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National parks often serve as hotspots for environmental crime such asillegal deforestation and animal poaching. Previous attempts to modelenvironmental crime were either discrete and network-based or required veryrestrictive assumptions on the geometry of the protected region and made heavyuse of radial symmetry. We formulate a level set method to track criminalsinside a protected region which uses real elevation data to determine speed oftravel, does not require any assumptions of symmetry, and can be applied toregions of arbitrary shape. In doing so, we design a Hamilton-Jacobi equationto describe movement of criminals while also incorporating the effects ofpatrollers who attempt to deter the crime. We discuss the numerical schemesthat we use to solve this Hamilton-Jacobi equation. Finally, we apply ourmethod to Yosemite National Park and Kangaroo Island, Australia and designpractical patrol strategies with the goal of minimizing the area that isaffected by criminal activity.

Objective: There is often unfamiliarity with the care of artificial airway devices (ie, endotracheal tubes, tracheostomies, and laryngectomies). The objective of this study was to design an Airway Quality Improvement Program (AQIP) to improve airway care., Methods: This was a retrospective chart review of a prospectively-initiated AQIP. The AQIP has 3 parts: 1) Mandatory "airway signs" 2) In-service teaching with a corresponding order set and 3) an overhead "Surgical Airway Emergency" page involving automatic pages to Anesthesia, Otolaryngology, and Respiratory Therapy. Pre- and post-intervention survey data was collected. The incidence of airway emergency was the primary patient outcome and was hypothesized to decrease after AQIP intervention., Results: Airway emergencies decreased 8.4% after AQIP ( P  = .45). Length of stay decreased after AQIP, 47.0 ± 76.5 days compared to 23.5 ± 23.6 ( P  = .004). Two hundred eight-one nurses and 76 respiratory therapists were educated. Pre-AQIP comfortability scores improved for the routine care of endotracheal tubes, tracheostomies, and laryngectomies, 4.3 ± 0.9, 4.3 ± 0.8, and 3.5 ± 1.2, compared to 4.7 ± 0.6, 4.5 ± 0.7, and 4.4 ± 0.7 post-AQIP ( P  = .0006, P  = .02, P  = .0001). The same improvement was noted for emergency airway care. Tracheostomy vs. laryngectomy recognition increased from 66.5 to 97.0% ( P  = .0001). Quiz questions regarding emergency airway management for laryngectomies improved from 76.2 to 93.8% ( P  = .0001)., Conclusion: The AQIP was associated with decreased length of hospital stay and improved competency in airway care among hospital staff. Further application of AQIP is needed for replication in other institutions and long-term application., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Salivary gland neoplasms are uncommon, and most exhibit epithelial differentiation. Mesenchymal neoplasms of the salivary gland are rare, and the incidence ranges from 1.9% to 5%. The aim of this study is to identify the types and clinical-pathological features of mesenchymal salivary neoplasm and review their differential diagnosis. A retrospective search for mesenchymal neoplasms of salivary glands from our institution's pathology archives from the 2004-2021 period and consultation files of one of the authors (AER) was performed. The clinical data were obtained from available medical records, and the histological slides and ancillary studies were retrieved and reviewed. We identified a total of 68 cases that form the study cohort. Thirty-five patients were male, and thirty-three patients were female, with a mean age of 48 years (range, 7 months-79 years), and the male to female ratio was 1:.94. Sixty-three (92.6%) of sixty-eight tumors were benign and included: 38 (56%) lipomas, 9 (13%) hemangiomas, 7 (10.3%) schwannomas, 3 (4.4%) neurofibromas, 3 (4.4%) lymphangioma, 2 (3%) solitary fibrous tumors, 1 (1.5%) myofibroma. Five of sixty-eight (7.4%) were malignant and included: 3 (4.4%) Adamantinoma-like Ewing sarcomas, 1 (1.5%) malignant peripheral nerve sheath tumor (MPNST), and 1 (1.5%) malignant solitary fibrous tumor. The involved sites included: parotid (55), submandibular gland (5), parapharyngeal space (5), buccal mucosa minor salivary gland (2), and sublingual gland (1). Sixty-seven patients underwent surgical resection. One patient with lymphangioma manifested a recurrence/persistence a week post-surgery. One patient with a parotid hemangioma developed post-operative numbness, and another patient developed chronic postauricular pain after surgery. Two patients with MPNST and one patient with adamantinoma-like Ewing sarcoma underwent neoadjuvant chemoradiation and were disease-free after treatment. The remaining 37 patients with available follow-up ranging from 7 days to 96 months (mean, 18 months) had a favorable outcome and were disease-free after treatment. Mesenchymal neoplasms of salivary gland are rare; most are benign and demonstrate adipocytic, endothelial, and schwannian differentiation; awareness of their development is important for adequate diagnosis. The mainstay of treatment is surgical excision, with the extent determined by tumor type. Adjuvant therapy is reserved for high-grade sarcomas and may be given in a neoadjuvant or adjuvant setting., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: A closed suction drain (CSD) is often utilized in head and neck surgical procedures to obliterate dead space. CSDs reduce seroma and hematoma formation, thereby improving skin apposition and wound healing. The use of drains for prolonged periods of time, however, may increase the risk of wound infection. Interestingly, the evidence regarding the need for, and management of, post-operative CSDs after head and neck surgery is scarce. The current criterion of drain removal when output is less than 30 cubic centimeters (cm 3 ) within a 24-hour period and/or on the third post-operative day (POD) is widely utilized. The aforementioned criterion is based on anecdotal evidence from small studies with specific surgical procedures. In this study, we aim to evaluate the criteria for drain removal and to lay the groundwork for an updated paradigm for drain management in head and neck oncologic surgery., Study Design: Retrospective cohort study Setting: Academic tertiary care hospital Methods: A retrospective study was performed. Patients were included if they underwent head and neck surgery at the University of Miami Hospital between January 1, 2019 and July 1, 2020 and had at least one CSD. Volume of drain output on each POD was recorded until the day of drain removal. The development of post-operative wound complications (i.e., seroma, hematoma, infection/abscess, and dehiscence) was also recorded., Results: From our initial cohort of 302 patients, 145 patients met inclusion criteria. A total of 10 patients developed a post-operative wound complication. Patients had a mean age of 58.3 ± 15.0 years. The median inter-quartile range (IQR) drain output (cm 3 ) on the day of CSD removal from patients who developed a wound complication was similar (15; IQR, 5-37.5) when compared to those who did not develop a wound complication (25; IQR, 10-30). This difference was not statistically significant ( p = 0.60). Additionally, the cohort who developed a post-operative wound complication had their drain removed on an earlier POD (1; IQR, 1-1 (Mean 1.2)) when compared to the cohort who did not develop any complications (1; IQR, 1-1 (Mean 1.5)). This difference was also not statistically significant ( p = 0.48) ., Conclusion: There is no association between drain output (cm 3 ) or day of CSD removal with the development of wound complications. These results warrant further studies to prospectively evaluate earlier CSD removal in head and neck surgery., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Bohorquez et al.)

