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Purpose of Review: Nasoseptal flaps are a frequently used and well characterized means of reconstruction following endoscopic endonasal approach surgery (EEA). However, there are alternative means of reconstruction, including the extracranial pericranial flap (ePCF), that while used infrequently fulfill a specialized need in larger or salvage reconstructions. This review aims to better characterize long-term outcomes using ePCF where there is currently a paucity of objective data on use and outcomes., Recent Findings: A traditional pericranial flap involves elevating and rotating the flap through a craniotomy defect to reconstruct defects of the ventral skull base. The ePCF is implemented without performing a craniotomy, and instead tunnels the flap through a bony opening created at the level of the nasion. This review presents outcomes in a large single-center cohort of patients with ePCFs to better characterize the short- and long-term success, risks, and complications of this reconstructive method., Summary: Long-term follow-up demonstrates that obstruction of the frontal sinus outflow may occur but rarely requires surgical intervention. ePCF are a reasonable alternative to consider in cases where local tissue would be insufficient, is not available, or has already failed. There is a low risk of flap complications., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Tinnitus is a common otologic complaint which can range from bothersome to debilitating. Imaging is frequently utilized to rule out tumors, fractures, and other causes but can also cause significant medical and economic burden for patients. Furthermore, the pediatric population may require sedation for imaging. This study explored how commonly imaging was performed in pediatric patients with isolated tinnitus and whether imaging results affected clinical care., Methods: A retrospective case series of 266 patients aged 0-22 years diagnosed with tinnitus at a tertiary children's hospital was performed. Patients with otologic complaints other than tinnitus were excluded. Logistic regression, Wilcoxon rank-sum tests, and log-rank survival analysis were used for statistical analysis., Results: The mean age of tinnitus diagnosis was 13.4 years (IQR 10.8-16.7), 221/266 (83.1 %) of patients were white, and 139/266 (52.3 %) were male. In the 108 with details available, 29 (26.9 %) had pulsatile tinnitus. Twenty-one of two-hundred and sixty-six (7.9 %) had a history of migraines and 24/266 (9.0 %) had a history of psychiatric diagnosis. Seventy-four out of two-hundred and sixty-six (27.8 %) of patients completed CT and/or MRI imaging. Eleven out of forty-four (14.9 %) of those who underwent imaging had abnormal findings, and only 1 MRI and 1 CT showed new abnormal findings. Of note, the abnormal MRI and CT were of the same patient, and the CT was obtained as part of a trauma survey. Of the 64 patients with follow-up, 47 % of patients noted resolution of tinnitus. Patients with pulsatile tinnitus and a history of migraines were more likely to obtain imaging (OR = 8.14, 6.17; p < 0.001, <0.001, respectively). History of sinusitis, head/ear trauma, psychiatric diagnosis, and pulsatile tinnitus was not correlated with new abnormal imaging., Conclusions: In pediatric patients with isolated tinnitus, imaging very rarely reveals new abnormalities which can impact clinical care. Additional research is needed to optimize resource utilization and identify cohorts of pediatric patients with tinnitus in whom imaging can be deferred., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dennis Kitsko, DO reports financial support was provided by The project described was supported by the National Institutes of Health through Grant Number UL1 TR001857. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Purpose: To examine the audiometric outcomes of a footplate shoe (FPS) in total ossicular chain reconstruction prostheses (TORP) compared to TORP without shoe., Materials and Methods: Retrospective cohort study of patients who underwent TORP from 2010 to 2021 at a tertiary children's hospital. Patients without audiograms or unknown FPS status were excluded. Demographics, TORP indication, pure tone average (PTA) thresholds, and TORP revisions/replacements were recorded. Characteristics of patients with and without FPS were compared using exact logistic regression, t-test, Wilcoxon rank-sum, and log-rank tests., Results: Of 76 patients, 27 (36 %) were female, and median age was 9.9 years (range 2.5-22.0 years). FPS was present in 12 (16 %) cases. Mean pre-operative PTA was 49.4 dB (SD: 15.1 dB) (no FPS) and 47.1 dB (SD: 9.3 dB) (with FPS) (P = 0.62). The first post-operative median PTA (median 3 months following surgery) was 