A Cross-Sectional Evaluation of Publication Bias in the Plastic Surgery Literature

BACKGROUND

Publication bias (PB) is the preferential publishing of studies with statistically significant results. PB can skew findings of systematic reviews (SRs) and meta-analyses (MAs), with potential consequences for patient care and health policy. This study aims to determine the extent to which SRs and MAs in the plastic surgery literature evaluate and report PB.

METHODS

This cross-sectional study assessed PB reporting and analysis from plastic surgery studies published between January 1, 2015, and June 19, 2020. Full texts of SRs and MAs were assessed by two reviewers for PB assessment methodology and analysis. Post hoc assessment of studies that did not originally analyze PB was performed using Egger regression, Duval, Tweedie trim-and-fill, and Copas selection models.

RESULTS

There were 549 studies evaluated, of which 531 full texts were included. PB was discussed by 183 studies (34.5%), and formally assessed by 97 studies (18.3%). Among SRs and MAs that formally assessed PB, PB was present in 24 studies (10.7%), not present in 52 (23.1%), and inconclusive in eight (3.6%); 141 studies (62.7%) did not report the results of their PB assessment. Funnel plots were the most common assessment method [ n = 88 (39.1%)], and 60 studies (68.2%) published funnel plots. The post hoc assessment revealed PB in 17 of 20 studies (85.0%).

CONCLUSIONS

PB is inadequately reported and analyzed among studies in the plastic surgery literature. Most studies that assessed PB found PB, as did post hoc analysis of nonreporting studies. Increased assessment and reporting of PB among SRs and MAs would improve the quality of evidence in plastic surgery.

Primary fit tracheoesophageal puncture in primary versus salvage laryngectomy: Short-term and long-term complications and functional outcomes

BACKGROUND

Primary fit tracheoesophageal puncture (TEP) is widely preferred for individuals who have not undergone prior radiation. However, there is no consensus on the relative utility of primary-fit TEP in the setting of salvage laryngectomy.

METHODS

A retrospective, single-center review was conducted of individuals undergoing laryngectomy with primary fit TEP between 2012 and 2018. Multivariable analysis was conducted to compare short-term and long-term complications, as well as speech and swallowing outcomes, of those who underwent primary versus salvage laryngectomy.

RESULTS

In this study, 134 patients underwent total laryngectomy with primary fit TEP. Aside from a higher rate of peristomal dehiscence (13.1% vs. 1.4%) found in the salvage group, there was no difference in incidence of all other complications, including pharyngocutaneous fistula formation. The groups had comparable speech and swallow outcomes.

CONCLUSION

Primary fit TEP is a safe and effective surgical choice for individuals undergoing salvage laryngectomy who desire a voice prosthesis.

Auditory Outcomes Following Cochlear Implantation in Children with Unilateral Hearing Loss

OBJECTIVE

Unilateral hearing loss (UHL) in children is associated with speech and language delays. Cochlear implantation (CI) is currently the only rehabilitative option that restores binaural hearing. This study aims to describe auditory outcomes in children who underwent CI for UHL and to determine the association between duration of hearing loss and auditory outcomes.

STUDY DESIGN

Retrospective case series.

SETTING

Three tertiary-level, academic institutions.

PATIENTS

Children <18 years with UHL who underwent CI between 2018 and 2021.

INTERVENTION

Cochlear implantation.

MAIN OUTCOME MEASURES

Speech perception and Speech, Spatial and Qualities of Hearing Scale (SSQ) were assessed postimplantation. Scores >50% on speech perception and SSQ scores >8 points were considered satisfactory. Associations between duration of UHL and implantation age and outcomes were assessed using Spearman's rank correlation.

RESULTS

Of the 38 children included, mean age at CI was 7.9 ± 3.2 years and mean UHL duration was 5.0 ± 2.8 years. Mean datalogging was 8.1 ± 3.1 hours/day. Mean auditory testing scores were SSQ, 7.9 ± 1.2; BABY BIO, 68.1 ± 30.2%; CNC, 38.4 ± 28.4%; WIPI, 52.5 ± 23.1%. Scores >50% on CNC testing were achieved by 40% of patients. SSQ scores >8 points were reported by 78% (7/9) of patients. There were no significant correlations between UHL duration and auditory outcomes.