Primary sarcomas of the larynx are rare and are associated with diagnostic and treatment challenges. Studies of these tumors are limited, and most examples have been reported as small series. To further increase our understanding of laryngeal sarcomas, we reviewed our experience of an adult cohort. A retrospective search for laryngeal sarcomas from our pathology archives and consultation files of one of the authors was performed. We studied 27 primary laryngeal sarcomas that included 25 males, and 2 females, with a mean age of 60 years (range 33-85). The cases included conventional chondrosarcoma (16), well-differentiated liposarcoma (2), clear cell chondrosarcoma (1), leiomyosarcoma (2), high grade myxofibrosarcoma (2), high grade myofibroblastic sarcoma (1), low-grade myofibroblastic sarcoma (1), malignant granular cell tumor (1), and Kaposi sarcoma (1). Data on treatment and follow-up was available in 17 and 16 cases, respectively. 12 patients underwent partial laryngeal resection; five had total laryngectomy, and the patient with Kaposi sarcoma received combined highly active antiretroviral therapy and chemotherapy. Three patients developed local recurrence, and two patients developed metastases. The remaining patients with follow up had a favorable outcome and were disease-free after treatment. The important differential diagnosis of spindle cell sarcoma is sarcomatoid squamous cell carcinoma, and their distinction often requires extensive sampling of the mucosal surface and immunohistochemical analysis. The mainstay of treatment for laryngeal sarcomas is surgical removal, with the extent dictated by tumor type and grade. Adjuvant therapy is reserved for high-grade sarcomas and may be given in a neoadjuvant or adjuvant setting., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC part of Springer Nature.)

