1
|
Plonowska-Hirschfeld KA, Gulati A, Stephens EM, Ochoa E, Xu MJ, Ha PK, Heaton CM, Yom SS, Chan JW, Algazi A, Kang H, Ryan WR. Treatment Modality Impact on Patient-Reported Quality of Life in Human Papilloma Virus-Associated Oropharyngeal Carcinoma. Laryngoscope 2024; 134:1687-1695. [PMID: 37767815 DOI: 10.1002/lary.31065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 08/11/2023] [Accepted: 09/11/2023] [Indexed: 09/29/2023]
Abstract
OBJECTIVE To prospectively compare the impact of treatment modality on patient-reported quality of life (QOL) in human papillomavirus-associated oropharynx squamous cell carcinoma (HPV + OPSCC). STUDY DESIGN Prospective cohort study. SETTING Academic medical center. METHODS One hundred one patients with American Joint Committee on Cancer (AJCC) 8th edition T1-3 N0-2 HPV + OPSCC completed the European Organization for Research and Treatment of Cancer Quality of Life Core questionnaire and Head and Neck Module pretreatment and 3-month and 1-year posttreatment. Mean score changes were compared to published minimal clinically important differences. RESULTS Patients underwent surgery alone (SA: N = 42, 42%), surgery with adjuvant radiation (S-RT: N = 10, 10%), surgery with adjuvant chemoradiation (S-CRT: N = 8, 8%), definitive radiation (RT: N = 11, 11%), or definitive chemoradiation (CRT: N = 30, 30%). SA, S-[C]RT, and [C]RT patients all reported clinically significant difficulty with sense of taste/smell persisting at 1 year. S-[C]RT and [C]RT patients reported statistically and clinically significant worse salivary dysfunction and problems with social eating at 1 year than SA. S-[C]RT patients reported statistically and clinically significant worse fatigue and head and neck pain compared to [C]RT and SA patients at 3 months, but normalized at 1 year. S-CRT compared to S-RT had statistically and clinically worse physical and role functioning and swallowing difficulties at 3 months but this difference was resolved by 1-year posttreatment. CONCLUSION HPV + OPSCC patients after SA report the lowest posttreatment QOL impact, whereas after S-CRT report the highest symptom burden. Careful selection for definitive surgery is important given the possibility of adjuvant CRT. Patients can experience persistent sense taste and smell difficulties at 1 year with all treatment modalities. LEVEL OF EVIDENCE 3 Laryngoscope, 134:1687-1695, 2024.
Collapse
Affiliation(s)
- Karolina A Plonowska-Hirschfeld
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, U.S.A
| | - Arushi Gulati
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, U.S.A
| | - Erika M Stephens
- University of California- San Francisco School of Medicine, San Francisco, California, U.S.A
| | - Edgar Ochoa
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, U.S.A
| | - Mary Jue Xu
- Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, U.S.A
| | - Patrick K Ha
- Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, U.S.A
| | - Chase M Heaton
- Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, U.S.A
| | - Sue S Yom
- Department of Radiation Oncology, University of California-San Francisco, San Francisco, California, U.S.A
| | - Jason W Chan
- Department of Radiation Oncology, University of California-San Francisco, San Francisco, California, U.S.A
| | - Alain Algazi
- Department of Hematology and Oncology, University of California-San Francisco, San Francisco, California, U.S.A
| | - Hyunseok Kang
- Department of Hematology and Oncology, University of California-San Francisco, San Francisco, California, U.S.A
| | - William R Ryan
- Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, U.S.A
| |
Collapse
|
2
|
Souza SS, Stephens EM, Bourdillon AT, Bhethanabotla R, Farzal Z, Plonowska-Hirschfeld K, Qualliotine JR, Heaton CM, Ha PK, Ryan WR. Circulating tumor HPV DNA assessments after surgery for human papilloma virus-associated oropharynx carcinoma. Am J Otolaryngol 2024; 45:104184. [PMID: 38101135 DOI: 10.1016/j.amjoto.2023.104184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 12/06/2023] [Indexed: 12/17/2023]
Abstract
