR, 4-10), and 64.7% of patients completed college or graduate school. Education, income, and number of friends were not associated with time to diagnosis via multivariable linear regression modeling. Univariable multinominal logistic regression demonstrated an association between education and income for selecting ED versus ERMT, but no associations were noted for CTR. No associations were noted for time to recurrent surgical procedure via Kaplan Meier modeling and Cox proportional hazards regression. Conclusions: Patient education, income, and social support were not associated with time to diagnosis or time to disease recurrence. This suggests additional patient, procedure, or disease-specific factors contribute to the observed variations in iSGS surgical outcomes.

Background Drug-related bradycardia (DRB) is a common clinical conundrum and can result in multiple hospital admissions as a result of the increased prescription of rate-limiting medications that can predispose to presyncopal or syncopal episodes. Aim To evaluate the incidence of DRB in elderly hospital inpatients. Methods We conducted a retrospective analysis of all patients admitted to our acute medical unit between November 2018 and February 2019 and identified patients over the age of 70 with more than one diurnal bradycardic episode during their admission. We extracted patient demographics, presenting complaint, admission 12-lead ECG and medications from the hospital electronic database. Results We screened 2312 adults and identified 100 patients over the age of 70 years with two or more episodes of diurnal bradycardia during their hospital admission. This constituted 4.32% of total admissions. Beta blockers were the most commonly prescribed rate-limiting medication (n=54, 87.1%), of which bisoprolol was the most frequently prescribed (n=41) and sinus bradycardia was the most commonly identified rhythm disturbance in our cohort of patients (n=41, 41%). Syncope was the most common presenting symptom and occurred in 23 patients, 14 (60.9%) of which were diagnosed with a DRB. Atrial fibrillation was more common in those with DRB compared with those with bradycardia not caused by medications (35.5% vs 10.5%, p=0.006), and atrial fibrillation was a significant predictor of DRB (OR=10.2, 95% CI 3.3 to 31.6, p Conclusion Bradycardia is a significant cause of hospital admissions in older adults and can be avoided with pharmacovigilance. Caution should be exercised when initiating or changing the dose of rate-limiting agents in these patients; while those with atrial fibrillation should undergo regular review of their heart rate followed by appropriate medication dose adjustments.

Delivery of interventions through group sessions allows for in-depth discussions and creates opportunities for group members to work together to identify and solve common problems. However, low attendance may limit impact. We explored factors affecting attendance, active participation, and behavior change in an integrated group-based child development and maternal and child health intervention in Bangladesh. Community health workers (CHWs) facilitated two sessions a month including material on child stimulation; water, sanitation, and hygiene; nutrition, maternal depression, and lead exposure prevention. Sessions were conducted with 320 pregnant women and mothers with children younger than 24 months, in 16 villages in Kishoreganj district. After 4 and 9 months of intervention, we conducted focus group discussions and in-depth interviews with mothers (n = 55 and n = 48) to identify determinants of attendance and behavior change, and to examine potential for intervention scale-up. Recruiting family members to assist with childcare resulted in improved attention during sessions. Adopting a storytelling format for presentation of session materials resulted in more engaged participation during courtyard sessions. Session attendance and behavior change, especially purchasing decisions, were difficult for participants without the support of male heads of the household. Selecting a rotating leader from among the group members to remind group members to attend sessions and support CHWs in organizing the sessions was not successful. Facilitating self-appraisals and planning for water and sanitation allowed participants to identify areas for improvement and track their progress. Key determinants of a participant’s attendance were identified, and the resulting intervention shows promise for future implementation at scale.

Atrial fibrillation (AF) in hypertrophic cardiomyopathy (HC) is associated with significant symptomatic deterioration, heart failure, and thromboembolic disease. There is a need for better mechanistic insight and improved identification of at risk patients. We used cardiovascular magnetic resonance (CMR) to assess predictors of AF in HC, in particular the role of myocardial fibrosis. Consecutive patients with HC referred for CMR 2003 to 2013 were prospectively enrolled. CMR parameters including left ventricular volumes, presence and percentage of late gadolinium enhancement in the left ventricle (%LGE) and left atrial volume index (LAVi) were measured. Overall, 377 patients were recruited (age 62 ± 14 years, 73% men). Sixty-two patients (16%) developed new-onset AF during a median follow up of 4.5 (interquartile range 2.9 to 6.0) years. Multivariable analysis revealed %LGE (hazard ratio [HR] 1.3 per 10% (confidence interval: 1.0 to 1.5; p = 0.02), LAVi (HR 1.4 per 10 mL/m 2[1.2 to 1.5; p < 0.001]), age at HC diagnosis, nonsustained ventricular tachycardia and diabetes to be independent predictors of AF. We constructed a simple risk prediction score for future AF based on the multivariable model with a Harrell's C-statistic of 0.73. In conclusion, the extent of ventricular fibrosis and LA volume independently predicted AF in patients with HC. This finding suggests a mechanistic relation between fibrosis and future AF in HC. CMR with quantification of fibrosis has incremental value over LV and LA measurements in risk stratification for AF. A risk prediction score may be used to identify patients at high risk of future AF who may benefit from more intensive rhythm monitoring and a lower threshold for oral anticoagulation.

The purpose of the study was to determine the acute and long term services and supports (LTSS) utilization, cost of health care and disparities in access of care for individuals with Intellectual and Developmental Disabilities (IDD). Individuals with IDD on a waiver (receiving Medicaid-funded LTSS in community settings) compared to non-IDD individuals on a waiver control group were compared using Ohio Medicaid claims data from calendar year 2013. Results found the IDD Waiver population had lower utilization rates for emergency department visits, hospital admissions, and hospital readmissions within 30 days compared to the Non-IDD Waiver population and lower PMPM expenditures across all medical service categories except pharmacy. However, the IDD Waiver population possessed greater PMPM costs for LTSS and therefore greater overall costs of care. Furthermore, 94% of IDD Waiver individuals had an episode of care for neurological conditions, with the second most frequent episode of care being for mental health services. The two most frequent episodes of care for individuals in the Non-IDD Waiver group were for conditions related to treatment (medical/surgical) and musculoskeletal conditions. The goal of this research was to investigate the health care needs of individuals with IDD that may vary from other long term care populations. The differences in health care needs for individuals with IDD require health systems and care management that is tailored to the sub-population, with an emphasis on treatment for neurological and mental health conditions. The typical focus of care management efforts on reducing unnecessary utilization of hospital services may be less relevant to the IDD Waiver population. The results of this study will be used to make recommendations regarding the unique health care needs of individuals with IDD.