36.3 dB (range 13.8-101.3 dB) (no FPS) and 31.6 dB (range 16.9-56.3 dB) in FPS group (P = 0.24). At the second post-operative visit (median 30.5 months following first audiogram), PTA increased to 45.6 dB (SD: 18.1 dB) (no FPS) compared to the first postoperative visit (P = 0.001). However, PTA was stable in the FPS group at the second postoperative visit (mean 35.6 dB, SD: 22.0 dB) compared to the first postoperative visit (P = 0.50)., Conclusions: Surgical intervention, regardless of FPS status, demonstrates significant improvement in audiometric outcomes at the first post-operative visit. At the second post-operative, there were no differences in audiometric outcomes among the FPS group, while the no FPS group had worse audiometric outcomes., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction: In the United States, 5%-10% of breast cancer cases are due to genetic predisposition. Among this population, prophylactic mastectomy is viable risk-reducing option., Objective: The objective of this study is to understand the timing to prophylactic mastectomy in patients with genetic predisposition to breast cancer and uncover factors influencing this decision., Methods: This study is a retrospective review of patients diagnosed with genetic predisposition for breast cancer from 2010 to 2020., Results: In a cohort of 506 patients with genetic predisposition for breast cancer, 154 (30.4%) underwent prophylactic mastectomy, the remainder opted for surveillance alone. The median time from diagnosis to mastectomy was 1.1 years (IQR, 0.5-3.1 years). During the surveillance period, 118 patients (33.5%) underwent breast biopsy. Of the patients with benign or atypical findings, 35 (36.8%) pursued prophylactic mastectomy, a median of 0.5 years (IQR, 0.2-1.6 years) after their gene diagnosis. The most common factor impacting the decision to undergo prophylactic mastectomy was having a family member with cancer (54.7%) followed by a personal diagnosis of other cancer(s) (27.5%)., Conclusion: Understanding the factors influencing the decision to undergo prophylactic surgery will allow for more effective shared decision-making for primary care providers, breast surgeons, and reconstructive surgeons., (© 2024 The Author(s). Journal of Surgical Oncology published by Wiley Periodicals LLC.)

Objectives: The purpose of this study is to determine the predictors of neck lymphedema and to explore its association with symptoms and patient-reported outcomes (PROs) in Head and Neck Cancer (HNC) patients who underwent non-operative treatment., Methods: This study involved a cross-sectional secondary analysis of data from patients diagnosed with head and neck squamous cell carcinoma who underwent radiation therapy (±chemotherapy). Patients with visits <6 weeks or >2 years following completion of radiation and those with recurrent or metastatic cancer were excluded. Presence of post-treatment lymphedema, demographics, clinical characteristics, health-related behaviors, and symptoms were collected. PROs were obtained using validated questionnaires that assessed depression, anxiety, swallowing dysfunction, and quality of life (QOL). Multivariable regression models were used to examine the relationship between lymphedema with predictors and symptoms., Results: Of the 203 patients included, 88 (43.4%) developed post-treatment lymphedema. In multivariable analysis, pre-treatment Body Mass Index (BMI) (odds ratio [OR] = 1.07, 95% confidence interval [CI] [1.01, 1.14] p = 0.016) and N stage (OR = 1.96, 95% CI [1.06, 3.66], p = 0.032) were found to be independently associated with lymphedema. Regarding PROs, lymphedema was associated with greater swallowing dysfunction (3.48, 95% CI [0.20, 6.75], p = 0.038), decreased mouth opening (-3.70, 95% CI [-7.31, -0.10], p = 0.044), and increased fatigue (1.88, 95% CI [1.05, 3.38], p = 0.034)., Conclusion: Higher pre-treatment BMI and greater N stage are identified as independent predictors for lymphedema development in non-operative HNC patients. Additionally, patients experiencing lymphedema reported worsening swallowing dysfunction and increased symptoms related to trismus and fatigue. Recognizing patients at elevated risk for lymphedema allows for early intervention, alleviation of symptom burden, and optimization of health care resources., Level of Evidence: 4 Laryngoscope, 134:3656-3663, 2024., (© 2024 The Authors. The Laryngoscope published by Wiley Periodicals LLC on behalf of The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: Sentinel lymph node (SLN) mapping is a surgical technique with high accuracy in detecting metastases while limiting morbidity associated with full lymphadenectomy in endometrial cancer. Cervical injection of indocyanine green (ICG) dye is associated with very