CONCLUSION

Overall, children with UHL who undergo CI can achieve satisfactory speech perception scores and SSQ scores. There were no associations between duration of hearing loss and age at implantation with auditory outcomes. Multiple variables may impact auditory outcomes, including motivation, family support, access to technology, and consistent isolated auditory training postactivation and should be taken into consideration in addition to age at implantation and duration of UHL in determination of CI candidacy.

[Analysis methods and case analysis of effect modification (3): effect modification in individual patient data Meta-analysis]

This paper briefly introduces the unique advantages, overall analysis ideas and existing analysis methods of individual patient data Meta-analysis in terms of effect modification. In addition to Meta-regression and subgroup analysis, this paper also introduces the analysis methods based on part of individual patient data integrated with aggregated data and summarizes the current reporting of the above mentioned methods. In addition, the application and results interpretation of the above mentioned methods in individual patient data Meta-analysis are presented in this paper by taking "Effects of sodium-glucose cotransporter 2 inhibitors on SBP in patients with type 2 diabetes" as an example and by introducing their advantages and limitations.

[Analysis methods and case analysis of effect modification (2): effect modification in network Meta-analysis]

This paper briefly introduces the characteristics, research significance, and global reporting status of effect modification in network Meta-analysis, demonstrates the heterogeneity caused by effect modification in network Meta-analysis, and emphasizes the importance of exploring effect modification in network Meta-analysis. This paper also summarizes the normalized description and analysis strategies of effect modification in network Meta-analysis. Finally, by the case of "comparison of efficacy of three new hypoglycemic drugs in reducing body weight in type 2 diabetes patients", this paper demonstrates the realization of subgroup analysis and network Meta-regression in exploring effect modification, summarizes the advantages and disadvantages of the two methods, to provide references for future researchers.

[Analysis methods and case analysis of effect modification (1): effect modification in epidemiology and traditional Meta-analysis]

This paper briefly introduces the definition, classification and significance of effect modification in epidemiological studies, summarizes the difference between effect modifier and confounders, and analyze the influence as well as the role of effect modification in epidemiological studies and Meta-analysis. In this paper, the possible scenarios of effect modification and related analysis strategy in Meta-analysis are indicated by graphics, aiming to arouse researchers' attention to effect modification. This paper also demonstrates how to identify and deal with effect modification in Meta-analysis through a study case of "Efficacy of sodium-glucose cotransporter 2 inhibitors in patients with type 2 diabetes", and shows the analysis process and interpretation of results of subgroup analysis and Meta-regression methods respectively. The advantages and disadvantages of these two methods are summarized to provide reference for the method selection of future research.

Upper Extremity Wounds Treated with Biodegradable Temporizing Matrix versus Collagen-Chondroitin Silicone Bilayer

Objective  This study aims to compare outcomes between Novosorb Biodegradable Temporizing Matrix (BTM) and Integra collagen-chondroitin silicone for upper-extremity wound reconstruction. Methods  This retrospective study analyzed adult patients who underwent wound reconstruction with either BTM or Integra at our institution between 2015 and 2020. Results  Forty-eight patients were included: 31 (64.6%) BTM and 17 (35.4%) Integra. Mean age was 44.0 (range: 18-68) years. Age, race, sex, smoking, comorbidities, and defect size were similar between groups. Wound etiologies included 12 (25.0%) burn, 22 (45.8%) trauma, and others. Median template size was 133 cm 2 for BTM and 104 cm 2 for Integra ( p  = 0.526). Skin grafting was performed after 14 (45.2%) and 14 (82.4%) wounds treated with BTM and Integra, respectively ( p  = 0.028). Template complications of infection and dehiscence were comparable. Skin-graft complications occurred in five (35.7%) and three (21.4%) wounds in BTM and Integra, respectively ( p  = 0.031). Skin-graft failure rates were comparable ( p  = 0.121). Mean number of secondary procedures required after template placement was higher in the Integra group (BTM, 1.0; Integra, 1.9; p  = 0.090). Final healing was achieved in 17 (54.8%) BTM and 11 (64.7%) Integra wounds ( p  = 0.694). Median time to healing was 4.1 months after BTM and 2.6 months after Integra placement ( p  = 0.014). Conclusion  Compared with Integra, BTM achieved comparable wound healing and complication rates. Fewer secondary procedures and skin grafts were observed in BTM wounds, likely as a result of the coronavirus disease 2019 pandemic. At our institution, 100 cm 2 of product costs $850 for BTM and $3,150 for Integra, suggesting BTM as an economical alternative to fulfill the high functional and aesthetic requirements of upper-extremity wounds.