PURPOSE To understand the utility of circulating tumor human papillomavirus DNA (ctHPVDNA) blood testing for HPV-associated oropharynx squamous cell carcinoma (HPV + OPSCC) after definitive surgery. MATERIALS AND METHODS Prospective cohort study of HPV(+)OPSCC patients with ctHPVDNA test data to assess its accuracy in detecting biopsy-confirmed disease at various post-treatment time points. Eligible patients had p16(+)/HPV(+) OPSCC and ctHPVDNA testing performed at any time pre-operatively and/or postoperatively. In cases of recurrence, patients were excluded from analysis if ctHPVDNA testing was not performed within 6 months of biopsy. RESULTS 196 all-treatment-type patients had at least one PT ctHPVDNA test. The initial post-treatment (PT) ctHPVDNA sensitivity, specificity, PPV, and NPV were 69.2 % (9/13), 96.7 % (177/183), 60.0 % (9/15), and 97.8 % (177/181). 61 surgery alone (SA) patients underwent 128 PT tests. The initial PT SA ctHPVDNA sensitivity, specificity, PPV, and NPV were 100 % (2/2), 96.0 % (48/50), 50 % (2/4), and 100 % (48/48). 35 of 61 (57.4 %) SA patients had NCCN-based histopathologic indications for adjuvant (chemo)radiation but declined. 3 of 35 (8.57 %) had a positive PT ctHPVDNA test of which 1 of 3 (33 %) had biopsy-proven recurrence. Prospectively, ten patients had a PreT positive ctHPVDNA, underwent SA, refused adjuvant treatment, had an undetectable ctHPVDNA within 2 weeks of SA, and remained free of disease (mean 10.3 months). CONCLUSION The high specificity and NPV of ctHPVDNA after SA suggest ctHPVDNA may have a role in determining the omission of PT adjuvant (chemo)radiation in select patients.
Collapse
Affiliation(s)
- Spenser S Souza
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, United States of America
| | - Erika M Stephens
- School of Medicine, University of California-San Francisco, United States of America
| | - Alexandra T Bourdillon
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, United States of America
| | | | - Zainab Farzal
- Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, United States of America
| | - Karolina Plonowska-Hirschfeld
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, United States of America
| | - Jesse R Qualliotine
- Division of Head and Neck Oncologic Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Diego, United States of America
| | - Chase M Heaton
- Division of Head and Neck Oncologic Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Diego, United States of America
| | - Patrick K Ha
- Division of Head and Neck Oncologic Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Diego, United States of America
| | - William R Ryan
- Division of Head and Neck Oncologic Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Diego, United States of America.
| |
Collapse
|
3
|
Stephens EM, Eltawil Y, Khalsa IK, Manjarrez L, Stephans J, Chan DK. Sociodemographic Disparities in Educational Services in Children who are Deaf or Hard of Hearing. Otolaryngol Head Neck Surg 2024; 170:544-551. [PMID: 37747036 DOI: 10.1002/ohn.539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/09/2023] [Accepted: 09/02/2023] [Indexed: 09/26/2023]
Abstract
OBJECTIVE Examine the association between sociodemographic factors and Individualized Education Program (IEP) establishment. DESIGN Retrospective cohort study. SETTING Tertiary referral center. METHODS Participants included deaf or hard-of-hearing children who were eligible for an IEP with "deafness" or "hard of hearing" as a primary or secondary disability. Primary outcome measures were time intervals between initial referral for services and parental consent; parental consent to determination of eligibility; and initial referral to eligibility (the sum of the previous 2 intervals). Student's t tests and linear regression were used to examine the association between sociodemographic factors and the primary outcome variables. RESULTS Of the 88 participants, 51 (58%) were male, 45 (51%) were from underrepresented minority (URM) groups, 35 (40%) spoke a primary language other than English, and 53 (60%) utilized public insurance. IEP establishment was significantly delayed in participants who required an English-language interpreter. Most of the delay occurred in the time between the initial referral and parental consent (mean: 115 vs 37 days, P = .02). There were also significant delays from the time of referral for services to eligibility in URM participants (mean: 159 vs 85 days, P = .04). Significant delays were also associated with Minority Status and Language within social vulnerability index percentile rankings. CONCLUSION This study found that IEP establishment was delayed in both URM participants and those who required an English-language interpreter. These results highlight the importance of clear communication between the school system and caregivers in the IEP establishment process, particularly with families who require an English-language interpreter or identify as URM.