Background: Coronavirus has serially overtaken our metropolitan hospitals. At peak, patients with acute respiratory distress syndrome may outnumber mechanical ventilators. In our Miami Hospital System, COVID-19 cases have multiplied for 4 weeks and elective surgery has been suspended., Methods: An Otolaryngologic Triage Committee was created to appropriately allocate resources to patients. Hospital ethicists provided support. Our tumor conference screened patients for nonsurgical options. Patients were tested twice for coronavirus before performing urgent contaminated operations. N95 masks and protective equipment were conserved when possible. Patients with low-grade cancers were advised to delay surgery, and other difficult decisions were made., Results: Hundreds of surgeries were canceled. Sixty-five cases screened over 3 weeks are tabulated. Physicians and patients expressed discomfort regarding perceived deviations from standards, but risk of COVID-19 exposure tempered these discussions., Conclusions: We describe the use of actively managed surgical triage to fairly balance our patient's health with public health concerns., (© 2020 Wiley Periodicals, Inc.)

Objectives: To determine the accuracy of the minimum leak test as a surrogate for target endotracheal cuff pressure of 20-30 cm H 2 O in intubated patients., Methods: Cuff pressures were measured at the University of Miami Hospital using the minimum leak test on every intubated patient once per shift, then cuff pressure was reevaluated using handheld numerical manometers and recorded pressures above or below the target range, readjusting the pressure as needed. This assessment was repeated throughout each patient's intubation for up to 6 days. The readjustment rate of the test and the probability of a patient needing at least one adjustment were determined., Results: One hundred twenty-two patients were evaluated. Median age was 67 years (range 29-95), 52% were male, 48% were female. Patients were followed for an average of 4.7 days. Seven hundred twenty-two minimum leak tests were performed. Of these, 170 required readjustment into the target range (24% readjustment rate). Of the tests outside target range, 66% of cuffs were overinflated and 34% were underinflated. Fifty-five percent of patients required at least one adjustment., Conclusion: Despite ubiquitous use of the minimum leak test for endotracheal cuff pressure adjustment, the test has an unacceptably high error rate resulting in cuff pressures above or below the target range. Most patients will require at least one adjustment throughout an intubation, putting them at risk for tracheal injury, stenosis, or leak and aspiration. The minimum leak test is not sufficiently accurate for endotracheal cuff pressure monitoring. Formal manometry is superior and should be used to optimize patient outcomes., Level of Evidence: 4 Laryngoscope, 130:1646-1650, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Optimal transoral surgical modality for oropharyneal carcinoma is currently unclear. Transoral laser surgery (TLS), transoral robotic surgery (TORS), and conventional direct transoral (DT) oropharyngectomy are the main current transoral surgical modalities for oropharyngeal carcinoma., Methods: MEDLINE was systematically searched through PubMed. Reference lists were reviewed. Random-effects models were used to combine studies within each group. Tests for heterogeneity were used to explore difference in effect size between groups in subgroup analysis., Results: Nine studies (404 patients) in TORS arm, five studies (498 patients) in TLS arm, and three studies (335 patients) in DT arm were included. Early T classification (T1-T2) for TORS and DT were higher compared to TLS group (P < .001). There was no significant difference between groups in the rate of invaded margin, post-operative oropharyngeal bleeding, temporary tracheotomy, and gastrostomy dependence., Conclusion: The available data do not yet provide clear evidence of superiority of any one modality., (© 2019 Wiley Periodicals, Inc.)

