Static and dynamic stress heterogeneity in a multiscale model of the asthmatic airway wall.

Airway hyper-responsiveness (AHR) is a key characteristic of asthma that remains poorly understood. Tidal breathing and deep inspiration ordinarily cause rapid relaxation of airway smooth muscle(ASM) (as demonstrated via application of length fluctuations to tissue strips) and are therefore implicated in modulation of AHR, but in some cases (such as application of transmural pressure oscillations to isolated intact airways) this mechanism fails. Here we use a multiscale biomechanical model for intact airways, that incorporates strain-stiffening due to collagen recruitment and dynamic force generation by ASM cells, to show that the geometry of the airway, together with interplay between dynamic active and passive forces, give rise to large stress and compliance heterogeneities across the airway wall that are absent in tissue strips. We show further that these stress heterogeneities result in auxotonic loading conditions that are currently not replicated in tissue-strip experiments; stresses in the strip are similar to hoop stress only at the outer airway wall and are under- or over-estimates of stresses at the lumen. Taken together these results suggest that a previously underappreciated factor - stress heterogeneities within the airway wall and consequent ASM cellular response to this micromechanical environment - could contribute to AHR and should be explored further both theoretically and experimentally.

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Age-induced oxidative stress: How does it influence skeletal muscle quantity and quality?

With advancing age, skeletal muscle function declines as a result of strength loss. These strength deficits are largely due to reductions in muscle size (i.e., quantity) and its intrinsic force producing capacity (i.e., quality). Age-induced reductions in skeletal muscle quantity and quality can be the consequence of several factors, including accumulation of reactive oxygen and nitrogen species (ROS/RNS), also known as oxidative stress. In old muscle, oxidative stress has the potential to reduce muscle quantity by shifting protein balance in a deficit, and muscle quality by impairing activation at the neuromuscular junction, excitation-contraction (EC) coupling at the ryanodine receptor (RyR) and cross-bridge cycling within the myofibrillar apparatus. Of these, EC coupling failure mediated by RyR dysfunction via oxidation and/or nitrosylation appears to be the strongest candidate based on the publications reviewed. However, it is clear that age-associated oxidative stress has the ability to alter strength through several mechanisms and at various locations of the muscle fiber.

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Effects of hypervolemia by protein and glucose supplementation during aerobic training on thermal and arterial pressure regulations in hypertensive older men

The incidence of heat illness in older people has rapidly increased during midsummer for the last decade in Japan, and we suggested that whey-protein + carbohydrate supplementation during aerobic training increased plasma volume (PV) to enhance thermoregulatory adaptation in older men (J Appl Physiol, 107: 725-733, 2009); however, >60% of people age 65 and older suffer from hypertension and the symptoms may be worsened by the hypervolemia. To examine this, we randomly divided 21 older men (~69 years) with ~160 mmHg for systolic and ~90 mmHg for diastolic blood pressure at rest into two groups; Glc (N=11) consuming glucose alone (25g) and Pro-Glc (N=10) consuming whey-protein (10g) + glucose (15g), immediately after cycling exercise at 60-75% of peak aerobic capacity (VO_2peak) for 60 min·day^-1, 3 days·week^-1, for 8 weeks. Before and after training, we measured PV (dye dilution), baroreflex sensitivity (BRS) of heart rate (Valsalva maneuver), and carotid arterial compliance (CAC) from carotid arterial diameter (ultrasound imaging) responses to pulsatile arterial pressure change (photoplethysmography) at rest. Additionally, we measured esophageal temperature (T_es) and forearm skin blood flow (plethysmography) during exercise at 60% pre-training VO_2peak for 20 min in a warm environment. We found that the forearm skin vascular conductance response to increased T_es was enhanced in Pro-Glc with increased PV, but this was not found in Glc; however, despite the increased PV, arterial blood pressures rather decreased with increased CAC and BRS in Pro-Glc. Thus, the prescription was applicable to older men with hypertension to prevent heat illness during exercise.

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Alcohol Breath Test: Gas Exchange Issues

The alcohol breath test is reviewed with a focus on gas exchange factors affecting its accuracy. The basis of the alcohol breath test is the assumption that alveolar air reaches the mouth during exhalation with no change in alcohol concentration. Recent investigations have shown that alcohol concentration is altered during its transit to the mouth. The exhaled alcohol concentration is modified by interaction with the mucosa of the pulmonary airways. Exhaled alcohol concentration is not an accurate indicator of alveolar alcohol concentration. Measuring alcohol concentration in the breath is very different process than measuring a blood level from air equilibrated with a blood sample. Airway exchange of alcohol leads to a bias against certain individuals depending on the anatomic and physiologic characteristics. Methodological modifications are proposed to improve the accuracy of the alcohol breath test to become fair to all.

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Separate and combined effects of a 10-d exposure to hypoxia and inactivity on oxidative function in vivo and mitochondrial respiration ex vivo in humans.

