Outcomes for Organ Preservation with Chemoradiation Therapy for T4 Larynx and Hypopharynx Cancer

alexandrossfakianakis shared this article with you from Inoreader Outcomes for Organ Preservation with Chemoradiation Therapy for T4 Larynx and Hypopharynx Cancer via The Laryngoscope Limited data exists on the non-surgical management of stage T4 larynx and hypopharynx cancer patients who are not surgical candidates or refuse surgery. This study aims to investigate the clinical and functional outcomes of non-surgical management of T4 larynx and hypopharynx cancer patients. The outcomes reported in this study will provide guidance for those who have unresectable disease or refuse surgery for advanced laryngeal and hypopharyngeal cancer patients. Objective Limited data is available to guide non-surgical management of Stage T4 larynx and hypopharynx cancer patients who have inoperable disease or refuse surgery. We aim to review the nonoperative management of T4 laryngeal and hypopharyngeal cancer and report the long-term therapeutic and functional outcomes. Methods We reviewed the nonoperative management of T4 laryngeal (n = 44) and hypopharyngeal (n = 53) cancer from 1997 to 2015 and performed a univariate analysis (UVA). Results The 2-/5-year OS rates were 73%/38% for larynx patients and 52%/29% for hypopharynx patients. Locoregional failure (LRF) occurred in 25% and 19% of larynx and hypopharynx patients, respectively. On UVA of the larynx subset, N3 nodal status and non-intensity-modulated radiation therapy were negatively associated with OS; treatment with radiation therapy alone impacted disease-free survival; and age >70 was associated with LRF. On UVA of the hypopharynx subset, only T4b status significantly impacted OS. In the larynx and hypopharynx groups, 68% and 85% received a percutaneous endoscopic gastrostomy (PEG) tube and 32% and 40% received a tracheostomy tube, respectively. At the last follow-up visit, 66% of our larynx cohort had neither tracheostomy or PEG placed and 40% of our hypopharynx cohort had neither. Conclusion We report better than previously noted outcomes among T4 larynx and hypopharynx patients who have unresectable disease or refuse surgery. Level of Evidence Level 4 Laryngoscope, 2022 View on Web

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Predicting Progression of Oral Lesions to Malignancy Using Machine Learning

alexandrossfakianakis shared this article with you from Inoreader Predicting Progression of Oral Lesions to Malignancy Using Machine Learning via The Laryngoscope Objective To use large-scale electronic health record (EHR) data to develop machine learning models predicting malignant transformation of oral lesions. Methods A multi-institutional health system database was used to identify a retrospective cohort of patients with biopsied oral lesions. The primary outcome was malignant transformation. Chart review and automated system database queries were used to identify a range of demographic, clinical, and pathologic variables. Machine learning was used to develop predictive models for progression to malignancy. Results There were 2192 patients with a biopsied oral lesion, of whom 1232 had biopsy proven oral dysplasia. There was malignant transformation in 34% of patients in the oral lesions dataset, and in 54% of patients in the dysplasia subset. Multiple machine learning-based models were trained on the data in two experiments, (a) including all patients with biopsied oral lesions and (b) including only patients with biopsy-proven dysplasia. In the first experiment, the best machine learning models predicted malignant transformation among the biopsied oral lesions with an area under the curve (AUC) of 86%. In the second experiment, the random forest model predicted malignant transformation among lesions with dysplasia with an AUC of 0.75. The most influential features were dysplasia grade and the presence of multiple lesions, with smaller influences from other features including anemia, histopathologic description of atypia, and other prior cancer history. Conclusion With diverse features from EHR data, machine learning approaches are feasible and allow for generation of models that predict which oral lesions are likely to progress to malignancy. Level of Evidence 3 Laryngoscope, 2022 View on Web