Warthin tumor (WT) is the second most common benign salivary gland neoplasm and has characteristic cytologic and histologic findings. Fine-needle aspiration is a common and useful preoperative diagnostic technique, which sometimes leads to ischemic injury resulting in the infarction of these lesions. Infarcted WT may demonstrate variable gross and histologic alterations that may render the diagnosis challenging, particularly during intraoperative frozen section evaluation. In this study, we collected 11 resection specimens from 9 patients with infarcted WT. Seven patients were men and 2 were women, ranging from 49 to 85 years (mean, 69). All the patients had fine-needle aspiration before the resection. Macroscopically, the tumors were tan-white and contained soft, yellow, exudative material. The histologic findings were variable and included necrosis, ghosts of papillae, squamous metaplasia, cholesterol clefts, foamy macrophages, multinucleated giant cell reaction, necrotizing granulomas, and fibrosis. Each case predominantly demonstrated 1 or 2 of these histomorphologic features. In the permanent sections, additional sampling revealed foci of residual viable WT in 8 cases. Three cases were completely infarcted; however, they all had ghost-like papillae in which the architecture of WT was evident. Infarcted WT may present a diagnostic challenge during intraoperative frozen section evaluation. Associated morphologic alterations may preclude a definitive diagnosis of WT and may mimic malignancy. Awareness of the gross and microscopic features associated with infarcted WT is important, particularly for accurate frozen section evaluation of these salivary gland tumors., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Solitary fibrous tumors represent fewer than 2% of all soft tissue tumors, and only about 12-15% of them occur in the head and neck. We report a case of a 38-year-old male who presented with a six-month history of increasing right cheek swelling. Computed tomography of the paranasal sinuses with contrast demonstrated a well-circumscribed avidly enhancing mass in the right retroantral fat. On magnetic resonance imaging the lesion was homogenously slightly hyperintense to muscle on T1 weighted and T2 weighted images and enhanced avidly with contrast. Surgical resection was performed and pathology was consistent with solitary fibrous tumor. There have been very few reported cases of solitary fibrous tumors in the infratemporal fossa and none described as originating in the retroantral fat.

Objectives: To determine the prevalence of professional burnout among microvascular free-flap (MVFF) head and neck surgeons and to identify modifiable risk factors with the intent to reduce MVFF surgeon burnout., Design: A cross-sectional, observational study., Setting: A questionnaire mailed to MVFF surgeons in the United States., Participants: A total of 60 MVFF surgeons., Main Outcomes Measures: Professional burnout was quantified using the Maslach Burnout Inventory- Human Services Study questionnaire, which defines burnout as the triad of high emotional exhaustion (EE), high depersonalization (DP), and low personal accomplishment. Additional data included demographic information and subjective assessment of professional stressors, satisfaction, self-efficacy, and support systems using Likert score scales. Potential risk factors for burnout were determined via significant association (P < .05) by Fisher exact tests and analyses of variance., Results: Of the 141 mailed surveys, 72 were returned, for a response rate of 51%, and 60 of the respondents were practicing MVFF surgeons. Two percent of the responding MVFF surgeons experienced high burnout (n = 1); 73%, moderate burnout (n = 44); and 25%, low burnout (n = 15). Compared with other otolaryngology academic faculty and department chairs, MVFF surgeons had similar or lower levels of burnout. On average, MVFF surgeons had low to moderate EE and DP scores. High EE was associated with excess workload, inadequate administration time, work invading family life, inability to care for personal health, poor perception of control over professional life, and frequency of irritable behavior toward loved ones (P < .001). On average, MVFF surgeons experienced high personal accomplishment., Conclusions: Most MVFF surgeons experience moderate professional burnout secondary to moderate EE and DP. This may be a problem of proper balance between professional obligations and personal life goals. Most MVFF surgeons, nonetheless, experience a high level of personal accomplishment in their profession.

Background: We reviewed management of the cervical lymph nodes in patients with Merkel cell carcinoma (MCC) of the head and neck., Methods: Records of 15 patients with MCC of the head and neck area were evaluated for the type of surgical treatment, including wide local excision, sentinel lymph node (SLN) biopsy, neck dissection, postoperative radiation therapy, and clinical outcomes., Results: Median follow-up was 24 months (range, 5-84 months). Ten patients were treated with wide local excision plus SLN, with or without neck dissection. Five patients were treated with wide local excision only or wide local excision plus neck dissection. One patient died of distant metastases (7%), and 14 patients remain alive (93%), over a mean follow-up of 24 months., Conclusion: Wide excision and SLN biopsy for primary MCC with N0 neck is feasible for early-stage, previously untreated lesions. SLN biopsy was helpful in determining the nodal levels to be dissected or irradiated., ((c) 2008 Wiley Periodicals, Inc.)