An integrative evaluation of oxidative metabolism was carried out in 9 healthy young men (age: 24.1±1.7 years [mean±SD]) prior to (CTRL) and following a 10-day horizontal bed rest, carried out in normoxia (N-BR) or hypoxia (F_IO₂=0.147; H-BR). H-BR was aimed to simulate planetary habitats. Pulmonary O₂ uptake (V'O₂) and vastus lateralis fractional O₂ extraction (changes in deoxygenated hemoglobin+myoglobin concentration, [deoxy(Hb+Mb)]; near-infrared spectroscopy) were evaluated, in normoxia, during an incremental cycle ergometer exercise (CE) and one-leg knee extension exercise (KE) (aimed at reducing cardiovascular constraints to oxidative function). Mitochondrial respiration was evaluated ex vivo by high-resolution respirometry in permeabilized vastus lateralis fibers. During CE V'O₂peak and [deoxy(Hb+Mb)]peak were lower (P<0.05) after both N-BR and H-BR vs. CTRL; during KE the variables were lower after N-BR, but not after H-BR. During CE the "overshoot" of [deoxy(Hb+Mb)] during constant work rate exercise was greater in N-BR and H-BR vs. CTRL, whereas during KE a significant difference vs. CTRL was observed only after N-BR. Maximal mitochondrial respiration determined ex vivo was not affected by both interventions. In N-BR, a significant impairment of oxidative metabolism occurred downstream of central cardiovascular O₂ delivery and upstream of mitochondrial function, possibly at the level of the intramuscular matching between O₂ supply and utilization (see the [deoxy(Hb+Mb)] overshoot) and peripheral O₂ diffusion. Superposition of H on BR did not aggravate, and partially reversed, the impairment of muscle oxidative function in vivo induced by BR. The effects of longer exposures will have to be determined.

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Role of histidyl dipeptides in contractile function of fast and slow motor units in rat skeletal muscle

The physiological role of the muscle histidyl dipeptides carnosine and anserine in contractile function of various types of muscle fibres in vivo is poorly understood. Ten adult male Wistar rats were randomly assigned to two groups: control and supplemented for 10 weeks with beta-alanine, the precursor of carnosine (~640 mg/kg BW/day). Thereafter, contractile properties and fatigability of isolated fast fatigable (FF), fast resistant to fatigue (FR), and slow motor units (MUs) from the medial gastrocnemius were determined in deeply anaesthetized animals. The fatigue resistance was tested with a 40 Hz fatigue protocol followed by a second protocol at 40 Hz in fast and 20 Hz in slow units. In the supplemented rats, histidyl dipeptide concentrations significantly increased (P < 0.05) by 25% in the red portion of the gastrocnemius and carnosine increased by 94% in the white portion. The twitch force of FF units and maximum tetanic force of FR units were significantly increased (P < 0.05) and the half-relaxation time was prolonged in slow units (P < 0.05). FF units showed less fatigue during the first 10 s and FR units between 10 and 60 s during the 40 Hz fatigue test. In slow units, forces declined less during the first 60 s of the 20 Hz test. In conclusion, this in vivo experiment demonstrates that an elevation in muscle histidyl dipeptide content elicits beneficial changes in MU contractile characteristics and fatigue resistance. Carnosine and anserine seem to play an important yet divergent role in various MUs.

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Age-induced oxidative stress: How does it influence skeletal muscle quantity and quality?

With advancing age, skeletal muscle function declines as a result of strength loss. These strength deficits are largely due to reductions in muscle size (i.e., quantity) and its intrinsic force producing capacity (i.e., quality). Age-induced reductions in skeletal muscle quantity and quality can be the consequence of several factors, including accumulation of reactive oxygen and nitrogen species (ROS/RNS), also known as oxidative stress. In old muscle, oxidative stress has the potential to reduce muscle quantity by shifting protein balance in a deficit, and muscle quality by impairing activation at the neuromuscular junction, excitation-contraction (EC) coupling at the ryanodine receptor (RyR) and cross-bridge cycling within the myofibrillar apparatus. Of these, EC coupling failure mediated by RyR dysfunction via oxidation and/or nitrosylation appears to be the strongest candidate based on the publications reviewed. However, it is clear that age-associated oxidative stress has the ability to alter strength through several mechanisms and at various locations of the muscle fiber.

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How does an airway and subsequently the lung become hyperresponsive?

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Static and dynamic stress heterogeneity in a multiscale model of the asthmatic airway wall.

Airway hyper-responsiveness (AHR) is a key characteristic of asthma that remains poorly understood. Tidal breathing and deep inspiration ordinarily cause rapid relaxation of airway smooth muscle(ASM) (as demonstrated via application of length fluctuations to tissue strips) and are therefore implicated in modulation of AHR, but in some cases (such as application of transmural pressure oscillations to isolated intact airways) this mechanism fails. Here we use a multiscale biomechanical model for intact airways, that incorporates strain-stiffening due to collagen recruitment and dynamic force generation by ASM cells, to show that the geometry of the airway, together with interplay between dynamic active and passive forces, give rise to large stress and compliance heterogeneities across the airway wall that are absent in tissue strips. We show further that these stress heterogeneities result in auxotonic loading conditions that are currently not replicated in tissue-strip experiments; stresses in the strip are similar to hoop stress only at the outer airway wall and are under- or over-estimates of stresses at the lumen. Taken together these results suggest that a previously underappreciated factor - stress heterogeneities within the airway wall and consequent ASM cellular response to this micromechanical environment - could contribute to AHR and should be explored further both theoretically and experimentally.