Collapse
Affiliation(s)
| | | | | | - Leslie Manjarrez
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, USA
| | - Jihyun Stephans
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, USA
| | - Dylan K Chan
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, USA
| |
Collapse
|
4
|
Gulati A, Plonowska-Hirschfeld K, Stephens EM, Kansara S, Zebolsky AL, Ochoa E, Xu MJ, Ha PK, Heaton CM, Yom SS, Chan JW, Algazi AP, Kang H, Ryan WR. A prospective evaluation of neck and shoulder function following treatments of early-stage human papillomavirus-associated oropharynx cancer. Clin Otolaryngol 2023; 48:756-765. [PMID: 37212448 DOI: 10.1111/coa.14076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 01/27/2023] [Accepted: 05/06/2023] [Indexed: 05/23/2023]
Abstract
OBJECTIVES To compare post-treatment neck and shoulder function between human papillomavirus-associated oropharynx squamous cell carcinoma (HPV + OPSCC) treatments. DESIGN Prospective, repeated-measures study. SETTING Tertiary care center. PARTICIPANTS Treatment-naïve patients with American Joint Committee on Cancer eighth edition stage T0-3/N0-2 HPV+OPSCC. MAIN OUTCOME MEASURES Patients completed the Neck Dissection Impairment Index (NDII) pre-treatment and 3-months and 1-year post-treatment. The NDII assesses 10 neck and shoulder functions scored 0-5 (total score 0-100), with higher scores suggesting better function. RESULTS A total of 106 patients underwent: surgery alone (SA, n = 46, 43%), surgery with adjuvant radiation ± chemotherapy (S + a[C]XRT, n = 18, 17%), or definitive radiation ± chemotherapy (d[C]XRT, n = 42, 40%). cTN classification and pre-treatment NDII scores did not differ between groups. SA patients reported worsened 3-month post-treatment versus pre-treatment self-care (4.6 vs. 5.0), lifting light (4.6 vs. 5.0) and heavy (4.2 vs. 4.8) objects, overhead reach (4.5 vs. 4.9), activity (4.5 vs. 4.9), socialization (4.7 vs. 4.9), recreation (4.6 vs. 4.9), and overall score (86.8 vs. 95.3) (all p < 0.05). One-year post-treatment scores (n = 34) were no different than pre-treatment in all domains. S + a[C]XRT patients reported worsened 3-month versus pre-treatment stiffness (4.0 vs. 4.8), lifting heavy objects (3.8 vs. 4.9), overhead reach (4.2 vs. 4.9), socialization (4.6 vs. 5.0), recreation (4.4 vs. 4.9) and overall score (82.4 vs. 96.0) (all p < 0.05). One-year post-treatment scores (n = 13) were no different than pre-treatment in all domains. d[C]XRT patients reported worsened 3-month versus pre-treatment difficulty lifting heavy objects (4.3 vs. 4.7) and recreation (4.3 vs. 4.7). One-year posttreatment scores (n = 21) were no different than pre-treatment in all domains. CONCLUSION HPV + OPSCC patients may experience mild shoulder/neck dysfunction 3 months after treatment that usually resolves by 1 year, independent of treatment modality.
Collapse
Affiliation(s)
- Arushi Gulati
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, California, USA
| | | | - Erika M Stephens
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, California, USA
| | - Sagar Kansara
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, California, USA
| | - Aaron L Zebolsky
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee-Memphis, Memphis, Tennessee, USA
| | - Edgar Ochoa
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, California, USA
| | - Mary J Xu
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Patrick K Ha
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, California, USA
| | - Chase M Heaton
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, California, USA
| | - Sue S Yom
- Department of Radiation Oncology, University of California, San Francisco, California, USA
| | - Jason W Chan
- Department of Radiation Oncology, University of California, San Francisco, California, USA
| | - Alain P Algazi
- Division of Hematology and Oncology, University of California, San Francisco, California, USA
| | - Hyunseok Kang
- Division of Hematology and Oncology, University of California, San Francisco, California, USA
| | - William R Ryan
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, California, USA
| |
Collapse
|
5
|
Stephens EM, Plonowska-Hirschfeld K, Gulati A, Kansara S, Qualliotine J, Zelbolsky AL, van Zante A, Ha PK, Heaton CM, Ryan WR. Prospective quality of life outcomes for human papillomavirus associated oropharynx cancer patients after surgery alone. Am J Otolaryngol 2023; 44:103915. [PMID: 37210888 DOI: 10.1016/j.amjoto.2023.103915] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 04/30/2023] [Indexed: 05/23/2023]
Abstract