Introduction: The novel Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2, may need intensive care unit (ICU) admission in up to 12% of all positive cases for massive interstitial pneumonia, with possible long-term endotracheal intubation for mechanical ventilation and subsequent tracheostomy. The most common airway-related complications of such ICU maneuvers are laryngotracheal granulomas, webs, stenosis, malacia and, less commonly, tracheal necrosis with tracheo-esophageal or tracheo-arterial fistulae. Materials and methods: This paper gathers the opinions of experts of the Laryngotracheal Stenosis Committee of the European Laryngological Society, with the aim of alerting the medical community about the possible rise in number of COVID-19-related laryngotracheal stenosis (LTS), and the aspiration of paving the way to a more rationale concentration of these cases within referral specialist airway centers. Results: A range of prevention strategies, diagnostic work-up, and therapeutic approaches are reported and framed within the COVID-19 pandemic context. Conclusions: One of the most important roles of otolaryngologists when encountering airway-related signs and symptoms in patients with previous ICU hospitalization for COVID-19 is to maintain a high level of suspicion for LTS development, and share it with colleagues and other health care professionals. Such a condition requires specific expertise and should be comprehensively managed in tertiary referral centers.

Background There is evidence supporting a pathophysiological role of oxytocin in attention deficit hyperactive disorder (ADHD) especially hyperactive and combined subtypes. It is known that children with ADHD show a high rate of social cognitive problems regarding emotion recognition. Oxytocin was assumed to play a role in the emergence of social cognition deficits in ADHD. Aim of this study is to assess social cognition (emotion recognition) deficits in relation to oxytocin level in different subtypes of ADHD among the study group. Forty male patients with ADHD were recruited from psychiatric outpatient clinic of Fayoum University Hospital, were diagnosed according to DSM-5, and were assessed using Conner’s parent rating scale–revised (L). Social cognition measured by CANTAB emotion recognition task (ERT) and the level of salivary oxytocin was measured by ELISA technique. Results Combined subtype had been lower in correctly detecting the emotions of fear and anger. Predominately, hyperactive impulsive ADHD subtype was more rapid while detecting the emotions of surprise and disgust. There was significant negative correlation between age of onset of ADHD and errors in detecting the emotion of anger and positive correlation between age of onset of ADHD and errors in detecting the emotion of surprise. Correct detection of the emotion of happiness was associated with increased oxytocin level but the correct detection of the emotion of fear was inversely related to oxytocin level. No statistically significant difference between different subtypes of ADHD regarding salivary oxytocin level. Conclusion Oxytocin may play a role in social cognitive deficits in ADHD. The presence of social cognitive deficits in ADHD prompts further investigations to focus on the specificity of these deficits and in turn identify ways of managing them. Studying oxytocin in this population and its relation to social cognitive deficits can support the notion that oxytocin is a biological marker for ADHD.

Epidermolysis bullosa simplex (EBS) is a debilitating condition affecting the skin and mucous membranes that is characterised by frequent ulceration and blistering on trivial trauma. In EBS, oral cavity mucosal injuries lead to a high propensity for developing squamous cell carcinomas. Locally advanced tongue carcinoma arising in this background presents a challenging therapeutic conundrum. To our knowledge, this is the first case of aggressive locally advanced tongue carcinoma that has developed sporadically in a patient with EBS and no family history. Routine screening of oral mucosal lesions will lead to early detection and timely management of this debilitating condition.

Aims Little is known regarding how the risk of suicide in refugees relates to their host country. Specifically, to what extent inter-country differences in structural factors between the host countries may explain the association between refugee status and subsequent suicide is lacking in previous literature. We aimed to investigate (1) the risk of suicide in refugees resident in Sweden and Norway, in general, and according to their sex, age, region/country of birth and duration of residence, compared with the risk of suicide in the respective majority host population; (2) if factors related to socio-demographics, labour market marginalisation (LMM) and healthcare use might explain the risk of suicide in refugees differently in host countries. Methods Using a nested case-control design, each case who died by suicide between the age of 18 and 64 years during 1998 and 2018 (17 572 and 9443 cases in Sweden and Norway, respectively) was matched with up to 20 controls from the general population, by sex and age. Multivariate-adjusted conditional logistic regression models yielding adjusted odds ratios (aORs) with 95% confidence intervals (95% CI) were used to test the association between refugee status and suicide. Separate models were controlled for factors related to socio-demographics, previous LMM and healthcare use. Analyses were also stratified by sex and age groups, by refugees' region/country of birth and duration of residence in the host country. Results The aORs for suicide in refugees in Sweden and Norway were 0.5 (95% CI 0.5–0.6) and 0.3 (95% CI 0.3–0.4), compared with the Swedish-born and Norwegian-born individuals, respectively. Stratification by region/country of birth showed similar statistically significant lower odds for most refugee groups in both host countries except for refugees from Eritrea (aOR 1.0, 95% CI 0.7–1.6) in Sweden. The risk of suicide did not vary much across refugee groups by their duration of residence, sex and age except for younger refugees aged 18–24 who did not have a statistically significant relative difference in suicide risk than their respective host country peers. Factors related to socio-demographics, LMM and healthcare use had only a marginal influence on the studied associations in both countries. Conclusions Refugees in Sweden and Norway had almost similar suicide mortality advantages compared with the Swedish-born and Norwegian-born population, respectively. These findings may suggest that resiliency and culture/religion-bound attitudes towards suicidal behaviour in refugees could be more influential for their suicide risk after resettlement than other post-migration environmental and structural factors in the host country.

Flexible laryngoscopy, the gold-standard evaluation of the larynx and the pharynx, is one of the most commonly performed procedures in otolaryngology. During the coronavirus disease 2019 (COVID-19) pandemic, flexible laryngoscopy represents a risk for patients and an occupational hazard for otolaryngologists and any clinic staff involved with the procedure or endoscope reprocessing. Here we present a set of recommendations on flexible laryngoscopy performance during the pandemic, including patient selection, personal protective equipment, and endoscope disinfection, based on a consensus reached during a virtual webinar on March 24, 2020, attended by approximately 300 participants from the American laryngology community.