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Exercise-induced endothelial progenitor cell mobilization is attenuated in impaired glucose tolerance and type 2 diabetes

Circulating endothelial progenitor cells (EPCs) contribute to vascular homeostasis and are fewer in those with type 2 diabetes mellitus (T2DM) compared with normal glucose tolerance (NGT), suggesting a link between EPCs and T2DM-associated vasculopathies. The purpose of this study was to assess EPC number and mobilization by acute submaximal exercise in older adults with NGT, impaired glucose tolerance (IGT) or T2DM. We tested the hypothesis that EPC mobilization is lower in IGT compared with NGT and further reduced in older adults with T2DM. Forty-five older (50-75 years of age) men and women with NGT (n=18), IGT (n=10), or T2DM (n=17) were characterized and underwent submaximal aerobic exercise tests with blood sampling for enumeration of vascular endothelial growth factor receptor 2+ (VEGFR2+) cells, CD34+ hematopoetic progenitor cells, and CD34+/VEGFR2+ EPCs by flow cytometry before and after exercise. Basal EPC number was 65% and 61% lower in the IGT and T2DM groups, respectively, compared with the NGT group (P<0.05). EPC number increased 23% after acute exercise in the NGT group (P<0.01), but did not change in the IGT or T2DMgroups. Before and after exercise, VEGFR2+ cell number was lower in a stepwise manner across the NGT, IGT and T2DM groups (P<0.05). Basal CD34+ cell number was lower in the IGT group compared with NGT (P<0.05), but did not change after exercise in any group. These findings suggest a CD34+/VEGFR2+ EPC mobilization defect in IGT and T2DM that could play a role in the cardiovascular diseases and capillary rarefaction associated with insulin resistance.

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Surgical Clinician Development in Otolaryngology Residency

Surgical Clinician Development in Otolaryngology Residency:

An educational curriculum that produces competent clinicians is the cornerstone of all residency training programs. The development of this clinical expertise has many components. Some, such as knowledge acquisition, technical expertise, and experience, are more tangible and measurable. Others, such as clinical judgment and critical thinking, are more enigmatic and yet equally if not more important. The challenge of how to teach these less tangible attributes has confounded medical educators since Hippocrates and continues to do so. Lacking better definition, we as educators tend to rely on a "we know it when we see it" method of assessing our trainees' progress in their acquisition. In general, there tends to be agreement among the faculty about resident expertise at the extremes: the residents we know will to do the right thing regardless of their level of training and the residents whose clinical decision-making we have difficulty trusting despite an adequate knowledge base. Sorting out the residents in between and defining the specific issues are that are impeding their progress along the clinical continuum is more difficult. To do better we need to be develop valid methods for measuring these "less tangible" qualities.

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Pediatric Tertiary Care Admission Practices After Adenotonsillectomy

Pediatric Tertiary Care Admission Practices After Adenotonsillectomy: This survey study assesses current group practice patterns associated with the perioperative care of children undergoing adenotonsillectomy at tertiary care children's hospitals following the release of the 2011 American Academy of Otolaryngology–Head and Neck Surgery clinical practice guidelines.

Importance  Pediatric adenotonsillectomy is a frequently performed procedure. Few studies have examined perioperative practice patterns for children undergoing adenotonsillectomy.

Objective  To assess current group practice patterns associated with the perioperative care of children undergoing adenotonsillectomy for sleep-disordered breathing at tertiary care children's hospitals following the release of the 2011 American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) clinical practice guidelines.

Design, Setting, and Participants  A cross-sectional survey was distributed to the chiefs of 72 pediatric otolaryngology divisions at tertiary care children's hospitals in the United States and Canada from March 25 to April 16, 2014.

Main Outcomes and Measures  Internet-based survey responses from the chiefs of pediatric otolaryngology at tertiary care children's hospitals in the United States and Canada, who responded regarding group, rather than individual, practices.

Results  Of the 72 surveys sent, 48 responses (67%) were received. Twenty-one respondents (44%) reported that their group has no official admission policy for children with sleep-disordered breathing. Seventy-three percent (29 of 40) reported using some measure of obesity as a criterion for postoperative admission. The AAO-HNS polysomnography criteria for severe obstructive sleep apnea were used by 40% of respondents (16 of 40) as admission criteria, whereas 15% (6 of 40) used the American Academy of Pediatrics criteria for severe obstructive sleep apnea. Seventy-three percent (29 of 40) reported requiring a child to be asleep while breathing room air without oxygen desaturation before discharge to home. An established minimum time for observation was reported by 43 of the respondents (90%). Institution size or volume of adenotonsillectomies performed did not affect the results.

Conclusions and Relevance  Many tertiary care children's hospitals in the United States do not have an official admission policy to guide adenotonsillectomy care. Even for institutions that do have an official admission policy, the policies are not universally aligned with the AAO-HNS clinical practice guidelines. These survey results demonstrate an opportunity to improve quality and safety regarding admission policy practice patterns after pediatric adenotonsillectomy.