PURPOSE To evaluate changes in patient-reported quality of life (QOL) to inform treatment decisions for human papillomavirus-associated oropharynx squamous cell carcinoma (HPV + OPSCC). MATERIALS AND METHODS Patients with American Joint Committee on Cancer (AJCC) 8th edition cT0-T3 and cN0-N3 HPV + OPSCC treated with transoral robotic surgery to the primary site with neck dissection completed questionnaires prior to surgery and at three-months and one-year post-operatively. Questionnaires included four validated instruments: the University of Washington Quality of Life Questionnaire (UW-QOL), European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) and Head and Neck Module (HN35), and the Neck Dissection Impairment Index (NDII). RESULTS Forty-eight patients filled out pretreatment and three-month questionnaires. 37 patients filled out one-year questionnaires. With the UW-QOL, at three-months, patients reported a statistically significant and clinically meaningful decreased mean score for appearance that resolved at one-year (presurgery: 92.4, 3-month: 81.0, p < 0.001; one year: 86.5). At three months and one-year, significant and clinically meaningful decreased mean taste scores persisted (presurgery: 98.0; three-months: 76.3, one-year: 80.3; all p < 0.001). With the EORTC QLQ-C30 and HN35, at one-year, only mean scores for sense of taste or smell (one-year: 13.1; p < 0.001) did not return to baseline. With the NDII, patients returned to functions comparable to baseline in all domains. CONCLUSION Post-treatment quality of life is high for HPV+ OPSCC patients treated with surgery alone. Mild taste and possibly smell dysfunction may continue in some patients. With careful selection, surgery alone for HPV + OPSCC offers favorable QOL outcomes. LAY SUMMARY Patients with HPV+ associated oropharynx cancer treated with surgery alone completed quality of life questionnaires before and after surgery. Quality of life remained high for most patients, with a subset of patients experiencing mild taste dysfunction one-year after surgery.
Collapse
Affiliation(s)
- Erika M Stephens
- School of Medicine, University of California-San Francisco, San Francisco, CA, United States of America
| | - Karolina Plonowska-Hirschfeld
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, CA, United States of America
| | - Arushi Gulati
- School of Medicine, University of California-San Francisco, San Francisco, CA, United States of America
| | - Sagar Kansara
- Our Lady of the Lake Head and Neck Center, Our Lady of the Lake Regional Medical Center, 4950 Essen Ln, Suite 400, Baton Rouge, LA, United States of America
| | - Jesse Qualliotine
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, CA, United States of America
| | - Aaron L Zelbolsky
- Department of Otolaryngology - Head and Neck Surgery, University of Tennessee-Memphis, Memphis, TN, United States of America
| | - Annemieke van Zante
- Department of Pathology, University of California-San Francisco, San Francisco, CA, United States of America
| | - Patrick K Ha
- Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, CA, United States of America
| | - Chase M Heaton
- Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, CA, United States of America
| | - William R Ryan
- Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, CA, United States of America.
| |
Collapse
|
6
|
Abstract
Objectives To characterize the treatment goals and values of adult patients with
obstructive sleep apnea (OSA). Study Design Mixed methods design based on semistructured interviews followed by
cross-sectional surveys. Setting Academic medical center and integrated managed care consortium. Methods Phase 1 involved qualitative analysis of focus groups and interviews to
define treatment goal categories. Phase 2 included analysis of
cross-sectional surveys on most important treatment goals from patients with
OSA presenting to sleep surgery clinic. Positive airway pressure (PAP) use,
Epworth Sleepiness Scale score, and apnea-hypopnea index were obtained to
determine influences on goal choices. Results During focus groups and interviews, treatment goal themes identified included
improving sleep quality, reducing daytime sleepiness, snoring sound
reduction, and health risk reduction. In phase 2, 536 patients were
surveyed, and they reported the primary treatment goals of health risk
reduction (35%), sleep quality improvement (28%), daytime sleepiness
improvement (21%), and snoring sound reduction (16%). The primary treatment
goal was associated with age (P < .0001), excessive
daytime sleepiness (Epworth Sleepiness Scale score >10,
P < .0001), PAP use status (P <
.0001), and OSA severity (apnea-hypopnea index, P <
.0001). Severity of OSA was associated with increasing proportion of
patients choosing health risk reduction as the main treatment goal
(P < .05). Conclusions Adult OSA treatment goal choices vary with age, symptoms, PAP history, and
OSA severity. Understanding patient-specific goals is the essential first
step in the shared decision-making process when choosing surgical or
nonsurgical treatments. Ultimately, goal-focused discussions ensure
alignment of priorities and definitions of success between the patient and
the provider.