Several age-related sensory and motor changes impact swallow function in the elderly. Dysphagia is a common and growing concern as the geriatric population expands and is associated with emotional, physical, and financial consequences. However, it is underdiagnosed and undertreated, especially in community-dwelling independent older adults who do not report issues with swallowing. Otherwise healthy older adults may have senescent swallowing that remains functional until it is disrupted by triggers and becomes dysphagia. Evaluating for dysphagia in the elderly is important, because it is frequently missed until complications requiring hospitalization develop. The evaluation of dysphagia in the independently living elderly relies on screening tests, clinical swallowing evaluations, and instrumental exams. However, limitations exist with the current data, including the lack of consistent swallowing evaluation tools used during screening. Dysphagia is a significant problem in the elderly, leading to increased morbidity and cost of care. Further research is necessary to define the prevalence and impact of dysphagia in this population.

The aim of the experiment was to investigate the productive and reproductive potential of pregnant Red Chittagong (RC) cows through improved feeding. A total of 30 pregnant RC cows from each of 30 farmers having six months pregnancy and between 2 and 3 parities old were used in the trial. The cows were randomly allocated to three dietary treatment groups, i.e., T0, T1 and T2. The cows of T0 group received farmers’ diet (63% of dry matter intake of cows according to ARC, 1995) without the supplementation and served as control. The cows of T1 group received farmer’s diet (63%) plus 25% supplementation of formulated concentrate diet for deficit of requirement of cows {(63 + 9.25) = 72.25% dry matter intake of cows according to ARC, 1995)} and T2 group received farmers diet (63%) plus formulated concentrate diet to meet 100% requirements of cows according to ARC (1995) {(63% +37%) = 100%}. The total live weight gain before calving of RC cows were observed significantly (P

To determine adverse events after endoscopic flexible vs endoscopic rigid cricopharyngeal myotomy for treatment of Zenker's diverticulum (ZD).Systematic review of MEDLINE, Web of Science, CINAHL, Clinicaltrials.gov, and Cochrane Central Register of Controlled Trials for all years according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Additional studies were identified from review citations and a by hand search of manuscripts referencing ZD.A structured literature search was conducted to identify studies for this systematic review. Methodological Index for Non-randomized Studies (MINORS) criteria were applied to assess study quality. For inclusion, each study had to provide data for at least 10 adult patients who had undergone endoscopic ZD repair reporting clear association with the postprocedure course in each case. Data extracted included all reported adverse events, recurrences, follow-up, and operative times.In total, 115 studies were included. All but 8 were retrospective case series. Sixty-one reported series of patients after rigid endoscopic stapler repair, 31 after rigid laser repair, and 13 with other rigid endoscopic instruments. Twenty-nine flexible endoscopic studies were included. Mortality, infection, and perforation were not significantly more likely in either the rigid or the flexible group, but bleeding and recurrence were more likely after flexible endoscopic techniques (20% vs10% and 4% vs 0%, respectively). Dental injury and vocal fold palsy were reported rarely in the rigid endoscopic groups.Adverse events are rare after endoscopic Zenker's repair. The flexible approach minimizes exposure limitations and can be completed in some patients without general anesthesia. Transoral rigid approaches result in fewer revision surgeries compared with flexible diverticulotomy.

Cancer is the second deadliest disease worldwide. Although recent advances applying precision treatments with targeted (molecular and immune) agents are promising, the histological and molecular heterogeneity of cancer cells and huge mutational burdens (intrinsic or acquired after therapy) leading to drug resistance and treatment failure are posing continuous challenges. These recent advances do not negate the need for alternative approaches such as chemoprevention, the pharmacological approach to reverse, suppress or prevent the initial phases of carcinogenesis or the progression of premalignant cells to invasive disease by using non-toxic agents. Although data are limited, the success of several clinical trials in preventing cancer in high-risk populations suggests that chemoprevention is a rational, appealing and viable strategy to prevent carcinogenesis. Particularly among higher-risk groups, the use of safe, non-toxic agents is the utmost consideration because these individuals have not yet developed invasive disease. Natural dietary compounds present in fruits, vegetables and spices are especially attractive for chemoprevention and treatment because of their easy availability, high margin of safety, relatively low cost and widespread human consumption. Hundreds of such compounds have been widely investigated for chemoprevention and treatment in the last few decades. Previously, we reviewed the most widely studied natural compounds and their molecular mechanisms, which were highly exploited by the cancer research community. In the time since our initial review, many promising new compounds have been identified. In this review, we critically review these promising new natural compounds, their molecular targets and mechanisms of anticancer activity that may create novel opportunities for further design and conduct of preclinical and clinical studies.

OBJECTIVES: To assess the impact of percutaneous dilational tracheostomy in coronavirus disease 2019 patients requiring mechanical ventilation and the risk for healthcare providers. DESIGN: Prospective cohort study; patients were enrolled between March 11, and April 29, 2020. The date of final follow-up was July 30, 2020. We used a propensity score matching approach to compare outcomes. Study outcomes were formulated before data collection and analysis. SETTING: Critical care units at two large metropolitan hospitals in New York City. PATIENTS: Five-hundred forty-one patients with confirmed severe coronavirus disease 2019 respiratory failure requiring mechanical ventilation. INTERVENTIONS: Bedside percutaneous dilational tracheostomy with modified visualization and ventilation. MEASUREMENTS AND MAIN RESULTS: Required time for discontinuation off mechanical ventilation, total length of hospitalization, and overall patient survival. Of the 541 patients, 394 patients were eligible for a tracheostomy. One-hundred sixteen were early percutaneous dilational tracheostomies with median time of 9 days after initiation of mechanical ventilation (interquartile range, 7-12 d), whereas 89 were late percutaneous dilational tracheostomies with a median time of 19 days after initiation of mechanical ventilation (interquartile range, 16-24 d). Compared with patients with no tracheostomy, patients with an early percutaneous dilational tracheostomy had a higher probability of discontinuation from mechanical ventilation (absolute difference, 30%; p < 0.001; hazard ratio for successful discontinuation, 2.8; 95% CI, 1.34-5.84; p = 0.006) and a lower mortality (absolute difference, 34%, p < 0.001; hazard ratio for death, 0.11; 95% CI, 0.06-0.22; p < 0.001). Compared with patients with late percutaneous dilational tracheostomy, patients with early percutaneous dilational tracheostomy had higher discontinuation rates from mechanical ventilation (absolute difference 7%; p < 0.35; hazard ratio for successful discontinuation, 1.53; 95% CI, 1.01-2.3; p = 0.04) and had a shorter median duration of mechanical ventilation in survivors (absolute difference, -15 d; p < 0.001). None of the healthcare providers who performed all the percutaneous dilational tracheostomies procedures had clinical symptoms or any positive laboratory test for severe acute respiratory syndrome coronavirus 2 infection. CONCLUSIONS: In coronavirus disease 2019 patients on mechanical ventilation, an early modified percutaneous dilational tracheostomy was safe for patients and healthcare providers and associated with improved clinical outcomes.