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19.9% incidence of Complications Following Pediatric Tracheotomy

Complications Following Pediatric Tracheotomy: This 13-year medical record review identifies the type and rate of complications arising from pediatric tracheotomy.

Importance  Pediatric tracheotomy is a complex procedure with significant postoperative complications. Wound-related complications are increasingly reported and can have considerable impact on clinical course and health care costs to tracheotomy-dependent children.

Objective  The primary objective of this study was to identify the type and rate of complications arising from pediatric tracheotomy.

Design, Setting, and Participants  A retrospective review of medical records of 302 children who underwent tracheotomy between December 1, 2000, and February 28, 2014, at a tertiary care pediatric referral center. Records were reviewed for preoperative diagnoses, gestational age, age at tracheotomy, tracheotomy technique, and incidence of complication.

Main Outcomes and Measures  Main outcome measures included incidence, type, and timing of complications. Secondary measures included medical diagnoses and surgical technique.

Results  Of the 302 children who underwent tracheotomy, the median (SD) age at time of tracheotomy was 5 months (64 months) and the range was birth to 21 years. The most frequent diagnosis associated with performance of a tracheotomy was ventilator-associated respiratory failure (61.9%), followed by airway anomaly or underdevelopment (25.2%), such as subglottic or tracheal stenosis, laryngotracheomalacia, or bronchopulmonary dysplasia. The remaining indications for tracheotomy included airway obstruction (11.6% [35 of 302]) and vocal fold dysfunction (1.3% [4 of 302]). No statistical significance was found associated with diagnosis and incidence of complications. Sixty children (19.9%) had a tracheotomy-related complication. Major complications, such as accidental decannulation (1.0% [3 of 302]). There were no deaths associated with tracheotomy. Minor complications, such as peristomal wound breakdown or granuloma (12.9% [39 of 302]) and bleeding from stoma (1.7% [5 of 302]), were more common. Of all complications, 70% (42 of 60) occurred early (≤7 days postoperatively) and 20% (12 of 60) were late (>7 days postoperatively).

Conclusions and Relevance  Pediatric tracheotomy at our institution is associated with an overall 19.9% incidence of complications. Although the rate of major complications such as accidental decannulation or death is low, rates of peristomal skin breakdown and development of granuloma are more frequently reported and can occur at any point following tracheotomy. Further work is necessary to understand and mitigate wound care issues in post-tracheotomy care.

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Intratympanic Ciprofloxacin in Tympanostomy Tube Placement

Intratympanic Ciprofloxacin in Tympanostomy Tube Placement: These 2 randomized clinical trials investigate the safety and efficacy of a single-dose intratympanic, intraoperative, extended-release, thermosensitive, otic suspension of ciprofloxacin administered to children undergoing tympanostomy tube placement.

Importance  Otorrhea after tympanostomy tube placement (TTP) in children is common. Although not approved by the US Food and Drug Administration, antibiotic ear drops are routinely used intraoperatively and prescribed for multidose, multiday postoperative administration by caregivers.

Objective  To investigate the safety and efficacy of a single-dose intratympanic, intraoperative, thermosensitive, otic suspension of ciprofloxacin (OTO-201) in children requiring TTP.

Design, Setting, and Participants  Two identically designed, prospective, double-blind, sham-controlled, multicenter phase 3 randomized clinical trials included 532 patients aged 6 months to 17 years with middle ear effusions. Patients with confirmed bilateral effusions on the day of TTP were randomized to TTP alone or to TTP with OTO-201 injection. Children underwent a 28-day observation period. Data were collected from November 14, 2013, to June 3, 2014. Final follow-up was completed on June 16, 2014, and intent-to-treat data were analyzed from June 10 to August 27, 2014.

Main Outcomes and Measures  Efficacy was assessed as treatment failure, including the presence of otorrhea, use of otic or systemic antibiotics, loss to follow-up, or missed visits. Safety was assessed for serious adverse events and treatment-emergent adverse events using audiometry, otoscopy, and tympanometry.

Results  Among the 532 patients included in the trials, 175 were randomized to TTP only and 357 to OTO-201 treatment (304 boys [57.1%]; 228 girls [42.9%]; mean [SD] age, 2.4 [2.1]). At day 15, the cumulative proportion of treatment failures (primary end point) was 24.6% (44 of 179 patients) in trial 1 and 21.3% (38 of 178 patients) in trial 2 in the OTO-201 groups vs 44.8% (39 of 87 patients) in trial 1 and 45.5% (40 of 88 patients) in trial 2 in the TTP-alone groups. At day 15 otorrhea-only treatment failures in trial 1 included 21 of 179 (11.7%) in the OTO-201 group vs 22 of 87 (25.3%) in the TTP-only group; in trial 2, 17 of 178 (9.6%) in the OTO-201 group vs 29 of 88 (33.0%) in the TTP-only group. The odds of otorrhea-only failure were significantly reduced in the OTO-201 groups compared with the TTP-only groups in both trials (age-adjusted odds ratios, 0.38 [95% CI, 0.19-0.75] and 0.19 [95% CI, 0.09-0.38]; P < .001 for both trials, post hoc analysis). No drug-related serious adverse events were seen, and most adverse events were mild or moderate. No evidence of increased tube occlusion and no negative effect on results of audiometry, tympanometry, or otoscopy were noted with OTO-201 administration.