Variations in Payer-Negotiated Prices for Head and Neck Reconstructive Surgery

OBJECTIVE

Little is known about pricing for reconstructive procedures of the head and neck. As of January 2021, the Centers for Medicare and Medicaid Services requires hospitals to disclose payer-negotiated prices for services, offering new insight into prices for privately insured patients.

STUDY DESIGN

Cross-sectional analysis.

SETTING

Turquoise database.

METHODS

Payer-negotiated facility fees for 41 reconstructive surgeries were grouped by procedure type: primary closure, skin grafts, tissue rearrangement, locoregional flaps, or free flaps. Prices were normalized to account for local labor costs, then calculated as percent markup in excess of Medicare reimbursement. The mean percent markup between procedure groups was compared by the Kruskal-Wallis test. Subset analyses were performed to compare mean percent markup using a Student's t test. We also assessed price variation by calculating the ratio of 90th/10th percentile mean prices both across and within hospitals.

RESULTS

In total, 1324 hospitals (85% urban, 81% nonprofit, 49% teaching) were included. Median payer-negotiated fees showed an increasing trend with more complex procedures, ranging from $379.54 (interquartile range [IQR], $230.87-$656.96) for Current Procedural Terminology (CPT) code 12001 ("simple repair of superficial wounds ≤2.5 cm") to $5422.60 ($3983.55-$8169.41) for CPT code 20969 ("free osteocutaneous flap with microvascular anastomosis"). Median percent markup was highest for primary closure procedures (576.17% [IQR, 326.28%-1089.34%]) and lowest for free flaps (99.56% [37.86%-194.02%]). Higher mean percent markups were observed for rural, for-profit, non-Northeast, nonteaching, and smaller hospitals.

CONCLUSION

Wide variation in private payer-negotiated facility fees exists for head/neck reconstruction surgeries. Further research is necessary to better understand how pricing variation may correlate with out-of-pocket costs and quality of care.

Survival Outcomes of Advanced Thyroid Cancer Enriched in Brain Metastases Following Treatment With Small Molecule Inhibitors

OBJECTIVE

Small molecule inhibitors (SMIs) are targeted therapies increasingly used in advanced thyroid carcinomas. This study aimed to evaluate the survival outcomes of thyroid cancer on SMI treatment, including in patients with brain metastases.

METHODS

This retrospective study included patients with thyroid carcinomas who received at least one SMI between 2008 and 2022 at a tertiary level, academic institution. SMI included lenvatinib, sorafenib, dabrafenib-trametinib, selpercatinib, and cabozantinib. Patients were grouped by the presence of brain metastasis. Kaplan-Meier and log-rank tests modeled the overall survival (OS), defined from detection of first metastasis.

RESULTS

In total, 116 patients (49.1% female, median age 61.1 years [IQR, 51.1-71.0]) were included. Thyroid cancer subtypes were: 57 (49.6%) papillary, 23 (19.8%) anaplastic, 23 (19.8%) medullary, and 13 (11.2%) follicular. There were 18 (15.5%) patients with brain metastases, and 98 (84.5%) with visceral metastases. Age, sex, thyroid subtype, SMI, and time to recurrence were not different between cohorts. OS was shorter in the brain metastasis cohort (31.7 vs 42.2 months, P =.44) and was not different after excluding anaplastic thyroid cancer (29.1 vs 62.3 months, P =.21). In the case of papillary thyroid cancer, patients with brain metastases trended toward worse OS (22.0 vs 59.9 months, P =.13). Nonanaplastic histology, total thyroidectomy (OR, 40.0; P <.001), number of unique therapies (OR, 10.9; P =.047), and mutation-directed therapy (OR, 24.7; P =.003) were associated with improved OS.

CONCLUSION

This single-institutional analysis reports survival outcomes of 116 patients with advanced thyroid cancer on targeted therapies, including 18 patients with brain metastases. Mutation-directed therapy for BRAFV600E mutations, RET mutations, RET fusions, and NTRK fusions had superior survival.