Aims Labour market marginalisation (LMM), i.e. severe problems in finding and keeping a job, is common among young adults with attention-deficit/hyperactivity disorder (ADHD). This study aimed to disentangle the extent of LMM as well as the heterogeneity in patterns of LMM among young adults with ADHD and what characterises those belonging to these distinct trajectories of LMM. Methods This population-based register study investigated all 6287 young adults, aged 22–29 years, who had their first primary or secondary diagnosis of ADHD in Sweden between 2006 and 2011. Group-based trajectory (GBT) models were used to estimate trajectories of LMM, conceptualised as both unemployment and work disability, 3 years before and 5 years after the year of an incident diagnosis of ADHD. Odds ratios (ORs) with 95% confidence intervals (CIs) for the association between individual characteristics and the trajectory groups of LMM were estimated by multinomial logistic regression. Results Six distinct trajectories of LMM were found: ‘increasing high’ (21% belonged to this trajectory group) with high levels of LMM throughout the study period, ‘rapidly increasing’ (19%), ‘moderately increasing’ (21%), ‘constant low’ (12%) with low levels of LMM throughout the study period, ‘moderately decreasing’ (14%) and finally ‘fluctuating’ (13%), following a reversed u-shaped curve. Individuals with the following characteristics had an increased probability of belonging to trajectory groups of increasing LMM: low educational level (moderately increasing: OR: 1.4; CI: 1.2–1.8, rapidly increasing: OR: 1.7; CI: 1.3–2.1, increasing high: OR: 2.9; CI: 2.3–3.6), single parents (moderately increasing: OR: 1.6; CI: 1.1–2.4, rapidly increasing: OR: 2.0; CI: 1.3–3.0), those born outside the European Union/the Nordic countries (rapidly increasing: OR: 1.7; CI: 1.1–2.5, increasing high: OR: 2.1; CI: 1.4–3.1), persons living in small cities/villages (moderately increasing: OR: 2.4; CI: 1.9–3.0, rapidly increasing: OR: 2.1; CI: 1.6–2.7, increasing high: OR: 2.6; CI: 2.0–3.3) and those with comorbid mental disorders, most pronounced regarding schizophrenia/psychoses (rapidly increasing: OR: 6.7; CI: 2.9–19.5, increasing high: OR: 12.8; CI: 5.5–37.0), autism spectrum disorders (rapidly increasing: OR: 4.6; CI: 3.1–7.1, increasing high: OR: 9.6; CI: 6.5–14.6), anxiety/stress-related disorders (moderately increasing: OR: 1.3; CI: 1.1–1.7, rapidly increasing: OR: 2.0; CI: 1.6–2.5, increasing high: OR: 1.8; CI: 1.5–2.3) and depression/bipolar disorder (moderately increasing: OR: 1.3; CI: 1.0–1.6, rapidly increasing: OR: 1.7; CI: 1.4–2.2, increasing high: OR: 1.5; CI: 1.2–1.9). Conclusions About 61% of young adults were characterised by increasing LMM after a diagnosis of ADHD. To avoid marginalisation, attention should especially be given to young adults diagnosed with ADHD with a low educational level, that are single parents and who are living outside big cities. Also, young adults with comorbid mental disorders should be monitored for LMM early in working life.

Background: Resistance to standard chemotherapy in metastatic triple-negative breast cancer (mTNBC) is associated with upregulation of the mitogen-activated protein kinase (MAPK) pathway. Cobimetinib, an MAPK/extracellular signal-regulated kinase (MEK) inhibitor, may increase sensitivity to taxanes and programmed death-ligand 1 inhibitors. COLET is a three-cohort phase II study evaluating first-line cobimetinib plus chemotherapy, with or without atezolizumab, in patients with locally advanced or mTNBC. Patients and methods: Patients were >= 18 years with locally advanced or mTNBC. Following a safety run-in, patients in cohort I were randomized 1:1 to cobimetinib (60 mg, D3-D23 of each 28-day cycle) or placebo, plus paclitaxel (80 mg/m(2), D1, 8, and 15). Additional patients were randomized (1:1) to cohort II or III to receive cobimetinib plus atezolizumab (840 mg, D1 and D15) and either paclitaxel (cohort II) or nab-paclitaxel [cohort III (100 mg/m(2), D1, D8, and D15)]. Primary endpoints were investigator-assessed progression-free survival (PFS) (cohort I) and confirmed objective response rate (ORR) (cohorts II/III). Safety and tolerability were also assessed. Results: In the expansion stages, median PFS was 5.5 months for cobimetinib/paclitaxel versus 3.8 months for placebo/paclitaxel in cohort I [hazard ratio 0.73; 95% confidence interval (CI) 0.43-1.24; P = 0.25]. In cohort I, ORR was 38.3% (95% CI 24.40-52.20) for cobimetinib/paclitaxel and 20.9% (95% CI 8.77-33.09) for placebo/paclitaxel; ORRs in cohorts II and III were 34.4% (95% CI 18.57-53.19) and 29.0% (95% CI 14.22-48.04), respectively. Diarrhea was the most common grade >= 3 adverse events across all cohorts. Conclusions: Cobimetinib added to paclitaxel did not lead to a statistically significant increase in PFS or ORR, although a nonsignificant trend toward a numerical increase was observed. Cobimetinib plus atezolizumab and a taxane did not appear to increase ORR. This demonstrates the potential activity of a combinatorial MEK inhibitor, chemotherapy, and immunotherapy in this difficult-to-treat population. This work was supported by F. Hoffmann-La Roche Ltd, Basel, Switzerland (no grant numbers apply). Support for third-party writing assistance for this manuscript, furnished by Stephen Salem, BSc, of Health Interactions, was provided by F. Hoffmann-La Roche Ltd. Brufsky, A (corresponding author), Univ Pittsburgh, Dept Med, Div Hematol Oncol, Med Ctr, 300 Halket St,Suite 4628, Pittsburgh, PA 15213 USA. Loi, S (corresponding author), Peter MacCallum Canc Ctr, Div Clin Med & Res, 305 Grattan St, Melbourne, Vic 3000, Australia. brufskyam@upmc.edu; sherene.loi@petermac.org