Conclusions and Relevance  Two large phase 3 randomized clinical trials demonstrate the safety and efficacy of a single intraoperative administration of OTO-201 for middle ear effusion at the time of TTP.

Trial Registration  clinicaltrials.gov Identifiers: NCT01949142 and NCT01949155

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Coblation Endoscopic Lingual Lightening for Obstructive Sleep Apnea

Coblation Endoscopic Lingual Lightening for Obstructive Sleep Apnea: This retrospective case-control study evaluates the clinical and polysomnographic outcomes of tongue base reduction using the coblation endoscopic lingual lightening procedure in multilevel surgery for obstructive sleep apnea.

Importance  Multilevel obstruction is involved in the pathogenesis of obstructive sleep apnea (OSA). Coblation endoscopic lingual lightening (CELL) is a variation of glossectomy to reduce tongue collapse and can be considered in the surgical management of adults with OSA.

Objective  To evaluate the clinical and polysomnographic outcomes of tongue base reduction using CELL in multilevel surgery for OSA.

Design, Setting, and Participants  A retrospective case-control study was performed to review the medical records of adults with OSA (apnea-hypopnea index [AHI], >20) and Friedman stage III (tongue position III and tonsil size I-II) who underwent combined CELL and relocation pharyngoplasty (group 1) or relocation pharyngoplasty alone (group 2) for OSA between January 1, 2012, and December 31, 2013, at a tertiary referral sleep center. The groups were matched by age, sex, body mass index, and AHI at baseline. The dates of the analysis were May 30 to June 29, 2014.

Intervention  Coblation endoscopic lingual lightening.

Main Outcomes and Measures Methods  The primary outcome measure was change in AHI after surgery (after ≥6 months). Other outcomes were differences in surgical response rates, perioperative apnea index, lowest oxygen saturation, and Epworth Sleepiness Scale score.

Results  The study cohort comprised 90 participants. Their mean (SD) age was 40.7 (9.2) years, and 96% (86 of 90) were male. Group 1 patients (n = 30) underwent combined CELL and relocation pharyngoplasty, and group 2 patients (n = 60) underwent relocation pharyngoplasty only. The mean (SD) AHI decreased from 48.4 (16.9) to 16.5 (11.2) (P < .001) in group 1 and from 44.2 (19.3) to 20.1 (15.6) (P < .001) in group 2 . Percentage change in AHI was significantly different between group 1 and group 2 (mean [SD], −65.5 [20.5] vs −53.2 [30.3]) (P = .047). The surgical response rate was greater in group 1 (73% [22 of 30]) than in group 2 (50% [30 of 60]) (P = .04).

Conclusions and Relevance  Without increasing complications, combined CELL and relocation pharyngoplasty achieved greater AHI reduction and a higher surgical response rate among adults with OSA and Friedman stage III compared with relocation pharyngoplasty alone.

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Supraglottic Mass

Supraglottic Mass:

A man in his 50s had a globus sensation in the throat and a 6-month history of throat pain; a CT scan of the neck revealed a submucosal hypodense supraglottic mass on the right side that was compressing the airway, and S100 protein immunostaining was positive. What is your diagnosis?

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Oral Cavity Squamous Cell Carcinoma

Quality Metrics and Survival in Oral Cavity Squamous Cell Carcinoma: This cohort study examines whether compliance with various process-related quality metrics is associated with improved survival in patients with oral cavity squamous cell carcinoma who receive definitive surgery with or without adjuvant therapy.

Importance  Quality metrics for patients with head and neck cancer are available, but it is unknown whether compliance with these metrics is associated with improved patient survival.

Objective  To identify whether compliance with various process-related quality metrics is associated with improved survival in patients with oral cavity squamous cell carcinoma who receive definitive surgery with or without adjuvant therapy.

Design, Setting, and Participants  A retrospective cohort study was conducted at a tertiary academic medical center among 192 patients with previously untreated oral cavity squamous cell carcinoma who underwent definitive surgery with or without adjuvant therapy between January 1, 2003, and December 31, 2010. Data analysis was performed from January 26 to August 7, 2015.

Interventions  Surgery with or without adjuvant therapy.

Main Outcomes and Measures  Compliance with a collection of process-related quality metrics possessing face validity that covered pretreatment evaluation, treatment, and posttreatment surveillance was evaluated. Association between compliance with these quality metrics and overall survival, disease-specific survival, and disease-free survival was calculated using univariable and multivariable Cox proportional hazards analysis.