high SLN detection rates; however, iodinated contrast allergy has traditionally been viewed as a contraindication to ICG use. The objective of this study was to describe the use of ICG in a population of patients with iodinated contrast allergies undergoing surgical staging for endometrial cancer., Methods: IRB approval was obtained. All patients with clinically early-stage endometrial cancer who underwent minimally invasive surgical staging with SLN mapping with ICG at a single academic institution from 1/1/2017 to 12/31/2020 were identified retrospectively. Patients with reported iodinated contrast allergies prior to surgery were identified. Data were collected through electronic medical record review and compared using descriptive statistics., Results: 820 patients who underwent minimally invasive surgical staging with SLN mapping with ICG were identified, and 25 had documented iodinated contrast allergies. Documented reactions included rash/hives (n = 10, 40 %), anaphylaxis (n = 6, 24 %), shortness of breath (n = 5, 20 %), diarrhea (n = 1, 4 %), and not specified (n = 3, 12 %). A majority (24/25, 96 %) received 4 mg intravenous dexamethasone during induction of general anesthesia as per the institutional enhanced recovery after surgery (ERAS) protocol. No patients experienced allergic reactions or other adverse events after ICG injection., Conclusions: No patients in this cohort demonstrated an adverse reaction after ICG injection for SLN mapping. This study supports the reasonable safety of ICG in patients with contrast allergies, particularly when routine ERAS protocols containing dexamethasone are utilized., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors. Published by Elsevier Inc.)

Importance: Socioeconomic deprivation is associated with increased risk of poor health and quality-of-life (QOL) outcomes in head and neck cancer (HNC) survivors. However, there are few data on how neighborhood deprivation affects patient-reported outcome measures (PROMs) in HNC survivors., Objective: To investigate whether neighborhood socioeconomic deprivation is associated with symptom burden, psychological distress, and QOL among HNC survivors., Design, Setting, and Participants: This cross-sectional study used prospectively collected data from patients seen in a university-affiliated multidisciplinary HNC survivorship clinic between September 2018 and September 2021 who received radiotherapy for squamous cell carcinoma of the oral cavity, oropharynx, and larynx or hypopharynx., Exposure: Neighborhood socioeconomic deprivation, measured using the Area Deprivation Index (ADI)., Main Outcomes and Measures: The PROMs pertaining to symptom burden and severity of psychological distress were measured using the Neck Disability Index, Insomnia Severity Index, the 10-item Eating Assessment Tool, the Generalized Anxiety Disorder 7-item scale, and the 8-item Patient Health Questionnaire. Physical and social-emotional QOL were obtained using the University of Washington QOL questionnaire. Multivariable linear regression analysis adjusting for individual-level sociodemographic, comorbidity, and treatment characteristics investigated the association between ADI and PROMs. A subgroup analysis was performed to compare the lowest (most affluent areas: ADI, 0%-20%) and highest (most deprived areas: ADI, 80%-100%) ADI quintiles., Results: A total of 277 patients were included in the final analysis (mean [SD] age, 64.18 [9.60] years; 215 [77.6%] male). Cancer sites were the oral cavity (52 [18.8%]), oropharyngeal area (171 [61.7%]), and larynx or hypopharynx (54 [19.5%]). Multivariable analysis showed that for every 1-point increase in ADI, social-emotional QOL changed by -0.14 points (95% CI, -0.24 to -0.05 points), anxiety increased by 0.03 points (95% CI, 0.01-0.06 points), and neck disability worsened by 0.05 points (95% CI, 0.01-0.10 points). Compared with patients in the most affluent areas, those in the most deprived areas had significantly lower physical (-15.89 points; 95% CI, -25.96 to -2.31 points; Cohen d = -0.83) and social-emotional (-13.57 points; 95% CI, -22.79 to -3.49 points; Cohen d = -0.69) QOL and higher depression (2.60 points; 95% CI, 0.21-4.40 points; Cohen d = 0.52), anxiety (3.12 points; 95% CI, 1.56-4.66 points; Cohen d = 0.61), insomnia (3.55 points; 95% CI, 0.33-6.41 points; Cohen d = 0.54), and neck disability (5.65 points; 95% CI, 1.66-9.55 points; Cohen d = 0.66) scores., Conclusions and Relevance: In this cross-sectional study, a higher ADI score was associated with higher risk of increased psychological distress, higher symptom burden, and decreased QOL after treatment among HNC survivors. These findings suggest that proactive, patient-centered interventions are needed to address these disparities.