Background: Free tissue transfer is an integral part of modern head and neck surgery in the adult population. Its use in the pediatric population has not been well described. Recently, there has been an increase in the application of these techniques in the pediatric population. The morbidity of free tissue transfer in small pediatric patients and its effect on growth has not been well described., Objective: To evaluate the utility of microvascular reconstruction techniques in the pediatric population., Study Design: A consensus study was performed by the microvascular committee of the American Academy of Otolaryngology-Head and Neck Surgery. Thirty active microvascular surgeons reviewed their databases to find patients less than 21 years of age who underwent free tissue transfer., Results: 49 free tissue transfers performed between 1999 and 2005. The mean age was 12.1 years (age range, 3-21). The types of flaps transferred were radial forearm (10), fibula (21), rectus abdominus (7), scapula (1), latissimus dorsi (3), groin (1), gracillus (4), and jejunum (2). Morbidity at the donor site was relatively minimal. Five patients developed wound breakdown. One of these required return to the operating room. Morbidity at the reconstructed site was also rare. Patients were followed for an average of 49 months (range, 1-131 months), and no problems were noted with growth at the donor or recipient sites., Conclusions: Free flaps in the pediatric population have morbidity and survival similar to those in the adult population., Significance: While indications differ from those in the adult population, these techniques are viable and valuable and should be considered in the pediatric reconstructive paradigm.

Study Design: A retrospective study was undertaken which evaluated the medical records and imaging studies of a subset of patients managed by the spine service at Jackson Memorial Hospital who were diagnosed with an esophageal perforation in the setting of spinal surgery., Objective: To assess the safety and efficacy of a sternocleidomastoid muscle flap in the repair of esophageal perforation in the setting of anterior cervical spine surgery., Summary of Background Data: The management of an esophageal fistula in the setting of spine surgery is challenging and starts with a prompt and accurate diagnosis. In addition to broad spectrum intravenous antibiotics, several methods have been described to repair the fistula, which range from enteral tube feeding, direct repair, and/or repair with a local or free muscle flap., Methods: The review encompassed medical records, discharge summaries, operative reports, and imaging studies. Data were gathered with specific attention to demographics, primary pathology, mechanism of esophageal injury, method of spinal stabilization, method of esophageal repair, and time to initiation of oral intake. Follow-up interviews were conducted either in-person or by telephone., Results: Six patients were treated over the study period. There were 3 men and 3 women. The mean age was 52.8 years. Primary pathologies were penetrating trauma, blunt trauma (2 cases), degenerative disease (2 cases), and tumor. Mechanisms of esophageal injury were penetrating trauma, acute iatrogenic, chronic iatrogenic (3 cases), and intubation trauma. The time to diagnosis ranged from immediate to 10 months. The method of spinal stabilization was anterior autograft followed by posterior instrumentation in 4 of 6 patients. The method of esophageal repair was an inferiorly based sternocleidomastoid (SCM) flap in 4 cases, primary repair in 1 case, and esophageal diversion alone in 1 case. The time to oral intake averaged 59.2 days (range, 23-113 days) in those with a SCM flap versus 153.5 days (range, 119-188 days) in those treated without a flap., Conclusion: The use of an SCM flap for the repair of esophageal injury, in the setting of anterior cervical spine surgery, is a safe and effective tool. An SCM flap appeared to improve the time in initiating oral intake without any significant morbidity.