Results  Among 192 patients, compliance with the individual quality metrics ranged from 19.7% to 93.6% (median, 82.8%). No pretreatment or surveillance metrics were associated with improved survival. Compliance with the following treatment-related quality metrics was associated with improved survival: elective neck dissection with lymph node yield of 18 or more, no unplanned surgery within 14 days of the index surgery, no unplanned 30-day readmissions, and referral for adjuvant radiotherapy for pathologic stage III or IV disease. Increased compliance with a "clinical care signature" composed of these 4 metrics was associated with improved overall survival, disease-specific survival, and disease-free survival on univariable analysis (log-rank test; P < .05 for each). On multivariable analysis controlling for pT stage, pN stage, extracapsular spread, margin status, and comorbidity, increased compliance with these 4 metrics was associated with improved overall survival (100% vs ≤50% compliance: adjusted hazard ratio [aHR], 4.2; 95% CI, 2.1-8.5; 100% vs 51%-99% compliance: aHR, 1.7; 95% CI, 1.0-3.1), improved disease-specific survival (100% vs ≤50% compliance: aHR, 3.9; 95% CI, 1.7-9.0; 100% vs 51%-99%: aHR, 1.3; 95% CI, 0.6-2.9), and improved disease-free survival (100% vs ≤50% compliance: aHR, 3.0; 95% CI, 1.5-5.8; 100% vs 51%-99% compliance: aHR, 1.6; 95% CI, 0.9-2.7).

Conclusions and Relevance  Compliance with a core set of process-related quality metrics was associated with improved survival for patients with surgically managed oral cavity squamous cell carcinoma. Multi-institutional validation of these metrics is warranted.

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Salivary Duct Carcinoma

A 20-Year Review of 75 Cases of Salivary Duct Carcinoma: This retrospective cohort study reviews a single institution's experience with salivary duct carcinoma over a 20-year period, focusing on demographics, presentation, treatment, and outcome.

Importance  Salivary duct carcinoma is a rare, aggressive malignancy of the salivary glands. Owing to its rare nature, clinical data are limited, and only a few clinical studies comprise more than 50 patients.

Objective  To review the University of Pittsburgh Medical Center's experience with salivary duct carcinoma over a 20-year period, focusing on demographics, presentation, treatment, and outcome.

Design, Setting, and Participants  This investigation was a retrospective cohort study in a multihospital institution with tertiary referral. A pathology database was reviewed for all cases of histopathologically diagnosed salivary duct carcinoma from January 1, 1995, to October 20, 2014. Patients who were referrals for pathology review only and were never seen at the institution were excluded. In total, 75 study patients were identified. The electronic medical record was reviewed for details regarding demographics, presentation, treatment, and outcome, including overall survival (OS) and disease-free survival (DFS). This study was supplemented with a review of the institution's Head and Neck Oncology Database for further clinical details.

Main Outcomes and Measures  Primary outcome measures consisted of OS and DFS.

Results  The study sample comprised 75 participants with a mean age at diagnosis of 66.0 years (age range, 33-93 years), and 29% (n = 22) were female. Most primary tumors were from the parotid gland (83%), with the next most frequent site being the submandibular gland (12%). Overall, 41% of the cases were carcinoma ex pleomorphic adenoma. Rates of other histologic features included the following: perineural invasion (69%), extracapsular spread (58%), ERBB2 (formerly HER2) positivity (31%) (62% of those who were tested), and vascular invasion (61%). The median OS was 3.1 years, and the median DFS was 2.7 years. Univariate Kaplan-Meier survival analyses demonstrated that facial nerve sacrifice and extracapsular spread were associated with lower OS (2.38 vs 5.11 years and 2.29 vs 6.56 years, respectively) and DFS (2.4 vs 3.88 years and 1.44 vs 4.5 years, respectively). Although underpowered, multivariable analysis demonstrated significantly worse OS in patients with N2 and N3 disease (hazard ratio [HR] 8.42, 95% CI, 1.84-38.5) but did not show significantly worse DFS or OS for facial nerve sacrifice or extracapsular spread. There was no association between ERBB2 positivity and survival and no difference in survival between patients receiving radiation therapy vs radiation therapy plus chemotherapy. No patients had recurrence or distant metastasis after 5 disease-free years.

Conclusions and Relevance  Salivary duct carcinoma is an aggressive disease. A large number of cases in this review were carcinoma ex pleomorphic adenoma and had classic negative prognostic indicators, such as perineural invasion, vascular invasion, and extracapsular spread.ERBB2 positivity was not associated with any difference in survival. Facial nerve involvement appears to indicate worse prognosis, as does nodal stage higher than N1. Recurrence and metastasis after 5 years are rare.

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Measuring Nontechnical Aspects of Surgical Clinician Development

Measuring Nontechnical Aspects of Surgical Clinician Development: This study evaluates use of the Clinical Practice Instrument, a validated tool to assess acquisition of nontechnical aspects of clinical practice ability to measure key diagnostic and treatment skills during residency training.

Importance  Surgical competency requires sound clinical judgment, a systematic diagnostic approach, and integration of a wide variety of nontechnical skills. This more complex aspect of clinician development has traditionally been difficult to measure through standard assessment methods.

Objective  This study was conducted to use the Clinical Practice Instrument (CPI) to measure nontechnical diagnostic and management skills during otolaryngology residency training; to determine whether there is demonstrable change in these skills between residents who are in postgraduate years (PGYs) 2, 4, and 5; and to evaluate whether results vary according to subspecialty topic or method of administration.