Collapse
Affiliation(s)
- Yi Cai
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Priyanka Tripuraneni
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Arushi Gulati
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Erika M Stephens
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Dang-Khoa Nguyen
- Department of Head and Neck Surgery, Kaiser Permanente, Oakland, California, USA
| | - Megan L Durr
- Department of Head and Neck Surgery, Kaiser Permanente, Oakland, California, USA
| | - Jolie L Chang
- Surgery Service, Department of Veterans Affairs Medical Center, San Francisco, California, USA
| |
Collapse
|
7
|
Gulati A, Stephens EM, Cai Y, Chang JL. Characterizing Decisional Conflict in Patients Presenting to Sleep Surgery Clinic and an Exploration of Resource Limitations. Laryngoscope 2021; 131:2384-2390. [PMID: 34152601 DOI: 10.1002/lary.29695] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/24/2021] [Accepted: 06/09/2021] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Numerous therapies exist for adult obstructive sleep apnea (OSA), creating potential for patient decisional conflict (DC) that impacts treatment adherence and post-treatment regret. We evaluated the prevalence of elevated DC in OSA patients presenting for positive airway pressure (PAP) alternative therapies and identified gaps in available resources about OSA therapies. STUDY DESIGN Cross-sectional study. METHODS A cross-sectional study was performed based on questionnaires completed by adult OSA patients presenting to an academic sleep surgery clinic from March to October 2020. Surveys examined sleep symptoms, sleep apnea treatment history, goals of therapy, and the SURE checklist, a validated 4-item DC screening scale. Additional qualitative data about OSA decision tool needs were queried with structured interviews in a smaller subset of patients. RESULTS Among 100 respondents, 60 were open to multiple treatment options, whereas 22 were not interested in surgical treatment. Eighty-one respondents (81%) had elevated DC (SURE score < 4). High DC was not associated with CPAP history, OSA severity, or daytime sleepiness (Epworth Sleepiness Scale score ≥ 10). Elevated DC was related to uncertainty regarding optimal treatment choice in 54% of respondents (n = 54), and lack of knowledge regarding risks and benefits of each treatment option in 71% (n = 71). Common themes identified in 9 interviewed patients suggested helpful resources should ideally compare treatment modalities and educate on surgery details, efficacy, and recovery. CONCLUSIONS The majority of OSA patients presenting to sleep surgery clinics have elevated decisional conflict influenced by limited knowledge about options and the risks and benefits of each therapy. There is a need for decision tools that can reduce decisional conflict and promote equitable knowledge about PAP alternative OSA treatments. LEVEL OF EVIDENCE Level 4 Laryngoscope, 2021.
Collapse
Affiliation(s)
- Arushi Gulati
- University of California San Francisco School of Medicine, San Francisco, California, U.S.A
| | - Erika M Stephens
- University of California San Francisco School of Medicine, San Francisco, California, U.S.A
| | - Yi Cai
- Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco School of Medicine, San Francisco, California, U.S.A
| | - Jolie L Chang
- Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco School of Medicine, San Francisco, California, U.S.A
| |
Collapse
|
8
|
Emerton R, Cloke HL, Stephens EM, Zsoter E, Woolnough SJ, Pappenberger F. Complex picture for likelihood of ENSO-driven flood hazard. Nat Commun 2017; 8:14796. [PMID: 28294113 PMCID: PMC5355947 DOI: 10.1038/ncomms14796] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 01/31/2017] [Indexed: 11/29/2022] Open
Abstract
El Niño and La Niña events, the extremes of ENSO climate variability, influence river flow and flooding at the global scale. Estimates of the historical probability of extreme (high or low) precipitation are used to provide vital information on the likelihood of adverse impacts during extreme ENSO events. However, the nonlinearity between precipitation and flood magnitude motivates the need for estimation of historical probabilities using analysis of hydrological data sets. Here, this analysis is undertaken using the ERA-20CM-R river flow reconstruction for the twentieth century. Our results show that the likelihood of increased or decreased flood hazard during ENSO events is much more complex than is often perceived and reported; probabilities vary greatly across the globe, with large uncertainties inherent in the data and clear differences when comparing the hydrological analysis to precipitation. El Niño and La Niña (ENSO) events influence global river flow and are often used as an early indicator of potential flooding. Here, the authors show that the probability of ENSO-driven flood hazard is more complex than is often perceived, and highlight the importance of considering hydrological response.