Importance Decision-making in the timing of tracheostomy in patients with coronavirus disease 2019 (COVID-19) has centered on the intersection of long-standing debates on the benefits of early vs late tracheostomy, assumptions about timelines of infectivity of the novel coronavirus, and concern over risk to surgeons performing tracheostomy. Multiple consensus guidelines recommend avoiding or delaying tracheostomy, without evidence to indicate anticipated improvement in outcomes as a result. Objective To assess outcomes from early tracheostomy in the airway management of patients with COVID-19 requiring mechanical ventilation. Design, Setting, and Participants A retrospective medical record review was completed of 148 patients with reverse transcriptase–polymerase chain reaction–confirmed COVID-19 requiring mechanical ventilation at a single tertiary-care medical center in New York City from March 1 to May 7, 2020. Interventions Open or percutaneous tracheostomy. Main Outcomes and Measures The primary outcomes were time from symptom onset to (1) endotracheal intubation, (2) tracheostomy; time from endotracheal intubation to tracheostomy; time from tracheostomy to (1) tracheostomy tube downsizing, (2) decannulation; total time on mechanical ventilation; and total length of stay. Results Participants included 148 patients, 120 men and 28 women, with an overall mean (SD) age of 58.1 (15.8) years. Mean (SD; median) time from symptom onset to intubation was 10.57 (6.58; 9) days; from symptom onset to tracheostomy, 22.76 (8.84; 21) days; and from endotracheal intubation to tracheostomy, 12.23 (6.82; 12) days. The mean (SD; median) time to discontinuation of mechanical ventilation was 33.49 (18.82; 27) days; from tracheostomy to first downsize, 23.02 (13.76; 19) days; and from tracheostomy to decannulation, 30.16 (16.00; 26) days. The mean (SD; median) length of stay for all patients was 51.29 (23.66; 45) days. Timing of tracheostomy was significantly associated with length of stay: median length of stay was 40 days in those who underwent early tracheostomy (within 10 days of endotracheal intubation) and 49 days in those who underwent late tracheostomy (median difference, −8; 95% CI, −15 to −1). In a competing risks model with death as the competing risk, the late tracheostomy group was 16% less likely to discontinue mechanical ventilation (hazard ratio, 0.84; 95% CI, 0.55 to 1.28). Conclusions and Relevance This cohort study from the first 2 months of the pandemic in New York City provides an opportunity to reconsider guidelines for tracheostomy for patients with COVID-19. Findings demonstrated noninferiority of early tracheostomy and challenges recommendations to categorically delay or avoid tracheostomy in this patient population. When aligned with emerging evidence about the timeline of infectivity of the novel coronavirus, this approach may optimize outcomes from tracheostomy while keeping clinicians safe.

Considerable evidence shows that the vestibular system contributes to adjusting sympathetic nervous system activity to maintain adequate blood pressure during movement and changes in posture. However, only a few prior experiments entailed recordings in conscious animals from brainstem neurons presumed to convey baroreceptor and vestibular inputs to neurons in the rostral ventrolateral medulla (RVLM) that provide inputs to sympathetic preganglionic neurons in the spinal cord. In this study, recordings were made in conscious felines from neurons in the medullary lateral tegmental field (LTF) and nucleus tractus solitarius (NTS) identified as regulating sympathetic nervous system activity by exhibiting changes in firing rate related to the cardiac cycle, or cardiac-related activity (CRA). Approximately 38% of LTF and NTS neurons responded to static 40° head up tilts with a change in firing rate of ~50%. However, few of these neurons responded to 10° sinusoidal rotations in the pitch plane, in contrast to prior findings in decerebrate animals that the firing rates of both NTS and LTF neurons are modulated by small-amplitude body rotations. Thus, as previously demonstrated for RVLM neurons, in conscious animals NTS and LTF neurons only respond to large rotations that lead to changes in sympathetic nervous system activity. The similar responses to head-up rotations of LTF and NTS neurons with those documented for RVLM neurons suggest that LTF and NTS neurons are components of the vestibulo-sympathetic reflex pathway. However, a difference between NTS/LTF neurons and RVLM was variability in CRA over time. This variability was significantly greater for RVLM neurons, raising the hypothesis that the responsiveness of these neurons to baroreceptor input is adjusted based on the animal’s vigilance and alertness.

OBJECTIVES/HYPOTHESIS Singers have high vocal demands and are at increased risk of developing voice disorders. Different singing genres place different technical demands on the voice. However, differences in laryngeal pathology based on genre have not been well-researched. The purpose of this study was to determine the prevalence of laryngeal pathology in different genres of professional and amateur singers who present with a voice complaint. STUDY DESIGN Retrospective review. METHODS Retrospective review of patients seen at a tertiary laryngology practice. Self-identified singers who reported their primary singing genre and categorized their singing as a full-time job, part-time job, or amateur involvement were included. Type and prevalence of pathology were calculated based on genre and professional status. RESULTS Of the 302 self-identified singers, 54% (n = 164) had laryngeal pathology. Among those with pathology, the most common finding was fibrotic lesion (38.4%, 63/164). Genres in which a majority of singers had pathology were other (69.2%, 9/13), choral (64.7%, 11/17), pop (63.2%, 12/19), musical theater (61.4%, 43/70), country (100%, 4/4), and Latin (100%, 2/2). The highest prevalence of pathology was seen in part-time professional singers (62.2%, 41/66) and full-time professionals (60.8%, 62/102), compared to amateurs (45.1%, 60/133). CONCLUSIONS Laryngeal pathology is prevalent in singers presenting with a voice complaint. Regardless of genre or professional status, fibrotic lesions were the most common pathological finding. This study provides preliminary data on the prevalence of different laryngeal pathologies found in singers by genre and degree of professional involvement. LEVEL OF EVIDENCE 4 Laryngoscope, 131:2076-2080, 2021.

The destruction of the World Trade Center (WTC) towers on the 11th of September, 2001 released a vast amount of aerosolized dust and smoke resulting in acute and chronic exposures to community members as well as responders. The WTC Environmental Health Center (WTC EHC) is a surveillance and treatment program for a diverse population of community members, including local residents and local workers with WTC dust exposure. Many of these patients have reported persistent lower respiratory symptoms (LRS) despite treatment for presumed asthma. Our goal was to identify conditions associated with persistent uncontrolled LRS despite standard asthma management. We recruited 60 patients who were uncontrolled at enrollment and, after a three-month run-in period on high-dose inhaled corticosteroid and long acting bronchodilator, reassessed their status as Uncontrolled or Controlled based on a score from the Asthma Control Test (ACT). Despite this treatment, only 11 participants (18%) gained Controlled status as defined by the ACT. We compared conditions associated with Uncontrolled and Controlled status. Those with Uncontrolled symptoms had higher rates of upper airway symptoms. Many patients had persistent bronchial hyper-reactivity (BHR) and upper airway hyper-reactivity as measured by paradoxical vocal fold movement (PVFM). We found a significant increasing trend in the percentage of Controlled with respect to the presence of BHR and PVFM. We were unable to identify significant differences in lung function or inflammatory markers in this small group. Our findings suggest persistent upper and lower airway hyper-reactivity that may respond to standard asthma treatment, whereas others with persistent LRS necessitate additional diagnostic evaluation, including a focus on the upper airway.