Background: Patients undergoing postoncologic breast reconstruction can experience upper extremity (UE) functional deficits., Objectives: In this study, we utilized the disabilities of the arm, shoulder, and hand (DASH) questionnaire to identify patient factors that impacted UE functional recovery., Methods: Patients who underwent oncologic followed by reconstructive surgery by a single surgeon from 2014 to 2019 and completed the DASH survey were included. A DASH score was calculated for each patient, with values ranging from 0 (no impairment) to 100 (severe impairment). Regression analysis was conducted to identify significant predictors for DASH score with a significance level for entry and stay set at P = .15., Results: Among 289 patients who underwent breast reconstruction, 157 completed the questionnaire. The average patient age was 52.6yrs ± 8.6 at the time of reconstruction. A total of 111 had implant-based reconstruction, 15 had autologous reconstruction, and 24 had a combination of both. Average DASH score was 7.7 (range 0.0-52.5), with 74.1% of patients having a score greater than 0. Regression analysis showed 5 variables associated with significantly higher DASH scores: age between 50 and 60 years (P = .13), history of radiation (P = .01), placement of a subpectoral implant (P = .06), postoperative complications (P = .10), and lymphedema (P < .01). Autologous breast reconstruction (P = .04) was associated with a significantly lower DASH score., Conclusions: Implant-based reconstruction, radiation history, postoperative complications, and age at reconstruction were associated with increased UE functional impairment in patients who underwent breast reconstructive surgery. Identification of these factors can inform areas for potential practice changes and improve patient counseling regarding postoperative expectations., (© The Author(s) 2023. Published by Oxford University Press on behalf of The Aesthetic Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: The war metaphor is one strategy used frequently in breast cancer to inspire individuals in a "fight" against cancer and assist patients in navigating their illness experience. Despite prominent use, the emotional impact of this language has not been examined in the context of meaning making among women with metastatic breast cancer (MBC)., Methods: This study involved a semi-structured interview considering the war metaphor's impact on women's illness experience with MBC. Participants (n = 22) had been diagnosed with MBC for at least 6 months or following 1 disease progression and were undergoing treatment at an NCI-designated cancer center in Western Pennsylvania at the time of interview. Each participant underwent an individual interview exploring the war metaphor's impact on illness experience. Qualitative thematic analysis was performed to assess feelings about the war metaphor and emotional response to the lived experience of cancer., Results: Two themes were identified surrounding metaphor use and participants' experiences with meaning making in cancer. First, women with MBC perceive the diagnosis as an "unfair fight" due to its incurable nature. Second, patients use alternative language of "living life" and communicate resistance to being defined by their cancer diagnosis., Conclusion: War metaphors are one collection of terminology people use to understand their diagnosis. However, their use may apply pressure to prioritize positivity in the face of diagnosis and treatment, in a unique clinical context where this may not be adaptive. These findings affirm a need to consider patients' lived experiences to best facilitate psychological adjustment to illness., (© 2024. The Author(s).)

Objectives  The aim of this study was to determine the clinical characteristics and cephalometric risk factors associated with decreased postoperative olfaction in patients in whom the transplanum and transtuberculum expanded endonasal approach (EEA) was performed. Methods  A retrospective cohort of 41 patients treated with the transplanum and transtuberculum EEA was divided into two groups based on the maximum change in the postoperative 22-item Sino-Nasal Outcome Test (SNOT22) olfaction score: prolonged olfactory loss group ( n  = 5) with a ΔSNOT22 olfaction score of ≥ 4 without a return to baseline and a preserved olfaction group ( n  = 36) with a ΔSNOT22 olfaction score ≤ 3 with return to baseline on follow-up of at least 3 months. Demographics, operative details, and cephalometric measurements were compared between the two groups. Results  There were no differences in terms of the type of surgical approach (transplanum and transtuberculum), resection of turbinates (middle and superior), use of reconstructive flap (nasoseptal flap and reverse flap), or tumor pathology between the two groups. In the prolonged olfactory loss group, there was a smaller angle between the planum and the face of the sella (89.75 ± 9.18 vs. 107.17 ± 16.57 degrees, p  = 0.05) and a smaller angle between the anterior nasal spine and the sphenoid sinus face (21.20 ± 2.49 vs. 25.89 ± 4.90 degrees, p  = 0.047) compared with the preserved olfaction group. Conclusion  Patients with a narrow angle between the planum and the face of the sella or that between the anterior nasal spine and the sphenoid sinus face are at a higher risk of prolonged olfactory dysfunction with the transplanum and transtuberculum approaches. Level of Evidence  IV., Competing Interests: Conflict of Interest None declared., (Thieme. All rights reserved.)