Despite advances in our ability to safely treat patients with recurrent cancer of the upper aerodigestive tract, outcomes for retreatment are generally poor and the first chance to cure these patients remains the best chance. Thorough knowledge of the outlook and options for patients with recurrent disease is also of significance in choosing therapy for patients with newly diagnosed disease. This is especially true for newly diagnosed patients making the choice between surgery and nonsurgical ("organ-sparing") options, who need to know the outlook for salvage surgery, should they recur after radiation with or without concomitant chemotherapy. Salvage surgery is generally the best option for previously irradiated patients who are faced with resectable, recurrent disease. Unfortunately, the results of surgical salvage are generally poor for patients with advanced stage recurrence and for those who recur after treatment of advanced disease. The site of initial and recurrent disease is important. Surgical salvage is most effective for patients with recurrent laryngeal cancer, least effective for recurrent cancer of the pharynx, and is intermediate for recurrence in the oral cavity. Patients choosing nonsurgical treatment for newly diagnosed cancer of the pharynx cannot rely on salvage surgery in the event of recurrence. Reirraditation for patients who have failed initial treatment that included radiation therapy has been used at a number of institutions with some success. Experience using reirradiation with or without concomitant chemotherapy continues to evolve. Palliative chemotherapy is an option for most patients, but response rates are generally poor and of short duration, after failure of initial treatment that includes radiation therapy. The best approach for many patients and families who face advanced recurrent disease is honest but compassionate communication and supportive care with the help of a hospice organization.

Background: Peptide sequence homology between the gene product of human MUC4 and rat sialomucin complex (SMC) has recently been reported. Each contains a mucin subunit with antiadhesive activity linked to the plasma membrane by means of a transmembrane subunit with two epidermal growth factor (EGF)-like domains that act as ligand for ErbB2. This study investigates MUC4 and ErbB2 receptor expression in major and minor salivary gland mucoepidermoid carcinoma and correlates patterns of expression with clinical outcomes., Methods: MUC4 antigens and ErbB2 receptor expression are localized by immunohistochemical studies that use archival formalin-fixed and paraffin-embedded tissue. Clinical outcomes are determined by retrospective chart review of all patients (n = 28) with available archived pathologic specimens at the University of Miami-affiliated hospitals treated between 1994 and 2000., Results: Median survival time was 24 months (range, 2-60 months) among the nine patients who died, whereas median follow-up time in the remaining 19 patients is 33.4 months (range, 4.7-73 months). A trend toward a reduction in MUC4 antigen expression in high-grade tumors (55% expression) compared with low-grade (91% expression) and intermediate-grade (100% expression) tumors is identified (chi square, p =.0975). Patients with tumors expressing MUC4 antigens are at reduced risk of death (hazard ratio [HR], 0.20; p =.0531). Adjustment for pathologic grade, T stage, and age results in a much higher risk of death for patients whose tumors do not express MUC4 antigens, although this does not meet statistical significance (HR, 26.6; p =.1). Analysis of recurrence adjusting for T stage reveals that patients whose tumors do not express MUC4 antigens are at increased risk of recurrence compared with patients whose tumor expresses MUC4 antigens (HR, 6.37; p =.03). ErbB2 receptor staining is noted in seven of 28 patients, with five of these seven showing 2+ and 3+ membrane-staining patterns. Adjustment for pathologic grade and age suggests that patients whose tumors express high levels of ErbB2 (2+, 3+) are at increased risk of death compared with patients with low or no expression of ErbB2 (HR, 2.29; p =.32). MUC4 antigen positivity is seen in two of the five cases with 2+ and 3+ staining for ErbB2. CONCLUSIONS.: These findings suggest MUC4 antigen positivity is associated with reduced risk of death and reduced risk of recurrence and may identify a subset of patients with more favorable prognosis. Although limited by small sample size, analysis reveals ErbB2 overexpression is not consistently associated with MUC4 antigen positivity and might be associated with increased risk of death., (Copyright 2004 Wiley Periodicals, Inc.)