Design, Setting, and Participants  Prospective study using the CPI, an instrument with previously established internal consistency, reproducibility, interrater reliability, discriminant validity, and responsiveness to change, in an otolaryngology residency training program. The CPI was used to evaluate progression in residents' ability to evaluate, diagnose, and manage case-based clinical scenarios. A total of 248 evaluations were performed in 45 otolaryngology resident trainees at regular intervals. Analysis of variance with nesting and postestimation pairwise comparisons were used to evaluate total and domain scores according to training level, subspecialty topic, and method of administration.

Interventions  Longitudinal residency educational initiative.

Main Outcomes and Measures  Assessment with the CPI during PGYs 2, 4, and 5 of residency.

Results  Among the 45 otolaryngology residents (248 CPI administrations), there were a mean (SD) of 5 (3) administrations (range, 1-4) during their training. Total scores were significantly different among PGY levels of training, with lower scores seen in the PGY-2 level (44 [16]) compared with the PGY-4 (64 [13]) or PGY-5 level (69 [13]) (P < .001). Domain scores related to information gathering and organizational skills were acquired earlier in training, while knowledge base and clinical judgment improved later in residency. Trainees scored higher in general otolaryngology (mean [SD], 72 [14]) than in subspecialties (range, 55 [12], P = .003, to 56 [19], P < .001). Neither administering the examination with an electronic scoring system, rather than a paper-based scoring system, nor the calendar year of administration affected these results.

Conclusions and Relevance  Standardized interval evaluation with the CPI demonstrates improvement in qualitative diagnostic and management capabilities as PGY levels advance.

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Parotid Gland Sarcoidosis

Clinical Characteristics of Parotid Gland Sarcoidosis:

This population-based study describes the epidemiologic features of parotid gland involvement in sarcoidosis, with an emphasis on clinical characteristics, in a geographically well-defined population.

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Patients with differentiated thyroid cancers.Utility of Diagnostic Molecular Markers

Utility of Diagnostic Molecular Markers:

This Viewpoint discusses the personalization of care and the critical factors in accomplishing this philosophy for patients with differentiated thyroid cancers.

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Perennial allergic rhinitis : Counts of immunoreactive cells to eotaxin-1 and eosinophils on the nasal mucosa

Effect of cigarette smoke on counts of immunoreactive cells to eotaxin-1 and eosinophils on the nasal mucosa in young patients with perennial allergic rhinitis

via ScienceDirect Publication: Brazilian Journal of Otorhinolaryngology

Publication date: Available online 19 May 2016
Source:Brazilian Journal of Otorhinolaryngology
Author(s): Bertha Beatriz Montaño-Velázquez, Eulalia Beatriz Flores-Rojas, Francisco Javier García-Vázquez, Silvio Jurado-Hernandez, Marco Antonio Venancio Hernández, Angélica Kathya Alanis Flores, Kathrine Jáuregui-Renaud
IntroductionIn teenagers with perennial allergic rhinitis, exposure to tobacco cigarette smoke increases the count of eosinophils in the nasal mucosa the recruitment of eosinophils arises from the combined action of a number of cellular and molecular signals, including eotaxina.ObjectiveTo assess the effect of exposure to tobacco cigarette smoke on the count of immunoreactive cells to eotaxin-1 and eosinophils on the nasal mucosa of children and teenagers with perennial allergic rhinitis.MethodsIn a cross-sectional study, forty-four patients were evaluated (aged 7–19 years old): 22 with and 22 with no exposure to tobacco cigarette smoke. After replying to 2 validated questionnaires, on Asthma and Allergies in Childhood and on the severity of nasal symptoms, nasal mucosal samples were obtained by scraping the middle one-third of the inferior turbinates. Then counts of immunoreactive cells to eotaxin-1 and eosinophils were assessed by immunohistochemistry.ResultsPatients with exposure to tobacco cigarette smoke showed higher cell counts of both eotaxin-1 and eosinophils than patients with no exposure to the smoke, with no correlation between the two variables. However, both counts, of eotaxin-1 and eosinophils, were related to the cotinine/creatinine ratio.ConclusionsExposure to tobacco cigarette smoke can increase eotaxin-1 and the count of eosinophils in the nasal mucosa of young patients with perennial allergic rhinitis.

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Human Papillomavirus in Otolaryngology

Human Papillomavirus in Otolaryngology:

A new diagnosis of upper airway human papillomavirus (HPV)–related disease, benign or malignant, invariably leads to some challenging discussions with patients and families. These clinical encounters often involve delicate, pointed, and sometimes uncomfortable follow-up queries from patients that are fairly unique in the world of otolaryngologic care: "How did I get this?" "Do I need to tell my wife/husband?" "Am I infectious?" "Do we need to use barrier protection?" "Does my wife/husband need to do anything to prevent this?" "Am I putting him/her at risk?" "Should he/she be vaccinated?" "What about our children?"