Incidence of Venous Thromboembolism Based on Caprini Score in Deep Inferior Epigastric Perforator Flap Breast Reconstruction

BACKGROUND

 Deep inferior epigastric perforator (DIEP) flaps are commonly used for autologous breast reconstruction, but reported rates of venous thromboembolism (VTE) are up to 6.8%. This study aimed to determine the incidence of VTE based on preoperative Caprini score following DIEP breast reconstruction.

METHODS

 This retrospective study included patients who underwent DIEP flaps for breast reconstruction between January 1, 2016 and December 31, 2020 at a tertiary-level, academic institution. Demographics, operative characteristics, and VTE events were recorded. Receiver operating characteristic analysis was performed to determine the area under the curve (AUC) of the Caprini score for VTE. Univariate and multivariate analyses assessed risk factors associated with VTE.

RESULTS

 This study included 524 patients (mean age 51.2 ± 9.6 years). There were 123 (23.5%) patients with the Caprini score of 0 to 4, 366 (69.8%) with scores 5 to 6, 27 (5.2%) with scores 7 to 8, and 8 (1.5%) patients with scores >8. Postoperative VTE occurred in 11 (2.1%) patients, at a median time of 9 days (range 1-30) after surgery. VTE incidence by the Caprini score was 1.9% for scores 3 to 4, 0.8% for scores 5 to 6, 3.3% for scores 7 to 8, and 13% for scores >8. The Caprini score achieved an AUC of 0.70. A Caprini score >8 was significantly predictive of VTE on multivariable analysis relative to scores 5 to 6 (odds ratio = 43.41, 95% confidence interval = 7.46-252.76, p < 0.001).

CONCLUSION

 In patients undergoing DIEP breast reconstruction, VTE incidence was highest (13%) in Caprini scores greater than eight despite chemoprophylaxis. Future studies are needed to assess the role of extended chemoprophylaxis in patients with high Caprini scores.

Margin Assessment Methods in Oral Cavity Squamous Cell Carcinoma and Recurrence: Tumor Bed vs Resection Specimen Sampling

Importance

Positive margins and margin clearance are risk factors for recurrence in oral cavity squamous cell carcinoma (OCSCC), and these features are used to guide decisions regarding adjuvant radiation treatment. However, the prognostic value of intraoperative tumor bed vs resection specimen sampling is not well defined.

Objective

To determine the prognostic implications of intraoperative margin assessment methods (tumor bed vs resection specimen sampling) with recurrence among patients who undergo surgical resection for OCSCC.

Design, Setting, and Participants

This was a retrospective study of patients who had undergone surgical resection of OCSCC between January 1, 2000, and December 31, 2021, at a tertiary-level academic institution. Patients were grouped by margin assessment method (tumor bed [defect] or resection specimen sampling). Of 223 patients with OCSCC, 109 patients had localized tumors (pT1-T2, cN0), 154 had advanced tumors, and 40 were included in both cohorts. Disease recurrence after surgery was estimated by the cumulative incidence method and compared between cohorts using hazard ratios (HRs). Data analyses were performed from January 5, 2023, to April 30, 2023.

Main Outcome and Measures

Recurrence-free survival (RFS).

Results

The study population comprised 223 patients (mean [SD] age, 62.7 [12.0] years; 88 (39.5%) female and 200 [90.0%] White individuals) of whom 158 (70.9%) had defect-driven and 65 (29.1%) had specimen-driven margin sampling. Among the 109 patients with localized cancer, intraoperative positive margins were found in 5 of 67 (7.5%) vs 8 of 42 (19.0%) for defect- vs specimen-driven sampling, respectively. Final positive margins were 3.0% for defect- (2 of 67) and 2.4% for specimen-driven (1 of 42) margin assessment. Among the 154 patients with advanced cancer, intraoperative positive margins were found in 29 of 114 (25.4%) vs 13 of 40 (32.5%) for defect- and specimen-driven margins, respectively. Final positive margins were higher in the defect-driven group (9 of 114 [7.9%] vs 1 of 40 [2.5%]). When stratified by margin assessment method, the 3-year rates of local recurrence (9.7% vs 5.1%; HR, 1.37; 95% CI, 0.51-3.66), regional recurrence (11.0% vs 10.4%; HR, 0.85; 95% CI, 0.37-1.94), and distant recurrence (6.4% vs 5.0%; HR, 1.10; 95% CI, 0.36-3.35) were not different for defect- vs specimen-driven sampling cohorts, respectively. The 3-year rate of any recurrence was 18.9% in the defect- and 15.2% in the specimen-driven cohort (HR, 0.93; 95% CI, 0.48-1.81). There were no differences in cumulative incidence of disease recurrence when comparing defect- vs specimen-driven cases.