Background: Home enteral nutrition (HEN) is most frequently prescribed for older adults. Medicare reimbursement policy limits in-home nursing visits, and in-home professional nutrition services are restricted to those patients with diabetes or predialysis kidney disease. Most older adults receiving HEN rely on informal (family) caregivers to provide HEN care. The purpose of this study was to apply care process theory to identify and investigate variables related to health care outcomes of HEN in a sample of older adults dependent on informal caregivers. We assessed relationships among patient characteristics, the HEN regimen prescription and adherence, formal provider involvement, and health care outcomes., Methods: In-home interviews were conducted with a multiethnic (14 white, 8 Hispanic, 7 African American, 1 Asian) sample of 30 older adults (mean = 68.4 years) during their first 3 months of HEN (mean = 1.83 months)., Results: Daily enteral intake averaged 1596 +/- 553 kcal. Gastrointestinal complications, occurring in up to 63.3% of patients, interrupted daily infusions. Further, one-third reported tube clogging or leaking, and one-third had tube displacement. Water intake was half of calculated need and associated with decreased urination (p = .001). Average weight change was -4.35 pounds (p = .001), and 17 patients had body mass indexes (BMIs) <18.5. Women had more complications (p = .004), lower enteral intake (p = .009), and lower BMIs (p = .02). Only 6 patients saw dietitians in follow-up care. Complications and type of feeding tube were associated with unscheduled health care visits and readmissions (p < .05)., Conclusion: The efficacy of HEN in older adults (ie, reversal of malnutrition and improvements in health, functionality and quality of life) requires more frequent monitoring, reassessment, and intervention from a highly skilled multidisciplinary team that includes dietitians.

Myringotomy with tube placement is the most frequently performed otolaryngologic procedure in the United States, and purulent otorrhea after this procedure is not uncommon. Believing that ototopical preparations have proved useful in treating this malady, our group was compelled to examine whether and in what quantities these preparations are able to penetrate tympanotomy tubes. To this end, models were constructed and in vitro testing carried out with several popular formulations.

Objectives: The primary goal of this study was to test the ability of 2f1-f2 distortion-product otoacoustic emissions (DPOAEs) to detect reduced cochlear function in the presence of normal behavioral sensitivity., Design: A prospective study was performed in normal-hearing young adults using simple and complex regression analyses to clarify the relationship between ultra-high frequency (UHF) hearing and DPOAE levels at lower frequencies, as well as the influence of hearing levels for frequencies within the conventional test range and subject age on this association., Methods: Average DPOAE levels between 4 to 8 kHz, which were elicited by equilevel primary tones of low to moderate levels, were measured as level-frequency functions, or distortion-product (DP) grams, and related to the mean UHF hearing levels from 11.2 to 20 kHz. The median hearing level for the UHF hearing was used to separate subjects into good and poor UHF hearers. This distinction was then used to compare DPOAE levels from 4 to 8 kHz for the 2 groups to determine if UHF hearing status influenced DPOAE levels at lower frequencies., Results: Simple regression analysis revealed that the 4-to 8-kHz DPOAE levels were significantly correlated with the pure-tone average (PTA) from 11.2 to 20 kHz. However, the PTA for 4 and 8 kHz was also significantly correlated with the PTA for UHF hearing. Further multiple regression analyses revealed that UHF hearing significantly and uniquely accounted for approximately 14% of the variance in DPOAE levels from 4 to 8 kHz for most of the primary-tone level combinations. In contrast, neither the PTA for the conventional hearing range nor subject age contributed significantly to the DPOAE variance., Conclusions: The findings suggest that UHF hearing influences DPOAEs at significantly lower frequencies because emissions are sensitive to subtle changes in outer hair cells not yet detected by pure-tone thresholds in this region or because alterations in the basal cochlea affect the generation of lower-frequency DPOAEs originating from more apical cochlear regions.

Use of the antihistamine terfenadine has been associated with QT prolongation and torsade de pointes. One possible mechanism is blockade of cardiac potassium channels. We therefore characterized the effects of terfenadine on potassium currents recorded from isolated human cardiac myocytes. We demonstrated terfenadine block of the transient outward current and a novel, ultra-rapidly activating, delayed rectifier K+ current (IKur), which is very sensitive to 4-aminopyridine. IKur is probably produced by the protein product of Kv1.5a, a Shaker-like potassium channel cDNA cloned from human heart. We also compared terfenadine blockade of fHK (Kv1.5a) currents stably expressed in a human embryonic kidney cell line with terfenadine blockade of IKur in human atrial myocytes. Using the patch-clamp technique, we found that terfenadine produced a time-dependent reduction in Kv1.5a current that was consistent with blockade from the cytoplasmic side of the channel. The terfenadine-sensitive Kv1.5a current in human embryonic kidney cells was similar to the 4-aminopyridine-sensitive current in human atrial myocytes. In addition to blockade of the transient outward current and IKur, terfenadine at clinically relevant concentrations blocked both the rapidly and slowly activating components of the delayed rectifier in human atrial myocytes. Blockade of these K+ currents may contribute to the cardiotoxicity associated with terfenadine usage.