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Dilation, Steroid Injection, and Cough Exercise for Correction of Posterior Glottic Stenosis

alexandrossfakianakis shared this article with you from Inoreader Dilation, Steroid Injection, and Cough Exercise for Correction of Posterior Glottic Stenosis via The Laryngoscope DISCO (Dilation, Steroid injection and post-operative Cough Exercise) is a novel protocol for correcting posterior glottic stenosis. Post-op cough acts as physical-therapy to improve motion and flexibility. It can restore mobility and expand glottic airway without insufficiency. Objective To describe the DISCO protocol (Dilation, Steroid injection, and post-operative Cough Exercise); a novel treatment for posterior glottic stenosis (PGS). Restoring glottic mobility in PGS is a major challenge. In orthopedic and plastic surgery, post-operative physical therapy is associated with improved motion range and flexibility; yet, this principle was never applied to laryngeal surgery. Methods A retrospective cohort of PGS adult patients, treated by the DISCO protocol during 2018–2020. DISCO involves the following: scar release, glottic dilation, and steroid injection, followed by post-operative cough as glottic physical therapy. Maximal glottic opening angle (MGOA), relative glottic opening area (RGOA), and relative glottic insufficiency area (RGIA) were calculated before and post-operatively. Results Seventeen patients were included; PGS etiology was post-intubation (n = 10), post-irradiation (n = 3), both (n = 1) and joint sclerosis (n = 3). Six patients also had additional airway disorders. Sixteen patients were tracheostomy-dependent. 2 (12%), 8 (47%) and 7 (41%) patients had type II, III and IV stenosis, respectively. Surgery included scar release, dilation and steroid injection alone in 7 patients; and additional unilateral sub-mucosal arytenoidectomy in 10. The mean follow-up was 17.5 months. There were no major complications. Successful outcomes (e.g., decannulation or permanent capping) were achieved in 14 (82%) patients with some restoration of joint movement. None had a persistent voice or swallowing complaints. Both MGOA and RGOA increased in all patients (p < 0.001). RGIA remained unchanged (p = 0.878). Conclusions The DISCO protocol is a novel, effective and safe approach for PGS correction that can be easily applied. It can restore vocal fold mobility and may expand the glottic airway without causing glottic insufficiency. Level of Evidence 4 Laryngoscope, 2022 View on Web

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Hospira Issues a Voluntary Nationwide Recall for One Lot of Propofol Injectable Emulsion, USP (Containing Benzyl Alcohol), Due to the Potential Presence of Visible Particulate

alexandrossfakianakis shared this article with you from Inoreader Hospira Issues a Voluntary Nationwide Recall for One Lot of Propofol Injectable Emulsion, USP (Containing Benzyl Alcohol), Due to the Potential Presence of Visible Particulate via Food and Drug Administration--Recalls/Safety Alerts Hospira, Inc., a Pfizer company, is voluntarily recalling one lot of Propofol Injectable Emulsion, USP (containing benzyl alcohol) to the user level due to a visible particulate observed in a single vial during annual examination of retain samples View on Web

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Understanding Etiologic Pathways Through Multiple Sequential Mediators: An Application in Perinatal Epidemiology

alexandrossfakianakis shared this article with you from Inoreader Understanding Etiologic Pathways Through Multiple Sequential Mediators: An Application in Perinatal Epidemiology via Epidemiology - Published Ahead-of-Print Background: Causal mediation analysis facilitates decomposing the total effect into a direct effect and an indirect effect that operates through an intermediate variable. Recent developments in causal mediation analysis have clarified the process of evaluating how – and to what extent – different pathways via multiple causally ordered mediators link the exposure to the outcome. Methods: Through an application of natural effect models for multiple mediators, we show how placental abruption might affect perinatal mortality using small-for-gestational-age (SGA) birth and preterm delivery as two sequential mediators. We describe methods to disentangle the total effect into the proportions mediated via each of the sequential mediators, when evaluating natural direct and natural indirect effects. Results: Under the assumption that SGA births causally precedes preterm delivery, an analysis of 16.7 million singleton pregnancies is consistent with the hypothesis that abruption exerts powerful effects on perinatal mortality (adjusted risk ratio=11.9; 95% confidence interval 11.6, 12.1). The proportions of the estimated total effect mediated through SGA birth and preterm delivery were 2% and 58%, respectively. The proportion unmediated via either SGA or preterm delivery was 41%. Conclusions: Through an application of causal mediation analysis with sequential mediators, we uncovered new insights into the pathways along which abruption impacts perinatal mortality. Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved. View on Web