OBJECTIVE Race predicts overall mortality (OM) of laryngeal squamous cell carcinoma (LSCC) in the United States (US). We assessed whether racial disparities affect cancer-specific mortality (CSM) using the Surveillance, Epidemiology, and End Results (SEER) database. METHODS Adults with LSCC from 2004 to 2015 were selected. Univariable and multivariable Cox proportional hazards and Fine-Gray competing-risks regression analysis adjusted for clinicodemographic factors defined hazard ratios (aHR). RESULTS We identified 14,506 patients. The median age was 63 years. Most were male (11,725, 80.8%) and white (11,653, 80.3%), followed by Black (2294, 15.8%). Most had early-stage disease (7544, 52.0%) and received radiotherapy only (4107, 28.3%), followed by chemoradiation (3748, 25.8%). With median follow-up of 60 months, overall 3- and 5-year OM were 34.0% and 43.2%; CSM were 16.0% and 18.9%, respectively. Black patients had higher OM than white patients on univariable (HR 1.35, 95% CI, 1.26-1.44, P

Objectives: Recurrent respiratory papillomatosis can be treated in the office or operating room (OR). The choice of treatment is based on several factors, including patient and surgeon preference. However, there is little data to guide the decision-making. This study examines the available literature comparing operative treatment in-office versus OR. Methods: A systematic review was performed following Preferred Reporting Items for Systematic Reviews guidelines. Of 2,864 articles identified, 78 were reviewed full-length and 18 were included. Outcomes of interest were recurrence and complication rates, number of procedures, time interval between procedures, and cost. Results: Only one study compared outcomes of operative in-office to OR treatments. The weighted average complication rate for OR procedures was 0.02 (95% confidence interval [CI] 0.00-0.32), n = 8, and for office procedures, 0.17 (95% CI 0.08-0.33), n = 6. The weighted average time interval between OR procedures was 10.59 months (5.83, 15.35) and for office procedures 5.40 months (3.26-7.54), n = 1. The weighted average cost of OR procedures was $10,105.22 ($5,622.51-14,587.83), n = 2 versus $2,081.00 ($1,987.64-$2,174.36), n = 1 for office procedures. Conclusion: Only one study compares office to OR treatment. The overall data indicate no differences aside from cost and imply that office procedures may be more cost-effective than OR procedures. However, the heterogeneous data limits any strong comparison of outcomes between office and OR-based treatment of laryngeal papillomas. More studies to compare the two treatment settings are warranted.

Importance Esophageal perforations are difficult to diagnose and have a high mortality rate. Cervical esophageal perforations (CEPs) are the second most common anatomic type of esophageal perforations and are most often due to iatrogenic injury. They are often managed more conservatively than thoracic perforations. The current literature on CEPs is mostly observational, with a paucity of prospective controlled studies. In addition, there is scarce literature focusing specifically on iatrogenic CEPs (iCEPs) as an entity of their own. Observations The existing studies on esophageal perforations address treatment by anatomic location and by cause, but few focus specifically on iCEPs. The cricopharynx is the most common site for injury in diagnostic endoscopy. The standard treatment is generally conservative management with drainage unless the perforation is greater than 2 cm, the diagnosis is delayed, or the patient shows signs of sepsis, which would prompt surgical intervention, most commonly in the form of primary repair via open or endoscopic approach. An open approach has been the mainstay of therapy; however, use of endoscopic clips, stents, and suturing is increasingly on the rise. Guideline recommendations on the optimal therapeutic approach for iCEPs are lacking. The most consistent recommendation in the literature is immediate and individualized treatment. Conclusions and relevance The management of iCEPs is controversial. There is a need for additional prospective studies comparing treatment options for iCEPs to establish a gold standard treatment and to assess for the expanding role of endoscopic interventions.

Objectives: To evaluate volume changes within the tongue post chemoradiation therapy (CRT) Study Design: Retrospective review Setting: Academic Medical Center Subjects and Methods: Subjects included 19 patients that received CRT as the primary treatment for tonsillar or hypopharynx squamous cell carcinoma. Tongue volumes were calculated by three raters from thin slice computed tomography images collected before treatment and up to 29 months post-CRT. Body mass index (BMI) was also collected at each time point. Results: Inter-rater reliability was high with an ICC of 0.849 (95% CI = 0.773, 0.905). Linear mixed effects modeling showed a mean decrease of 0.45 cm3 (standard error of the mean [SEM] = 0.11) in tongue volume per month post-CRT ( P 2 (4) = 25.0, P 3 (SEM = 0.49) in tongue volume per unit decrease in BMI ( P 3 ( P = .02). BMI significantly ( P Conclusion: Tongue dysfunction and decreased tongue strength are significant contributors to the dysphagia that patients experience after receiving CRT. In this study, both tongue volume and BMI decreased post-CRT; therefore, BMI could potentially be used as a predictor of tongue volume post-CRT.

OBJECTIVES/HYPOTHESIS Various animal models have been employed to investigate vocal fold (VF) and phonatory function. However, biomechanical testing techniques to characterize vocal fold structural properties vary and have not compared critical properties across species. We adapted a nondestructive, automated indentation mapping technique to simultaneously quantify VF structural properties (VF cover layer and intact VF) in commonly used species based on the hypothesis that VF biomechanical properties are largely preserved across species. STUDY DESIGN Ex vivo animal model. METHODS Canine, leporine, and swine larynges (n = 4 each) were sagittally bisected, measured, and subjected to normal indentation mapping (indentation at 0.3 mm; 1.2 mm/s) with a 2-mm spherical indenter to quantify normal force along the VF cover layer, structural stiffness, and displacement at 0.8 mN; two-dimensional maps of the free VF edge through the conus elasticus were created for these characterizations. RESULTS Structural stiffness was 7.79 gf/mm (0.15-74.55) for leporine, 2.48 gf/mm (0.20-41.75) for canine, and 1.45 gf (0.56-4.56) for swine. For each species, the lowest values were along the free VF edge (mean ± standard deviation; leporine: 0.40 ± 0.21 gf/mm, canine: 1.14 ± 0.49 gf/mm, swine: 0.89 ± 0.28 gf/mm). Similar results were obtained for the cover layer normal force at 0.3 mm. On the free VF edge, mean (standard deviation) displacement at 0.08 gf was 0.14 mm (0.05) in leporine, 0.11 mm (0.03) in canine, and 0.10 mm (0.02) in swine. CONCLUSIONS Automated indentation mapping yielded reproducible biomechanical property measurement of the VF cover and intact VF. Divergent VF structural properties across canine, swine, and leporine species were observed. LEVEL OF EVIDENCE NA Laryngoscope, 129:E26-E31, 2019.