Patients with locally advanced breast cancer have been considered unsuitable for curative surgical therapy and are usually approached with other treatment modalities. Review of the results of radical mastectomy in 228 patients with stage III breast cancer demonstrates actuarial survival of 33 per cent at five years and 22 per cent at ten years. Treatment with preoperative or postoperative radiotherapy as employed did not lead to survival superior to that of mastectomy alone. Evidence of local or regional recurrence developed in 27 per cent of patients. In 73 per cent the first recurrence was systemic. This retrospective study suggests that the prognosis for locally advanced breast cancer is not as dismal as has been previously reported. The importance of nodal involvement is again emphasized. A randomized trial of mastectomy with adjuvant chemotherapy for locally advanced breast cancer is warranted. Such a study is in progress at our institution.

This is a word of caution to anyone using ionization chambers protected by thin rubber sheaths in water. Four Farmer-type ionization chambers contaminated with talcum powder were received for calibration by the Accredited Dosimetry Calibration Laboratory at the University of Texas M. D. Anderson Cancer Center. The chambers show a marked energy dependence (5% to 20%) to soft orthovoltage x rays. The response of the contaminated chambers is compared with the chambers' response before contamination and after cleaning. Techniques for identifying contaminated chambers and suggestions for cleaning them are presented.

A combination chemotherapy (MACC) consisting of methotrexate, doxorubicin hydrochloride (Adriamycin), cyclophosphamide, and lomustine (CCNU) was given to 41 patients with stage III bronchogenic carcinoma, 34 of whom had disseminated disease. The objective response rate was 46% for all patients with a median actuarial survival of nine months. Response was seen in all cell types, including four of ten patients with squamous cell carcinoma, six of 17 with adenocarcinoma, and six of seven with small-cell anaplastic carcinoma. Prolongation of survival was apparent for patients of all cell types. Toxic reactions were moderate and allowed for easy outpatient use.

Forty-eight patients with measurable metastatic colorectal cancer were treated with leucovorin (FA), 80 mg/m2 as an intravenous (i.v.) infusion over 20 h, followed by 5-fluorouracil (5-FU), 400 mg/m2, i.v. push on days 1-3. This same dose of FA was then administered as a 1-h infusion on day 11 and weekly thereafter, followed by 5-FU, 400 mg/m2, slow intravenous (i.v.) push. Thirty patients had received no prior chemotherapy, and 18 patients had received chemotherapy with various other regimens. The drugs were well tolerated, with minimal hematologic toxicity and mild to moderate gastrointestinal and mucosal toxicity. Three complete responses (CRs) and nine partial responses (PRs) were observed. Nineteen additional patients remained stable for prolonged periods of time, and 12 patients continued to progress through treatment. The median survival for responders was 52.5 weeks. The patients who had received prior chemotherapy had lower response rates than the previously untreated patients, but responses were seen in both subsets. The CR plus PR rate in previously untreated patients was 30%, with 40% having stabilization of disease. The CR plus PR rate in patients previously treated with other chemotherapy regimens was 19%, with an additional 50% having stabilization of disease. Patients with stable disease appeared to have a clinical benefit similar to that of patients with PR. Toxicity was generally mild and acceptable and consisted mainly of nausea, vomiting, and mucositis. At these dosage levels, diarrhea was not a limiting toxicity. CRs and PRs occurred only in patients with Eastern Cooperative Oncology Group (ECOG) performance status 1 and 2. Carcinoembryonic antigen (CEA) levels generally reflected the type of clinical response and could often predict responders early on in the course of treatment, but did not quantitatively correlate with the degree of response. This regimen has efficacy at least similar to that of standard 5-FU regimens, and appears to have activity as a "salvage therapy" also. The minimal toxicity of this regimen, its convenience for outpatient use, and the relatively low expense as compared with regimens employing a higher dose of FA recommend it for further investigation.