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Vascular sinonasal lesions

Vascular sinonasal lesions. How useful is radiology in diagnosis of rare lesions?

via ScienceDirect Publication: Brazilian Journal of Otorhinolaryngology

    
Source:Brazilian Journal of Otorhinolaryngology
Author(s): Abdul Wadood Mohammed, Pearl Sara George

[PDF] από lesterthompsonmd.com

Update on Select Benign Mesenchymal and Meningothelial Sinonasal Tract Lesions

LDR Thompson, JC Fanburg-Smith - Head and neck pathology, 2016 - Springer

... The differential diagnosis includes sinonasal inflammatory polyps, hemangiomas (lobular capillary
hemangioma ... mucoserous glands, less fibrous stroma, and lack significant erectile-tissue
vasculature. ... a rich inflammatory component and a more ramifying vascular pattern, while ...

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Role of endoscopic surgery in the management of sinonasal and skull base schwannomas

A Karligkiotis, M Turri‐Zanoni, E Sica, C Facco… - Head & …, 2016 - Wiley Online Library

... could be taken into account when the radiological assessment excludes the vascular nature of ...
for doing so is to rule out the possibility of malignant lesions, which might ... however, several articles
have addressed cases of hypervascularized schwannomas of the sinonasal tract.[2 ...

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Radiologic Features of Sinonasal Tumors

KK Koeller - Head and neck pathology, 2016 - Springer

... This tumor is much less vascular than the angiofibroma, is found in the nasal cavity instead of ...
173–9. 6. Som PM, Shapiro MD, Biller HF, Sasaki C, Lawson W. Sino- nasal tumors and ... H, Ujita
M, Tada S, Fukuda K. Potentially distinctive fea- tures of sinonasal inverted papilloma ...

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[HTML] από nih.gov

[HTML] Glomangiopericytoma simulating an intracavernous meningioma

HA Al-Shaar, KI Macdonald… - Surgical Neurology …, 2016 - ncbi.nlm.nih.gov

... Diagnosing glomangiopericytoma is challenging, as it is frequently confused with other sinonasal
lesions. ... On imaging, the lesion was simulating a meningioma and our differential diagnosis at ...
fascicular, whorled, or storiform).[8,10,30] Variable sized vascular channels, forming ...

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[HTML] από theclinics.com

Sinonasal Malignancies of Anterior Skull Base: Histology-driven Treatment Strategies

P Castelnuovo, M Turri-Zanoni, P Battaglia… - … Clinics of North America, 2016 - Elsevier

... This is a rare tumor of vascular origin with low risk of malignancy and ... Indications and
contraindications for the endoscopic endonasal management of sinonasal and ASB malignancies. ...
Lesions involving the medial portion of the frontal sinus, Massive involvement of the frontal ...

Σχετικά άρθρα Όλες οι 5 εκδοχές Παράθεση Αποθήκευση

[HTML] από springer.com

Non-infectious Inflammatory Lesions of the Sinonasal Tract

TR Helliwell - Head and neck pathology, 2016 - Springer

... Cartilage erosion by mononuclear cells and vascular granulation tissue. ... Cocaine-Induced Midline
Destructive Lesions (CIMDL ... 1999;103(5 Pt 1):789–95.CrossRefPubMed. 2. Lawson W, Jiang
N, Cheng J. Sinonasal sarcoidosis: a new system of classification acting as a guide to ...

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Reconstructive techniques in skull base surgery after resection of malignant lesions: a wide array of choices

RA Hachem, A Elkhatib, A Beer-Furlan… - Current opinion in …, 2016 - journals.lww.com

... Reconstructive techniques in skull base surgery after resection of malignant lesions: a wide
array of choices. Hachem, Ralph Abi; Elkhatib, Ahmad; Beer-Furlan, Andre; Prevedello, Daniel;
Carrau, Ricardo. Article Outline. Collapse Box Author Information. ...

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Venous malformation of the ethmoid and sphenoid sinuses

AJ Gertel, JE Southwood, PE North, DM Poetker… - American journal of …, 2016 - Elsevier

... Those primarily affecting the venous vasculature, termed venous malformations, have an overall
incidence of 1 ... clinical presentation and appearance on radiological imaging modalities of different
varieties of vascular lesions in the nasopharynx and sinonasal cavity can be ...

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A Recurrent, Slow-Growing Retropharyngeal Lesion

JR Winters, BL Davis… - … –Head & Neck Surgery, 2016 - archotol.jamanetwork.com

... be considered when deciding appropriate treatment for similar in- sidious lesions in the ... AA,
Sharma MC, Singh MK, Bahadur S, Hatimota P. Vascular hamartoma of the ... Respiratory epithelial
adenomatoid hamartomas of the sinonasal tract and nasopharynx: a clinicopathologic ...

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Endoscopic surgery of the orbital apex: outcomes and emerging techniques

J Stokken, D Gumber, J Antisdel… - The …, 2016 - Wiley Online Library

... orbital apex is broad, and includes inflammatory, infectious, traumatic, vascular, and neoplastic ...
was entered for biopsy or tumor resection or 2) sinonasal lesions extending into ... Presenting
symptoms, lesion location, pathologic diagnosis, vision changes, and surgical techniques ...

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Estenose de MAE com perfuração do muro

Estenose de MAE com perfuração do muro:

 

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