The differential expression of two closelyassociated cyclooxygenase isozymes, COX-1 and COX-2, exhibited functions beyond eicosanoid metabolism. We hypothesized that COX-1 or COX-2 knockout lung fibroblasts may display altered protein profiles which may allow us to further differentiate the functional roles of these isozymes at the molecular level. Proteomic analysis shows constitutive production of macrophage migration inhibitory factor (MIF) in lung fibroblasts derived from COX-2-/- but not wild-type (WT) or COX-1-/- mice. MIF was spontaneously released in high levels into the extracellular milieu of COX2-/- fibroblasts seemingly from the preformed intracellular stores, with no change in the basal gene expression of MIF. The secretion and regulation of MIF in COX-2-/- was "prostaglandin-independent." GO analysis showed that concurrent with upregulation of MIF, there is a significant surge in expression of genes related to fibroblast growth, FK506 binding proteins, and isomerase activity in COX-2-/- cells. Furthermore, COX-2-/- fibroblasts also exhibit a significant increase in transcriptional activity of various regulators, antagonists, and co-modulators of p53, as well as in the expression of oncogenes and related transcripts. Integrative Oncogenomics Cancer Browser (IntroGen) analysis shows downregulation of COX-2 and amplification of MIF and/or p53 activity during development of glioblastomas, ependymoma, and colon adenomas. These data indicate the functional role of the MIF-COX-p53 axis in inflammation and cancer at the genomic and proteomic levels in COX-2-ablated cells. This systematic analysis not only shows the proinflammatory state but also unveils a molecular signature of a pro-oncogenic state of COX-1 in COX-2 ablated cells.

Objectives/hypothesis Although the primary goal of medialization laryngoplasty is to improve glottic closure, implant placement is also likely to alter the biomechanical properties of the vocal fold (VF). We sought to employ novel, nanoscale technology to quantify these properties following medialization based on the hypothesis that different medialization materials will likely yield differential biomechanical effects. Study design Ex vivo. Methods Nine pig larynges were divided into three groups: control, Silastic (Dow Corning, Midland, Michigan, U.S.A.) block medialization, or Gore-Tex (W.L. Gore & Associates, Newark, Delaware) medialization. Laryngoplasty was performed on excised, intact larynges. The larynges were then bisected in the sagittal plane and each subjected to dynamic nanomechanical analysis (nano-DMA) at nine locations using a 250-μm flat-tip punch and frequency sweep-load profile across the free edge of the VF and inferiorly along the conus elasticus. Results Silastic block and Gore-Tex implant introduced increased storage and loss moduli. Overall, storage moduli mean (maximum) increased from 38 kilopascals (kPa) (119) to 72 kPa (422) and 129 kPa (978) in control, Gore-Tex, and Silastic implants, respectively. Similarly, loss moduli increased from 13 kPa (43) to 22 kPa (201) and 31 kPa (165), respectively. Moduli values varied widely by location in the Silastic block and Gore-Tex groups. At the free VF edge, mean (maximum) storage moduli were lowest in the Gore-Tex group, 20 kPa (44); compared to control, 34.5 kPa (86); and Silastic, 157.9 kPa (978), with similar loss and complex moduli trends. Conclusion Medialization laryngoplasty altered VF structure biomechanical properties; Silastic and Gore-Tex implants differentially impact these properties. Level of evidence NA. Laryngoscope, 128:1163-1169, 2018.

Objective: To spot the frontal theta/beta ratio alterations during Tests of Variance of Attention (TOVA) in Egyptian attention deficit hyperactivity disorder (ADHD) children. Methods: This is a cross sectional study performed in Clinical Neurophysiology Unit, Cairo University, Egypt. It included 2 groups, each of 52 children (one of them with ADHD and the other were normal control). EEG was recorded for every subject during normal relaxing circumstance with eyes opened as well as during TOVA. Results: Comparing both groups revealed statistically significant difference in the theta/beta ratio in both state (normal relaxing with eyes opened and during TOVA), also we found that the theta/beta ratio decreased in normal group (during concentration) while in the ADHD group it increased with a specific pattern. Conclusion: The theta/beta ratio can be of value in helping for differential diagnosis in patients presenting with mild ADHD.

Objectives/Hypothesis To describe the distribution of recurrent respiratory papillomatosis (RRP) lesions across 21 laryngeal anatomic regions in previously untreated patients at initial presentation to provide insight regarding the natural history of RRP. Study Design Multi-institutional, retrospective case series. Methods Initial laryngoscopic examination videos of 83 previously untreated patients with adult-onset RRP were reviewed. Papilloma locations were recorded using a 21-region laryngeal schematic. Multivariate analyses by anatomic subsite were conducted for the entire population and for subgroups stratified by sex, age, and proton pump inhibitor (PPI) usage. Heat maps were generated, hierarchically color coding the anatomic distribution of disease. Results In this cohort, RRP was most likely to occur on the true vocal folds (TVFs) and anterior commissure (P

Objective Recent reports highlight the efficacy of small interfering RNA (siRNA) targeting SMAD3 to regulate transforming growth factor β (TGF-β)-mediated fibroplasia in vocal fold fibroblasts. The current study sought to investigate SMAD3 expression during wound healing in vivo and quantify the downstream transcriptional events associated with SMAD3 knockdown in vitro. Study Design In vivo and in vitro. Methods Unilateral vocal fold injury was created in a rabbit model. SMAD3 and SMAD7 mRNA expression was quantified at 1 hour and 1, 3, 7, 14, 30, 60, and 90 days following injury. In vitro, multi-gene analysis technology was employed in our immortalized human vocal-fold fibroblast cell line following TGF-β1 stimulation ± SMAD3 knockdown across time points. Results SMAD3 mRNA expression increased following injury; upregulation was significant at 3 and 7 days compared to control (both P