Collapse
Affiliation(s)
- R Emerton
- Department of Geography and Environmental Science, University of Reading, Reading RG6 6AB, UK.,Department of Meteorology, University of Reading, Reading RG6 6BB, UK.,European Centre for Medium-Range Weather Forecasts, Reading RG2 9AX, UK
| | - H L Cloke
- Department of Geography and Environmental Science, University of Reading, Reading RG6 6AB, UK.,Department of Meteorology, University of Reading, Reading RG6 6BB, UK
| | - E M Stephens
- Department of Geography and Environmental Science, University of Reading, Reading RG6 6AB, UK
| | - E Zsoter
- Department of Geography and Environmental Science, University of Reading, Reading RG6 6AB, UK.,European Centre for Medium-Range Weather Forecasts, Reading RG2 9AX, UK
| | - S J Woolnough
- National Centre for Atmospheric Science, Department of Meteorology, University of Reading, Reading RG6 6BB, UK
| | - F Pappenberger
- European Centre for Medium-Range Weather Forecasts, Reading RG2 9AX, UK
| |
Collapse
|
9
|
Stephens EM, Metcalf DH, Berry MT, Richardson FS. Near-ultraviolet absorption spectra and crystal-field analysis of Gd3+ in Na3. Phys Rev B Condens Matter 1991; 44:9895-9910. [PMID: 9998991 DOI: 10.1103/physrevb.44.9895] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
|
10
|
Stephens EM, Grisham CM. Lithium-7 nuclear magnetic resonance, water proton nuclear magnetic resonance, and gadolinium electron paramagnetic resonance studies of the sarcoplasmic reticulum calcium ion transport adenosine triphosphatase. Biochemistry 1979; 18:4876-85. [PMID: 228703 DOI: 10.1021/bi00589a016] [Citation(s) in RCA: 67] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The interactions of gadolinium ion, lithium, and two substrate analogues, beta,gamma-imido-ATP (AMP-PNP) and tridentate CrATP, with the calcium ion transport adenosine triphosphatase (Ca2+-ATPase) of rabbit muscle sarcoplasmic reticulum have been examined by using 7Li+ NMR, water proton NMR, and Gd3+ EPR studies. Steady-state phosphorylation studies indicate that Gd3+ binds to the Ca2+ activator sites on the enzyme with an affinity which is approximately 10 times greater than that of Ca2+. 7Li+, which activates the Ca2+-ATPase in place of K+, has been found to be a suitable nucleus for probing the active sites of monovalent cation-requiring enzymes. 7Li+ nuclear relaxation studies demonstrate that the binding of Gd3+ ion to the two Ca2+ sites on Ca2+-ATPase increases the longitudinal relaxation rate (1/T1) of enzyme-bound Li+. The increase in 1/T1 was not observed in the absence of enzyme, indicating that the ATPase enhances the parmagnetic effect of Gd3+ on 1/T1 of 7Li+. Water proton relaxation studies also show that the ATPase binds Gd3+ at two tight-binding sites. Titrations of Gd3+ solutions with Ca2+-ATPase indicate that the tighter of the two Gd3+-binding sites (site 1) provides a ghigher enhancement of water relaxation than the other, weaker Gd3+ site (site 2) and also indicate that the average of the enhancements at the two sites is 7.4. These data, together with a titration of the ATPase with Gd3+ ion, yield enhancements, epsilonB, of 9.4 at site 1 and 5.4 at site 2. Analysis of the frequency dependence of 1/T1 of water indicates that the electron spin relaxation taus of Gd3+ is unusually long (2 X 10(-9) s) and suggests that the Ca2+-binding sites on the ATPase experience a reduced accessiblity of solvent water. This may indicate that the Ca2+ sites on the Ca2+-ATPase are buried or occluded within a cleft or channel in the enzyme. The analysis of the frequency dependence is also consistent with three exchangeable water protons on Gd3+ at site 1 and two fast exchanging water protons at site 2. Addition of the nonhydrolyzing substrate analogues, AMP-PNP and tridenate CrATP, to the enzyme-Gd3+ complex results in a decrease in the observed enhancement, with little change in the dipolar correlation time for Gd3+, consistent with a substrate-induced decrease in the number of fast-exchanging water protons on enzyme-bound Gd3+. From the effect of Gd3+ on 1/T1 of enzyme-bound Li+, Gd3+-Li+ separations of 7.0 and 9.1 A are calculated. On the assumption of a single Li+ site on the enzyme, these distances set an upper limit on the separation between Ca2+ sites on the enzyme of 16.1 A.
Collapse
|
11
|
Hutton WC, Stephens EM, Grisham CM. Lithium-7 nuclear magnetic resonance as a probe of structure and function of the monovalent cation site on pyruvate kinase. Arch Biochem Biophys 1977; 184:166-71. [PMID: 921290 DOI: 10.1016/0003-9861(77)90338-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
|