Purpose: Benign phyllodes tumors (BPT) are rare breast neoplasms with clinical behavior that poses low recurrence risk. Guidelines regarding appropriate margins recommend surgical excision to negative margins, sometimes requiring re-excision surgery. Contemporary experience suggests that re-excision in the face of positive margins may not be needed., Methods: This is a retrospective review of a single-institution experience with BPT from 2010 to 2019 with 102 patients. Demographics, outcomes and follow-up were analyzed., Results: The median age was 37 years. 95% had a pre-operative biopsy and only 6% were confirmed BPT before surgery.56% had positive margins and were more likely to be younger and have a pre-operative diagnosis of fibroadenoma. The median follow-up was 33 months. Between the positive and negative margin groups, recurrence rates were not significantly different (p = 0.87)., Conclusion: Positive margins on excision of BPT poses a low recurrence risk and re-excision surgery is not necessary., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Maladaptive repair after AKI may lead to progressive fibrosis and decline in kidney function. Sphingosine 1-phosphate has an important role in kidney injury and pleiotropic effects in fibrosis. We investigated the involvement of sphingosine kinase 1 and 2 (SphK1 and SphK2), which phosphorylate sphingosine to produce sphingosine 1-phosphate, in kidney fibrosis induced by folic acid (FA) or unilateral ischemia-reperfusion injury. Analysis of Masson trichrome staining and fibrotic marker protein and mRNA expression 14 days after AKI revealed that wild-type (WT) and Sphk1 -/- mice exhibited more kidney fibrosis than Sphk2 -/- mice. Furthermore, kidneys of FA-treated WT and Sphk1 -/- mice had greater immune cell infiltration and expression of fibrotic and inflammatory markers than kidneys of FA-treated Sphk2 -/- mice. In contrast, kidneys of Sphk2 -/- mice exhibited greater expression of Ifng and IFN- γ -responsive genes ( Cxcl9 and Cxcl10 ) than kidneys of WT or Sphk1 -/- mice did at this time point. Splenic T cells from untreated Sphk2 -/- mice were hyperproliferative and produced more IFN- γ than did those of WT or Sphk1 -/- mice. IFN- γ blocking antibody administered to Sphk2 -/- mice or deletion of Ifng ( Sphk2 -/- Ifng -/- mice) blocked the protective effect of SphK2 deficiency in fibrosis. Moreover, adoptive transfer of Sphk2 -/- (but not Sphk2 -/- Ifng -/- ) CD4 T cells into WT mice blocked FA-induced fibrosis. Finally, a selective SphK2 inhibitor blocked FA-induced kidney fibrosis in WT mice. These studies demonstrate that SphK2 inhibition may serve as a novel therapeutic approach for attenuating kidney fibrosis., (Copyright © 2017 by the American Society of Nephrology.)

On 29 June 2015, Liberia's respite from Ebola virus disease (EVD) was interrupted for the second time by a renewed outbreak ("flare-up") of seven confirmed cases. We demonstrate that, similar to the March 2015 flare-up associated with sexual transmission, this new flare-up was a reemergence of a Liberian transmission chain originating from a persistently infected source rather than a reintroduction from a reservoir or a neighboring country with active transmission. Although distinct, Ebola virus (EBOV) genomes from both flare-ups exhibit significantly low genetic divergence, indicating a reduced rate of EBOV evolution during persistent infection. Using this rate of change as a signature, we identified two additional EVD clusters that possibly arose from persistently infected sources. These findings highlight the risk of EVD flare-ups even after an outbreak is declared over.