Background: African American (AA) women and patients with Triple Negative Breast Cancer (TNBC) have poor outcomes. It is unclear whether these worse outcomes in AA women are due to a higher frequency of TNBC in AA women. The purpose of our study was to determine difference in outcomes between AA and Caucasian (CA) female with TNBC. Methods: A retrospective study of women diagnosed with ER, PR and HER2 (1+) negative breast cancer between January 1/2001 and December 31/2013 at Vidant Medical Center (East Carolina University) in Greenville, North Carolina was undertaken. Patient demographics and tumor characteristics were analyzed to determine impact on overall survival. Results: In our institution, 4,434 women were diagnosed with breast cancer in this study period, of which 378 had TNBC. Our TNBC population was predominantly AA (53%). AA patients were younger (54.1 years vs 58.7 years, p=0.005), less often postmenopausal (62.6% vs 74.5%, p=0.013), more likely to have Medicaid (24.3% vs 7.9%, p Conclusions: Poorer outcomes in AA women cannot be attributed to the higher frequency of TNBC. Improved access to healthcare, with broader insurance coverage, may help minimize disparities in outcome by diagnosing TNBC at an earlier stage.Background: African American (AA) women and patients with Triple Negative Breast Cancer (TNBC) have poor outcomes. It is unclear whether these worse outcomes in AA women are due to a higher frequency of TNBC in AA women. The purpose of our study was to determine difference in outcomes between AA and Caucasian (CA) female with TNBC. Methods: A retrospective study of women diagnosed with ER, PR and HER2 (1+) negative breast cancer between January 1/2001 and December 31/2013 at Vidant Medical Center (East Carolina University) in Greenville, North Carolina was undertaken. Patient demographics and tumor characteristics were analyzed to determine impact on overall survival. Results: In our institution, 4,434 women were diagnosed with breast cancer in this study period, of which 378 had TNBC. Our TNBC population was predominantly AA (53%). AA patients were younger (54.1 years vs 58.7 years, p=0.005), less often postmenopausal (62.6% vs 74.5%, p=0.013), more likely to have Medicaid (24.3% vs 7.9%, p Conclusions: Poorer outcomes in AA women cannot be attributed to the higher frequency of TNBC. Improved access to healthcare, with broader insurance coverage, may help minimize disparities in outcome by diagnosing TNBC at an earlier stage. Citation Format: Mosquera C, Amin R, Wong JH. Effect of race on triple negative breast cancer outcomes [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-09-26.

Objective Given the recalcitrant nature of recurrent respiratory papillomatosis, targeted therapies to reduce disease burden are fundamental to improved patient care paradigms. We seek to demonstrate the safety of imiquimod injection into vocal fold mucosa by evaluating the degree of laryngeal edema, histopathologic changes to vocal fold structure, and serologic interferon α (IFNα) levels following injection. Study Design Preclinical. Setting Academic institution. Subjects and Methods Six New Zealand White rabbits underwent unilateral injection of 100 µg of sterile imiquimod (1 µg/µL), with 100 µL of normal saline injected into the contralateral vocal fold. Direct laryngoscopy was performed on days 3, 7, and 30 following injection. Larynges from 3 rabbits were harvested on postinjection day 7 for histologic analysis. The remaining 3 rabbit larynges were harvested on day 30. Serial serum samples were drawn for IFNα quantification via immunoassay. Results No signs of respiratory distress were observed at any point. Vocal fold appearance was not clinically divergent between imiquimod and control conditions via serial direct laryngoscopic evaluation. No inflammatory lesions or scarring were identified following injection. Histology showed no signs of acute inflammatory processes or changes in the control or imiquimod injection groups. Serum IFNα increased at days 3 and 7 following imiquimod injection ( P < .0001 and P = .0368, respectively), before returning to baseline by day 14. Conclusions Vocal fold imiquimod injection did not result in notable morbidity in this preclinical model. However, serum IFNα concentrations increased transiently. These data are critical to advance the therapeutic utility of this compound, particularly in the setting of recurrent respiratory papillomatosis.

We conducted a quality improvement project to increase the rate of discharges before noon (DBN) in the otolaryngology department at a tertiary care center.Based on a Plan-Do-Study-Act framework, monthly discharge data and observed-to-expected (O:E) length of stay were collected and shared with the department members monthly. A target of 43% DBN was predetermined by the center (Plan). The following interventions were implemented (Do): discharge planning starting at the time of admission, focus on early attending-to-resident team communication, placement of discharge order prior to rounding, and weekly reminders to the entire department.Discharges were monitored for 3 years. For the year prior to this study, a minority of patients were discharged before noon (12 months: 75 of 190, 36%). During the first 6 months of monitoring (Study), no significant improvement was identified (34 of 95, 36%). After interventions, performance significantly improved (31 months: 250 of 548, 68%). The performance was consistently above the predetermined target of 43%. During the study time, O:E length of stay remained below the predetermined target (O:E ratio, 0.90; hospital target, 0.93).Comprehensive discharge planning beginning at the time of admission, weekly reminders, and improved communication (Act) can help to prioritize DBN and increase the percentage of discharges before noon.By utilizing a quality improvement framework, significant improvements in timely discharge can be achieved and sustained with changes in workflow and departmental culture. These changes can be achieved without increases in resources or prolonging the length of stay.

The WASH Sector Development Plan (2011–2025) recognizes the absence of harmonized approaches as the root challenge to scaling up drinking water safety in Bangladesh. UNICEF is supporting the Government of Bangladesh (GoB) through the Department of Public Health Engineering (DPHE) and Policy Support Branch to re-engineer its approach to drinking water safety by integrating policy, systems strengthening & sustainable services delivery at national and sub-national levels. Some of the key contributions to the sector include the implementation of the UNICEF-DPHE Arsenic Safe Union model with the declaration of 106 Arsenic Safe Villages, reduction in arsenic contamination rates of new tubewells, a system for preventing elite capture of water points, and the adoption of the ASU model in a $240 million arsenic mitigation drinking water project using domestic resources. Relatedly, a Policy Support Branch has been established, the sector coordination mechanisms revised, WASH bottleneck analysis is ongoing & the National Implementation Plan on Arsenic has been reviewed: Next steps include the professionalisation of drilling by local drillers through a partnership with KTH, Sweden, the GoB and UNICEF.