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Circular Stapled Technique Versus Modified Collard Technique for Cervical Esophagogastric Anastomosis After Esophagectomy: A Randomized Controlled Trial

alexandrossfakianakis shared this article with you from Inoreader Circular Stapled Technique Versus Modified Collard Technique for Cervical Esophagogastric Anastomosis After Esophagectomy: A Randomized Controlled Trial via Annals of Surgery - Most Popular Articles Objective: This study was performed to investigate the efficacy of the modified Collard (MC) technique for reducing anastomotic stricture after esophagectomy compared with the circular stapled (CS) technique. Summary Background Data: The currently available techniques of anastomosis after esophagectomy are associated with a significant risk of anasto-motic complications. However, the optimal anastomotic technique after esophagectomy has not yet been established. Methods: We randomly allocated patients to either the CS group or the MC group. The primary endpoint was the incidence of anastomotic stricture. The secondary endpoints included the incidence of postoperative complications (including anastomotic leakage) and quality of life (QoL). All anastomoses were performed after indocyanine green evaluation for objective homogeni-zation of blood flow to the gastric conduit between the 2 techniques. Results: Among 100 randomized patients (CS group, n = 50; MC group, n = 50), anastomotic strictures were observed in 18 (42%) patients in the CS group and in no patients in the MC group. There were no significant between-group differences in anastomotic leakage (CS group, 7% vs MC group, 8%; P = 0.94). Quality of life domains of dysphagia and choking when swallowing at 3 months after surgery were significantly better in the MC group than in the CS group. Conclusions: The MC technique reduces the incidence of anastomotic stricture and improves postoperative quality of life. Furthermore, the incidence of anastomotic leakage is comparable between the 2 techniques based on accurate comparison under objective homogenization of the gastric conduit condition. View on Web

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Extramedullary focal fat - fluid level, a specific sign of osteomyelitis

Balaji Anvekar's Neuroradiology Cases

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Extramedullary focal fat - fluid level, a specific sign of osteomyelitis

Posted: 11 Jul 2022 09:37 PM PDT

 A 14 yo male with pain in calcaneum since 1months.

MRI foot for calcaneum with CT correlation shows:

Heterogeneous signal abnormality diffusely involving calcaneum with multiple low signal intensity foci diffusely scattered in calcaneum on T1-weighted images which are hyperintense on STIR. Rest of the intervening calcaneum medulla shows faint high signal on STIR.

No obvious density abnormality on CT. No obvious sclerotic or lytic lesion. No obvious cortical destruction or sclerosis.

There is a focal lentiform shaped parosteal collection measuring approximately 26 mm in height and 6 mm in thickness medially at 2 o'clock position and 4 mm in thickness laterally on plantar aspect at 7 o'clock position on axial section.

There is fat – fluid level within this collection, focal fat in the supernatant portion of this collection which is hyperintense on T1-weighted images with complete signal suppression on STIR, this portion follows classical fat density on CT.

There is an associated diffuse oedema involving muscles of plantar aspect of foot especially quadratus plantae muscle, medial as well as lateral teno synovitis.

This finding suggestive of extramedullary focal fat - fluid level which is a pathognomonic sign of acute to subacute osteomyelitis.

Findings were discussed with the referring physician before finalizing the report, who added that there is elevation of inflammatory markers in lab reports and the suspicion of osteomyelitis clinically as well, with a feedback of significant improvement clinically after IV antibiotics.

Take home note is during MSK MRI interpretation, a bone marrow signal abnormality with an associated focal periosteal extra medullary fat – fluid level, osteomyelitis should be in the list of your differential diagnosis.

References:

1. Extra-osseous fat fluid level: a specific sign for osteomyelitis. Kumar J, Bandhu S, Kumar A, Alam S. Skeletal Radiol. 2007 Jun;36 Suppl 1:S101-4. doi: 10.1007/s00256-006-0194-1. Epub 2006 Sep 19.

2. Intramedullary and extramedullary fat globules on magnetic resonance imaging as a diagnostic sign for osteomyelitis. Davies AM, Hughes DE, Grimer RJ. Eur Radiol. 2005 Oct;15(10):2194-9. doi: 10.1007/s00330-005-2771-4. Epub 2005 Apr 29.