Conclusions and Relevance

The findings of this retrospective cohort study indicate that margin assessment methods using either defect- or specimen-driven sampling did not demonstrate a clear association with the risk of recurrence after OCSCC resection. Specimen-driven sampling may be associated with reduced surgical margin positivity rates, which often necessitate concurrent chemotherapy with adjuvant radiation therapy.

Predictors of Complications in Autologous Breast Reconstruction Using DIEP Flaps: Implications for Management

BACKGROUND

Deep inferior epigastric perforator (DIEP) flaps are the standard for autologous breast reconstruction. This study investigated risk factors for DIEP complications in a large, contemporary cohort to optimize surgical evaluation and planning.

METHODS

This retrospective study included patients who underwent DIEP breast reconstruction between 2016 and 2020 at an academic institution. Demographics, treatment, and outcomes were evaluated in univariable and multivariable regression models for postoperative complications.

RESULTS

In total, 802 DIEP flaps were performed in 524 patients (mean age, 51.2 ± 9.6 years; mean body mass index, 29.3 ± 4.5). Most patients (87%) had breast cancer; 15% were BRCA -positive. There were 282 (53%) delayed and 242 (46%) immediate reconstructions and 278 (53%) bilateral and 246 (47%) unilateral reconstructions. Overall complications occurred in 81 patients (15.5%), including venous congestion (3.4%), breast hematoma (3.6%), infection (3.6%), partial flap loss (3.2%), total flap loss (2.3%), and arterial thrombosis (1.3%). Longer operative time was significantly associated with bilateral immediate reconstructions and higher body mass index. Prolonged operative time (OR, 1.16; P = 0.001) and immediate reconstruction (OR, 1.92; P = 0.013) were significant predictors of overall complications. Partial flap loss was associated with bilateral immediate reconstructions, higher body mass index, current smoking status, and longer operative time.

CONCLUSIONS

Prolonged operative time is a significant risk factor for overall complications and partial flap loss in DIEP breast reconstruction. For each additional hour of surgical time, the risk of developing overall complications increases by 16%. These findings suggest that reducing operative time through co-surgeon approaches, consistency in surgical teams, and counseling patients with more risk factors toward delayed reconstructions may mitigate complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Glycemic and metabolic sub-classification of prediabetes and risk factors for cardiovascular disease in the D2d cohort

Objectives

Prediabetes represents a spectrum of metabolic abnormalities, including insulin resistance and secretory impairment, that carries increased cardiovascular disease (CVD) risk. It is unclear whether specific glycemic and metabolic sub-classifications are associated with CVD risk. This cross-sectional analysis of 3946 participants from the Vitamin D and Type 2 Diabetes (D2d) study cohort aimed to determine the associations between various baseline CVD risk factors, glycemic sub-classifications of prediabetes (FPG, 2hPG, and HbA1c), and measures of insulin sensitivity and secretion from an OGTT.

Methods

The metabolic syndrome and atherosclerotic cardiovascular disease (ASCVD) risk scores were determined for tertiles of insulin sensitivity (HOMA2S) and insulinogenic index (IGI). Unadjusted analyses showed elevated CVD risk factors in the lowest tertile for both IGI and HOMA2S.

Results

After adjustment for age, gender, race, obesity, and smoking status, the association remained between HOMA2S and ASCVD score (r = -0.11, p< 0.001) but not for IGI. Those who met at least 2 diagnosic criteria for prediabetes had the largest proportion (> 40%) of participants with high ASCVD risk score >20. A higher percentage of individuals that met all 3 criteria for prediabetes had metabolic syndrome and ASCVD risk score >20 (87.2% and 15.3%, respectively) than those who only met 1 prediabetes criterion (51.6% and 7.1%, respectively).

Conclusions

In conclusion, multiple metabolic (HOMA2S, IGI) and glycemic criteria of prediabetes (FPG, 2hPG, & HbA1c) are needed to fully recognize the elevated CVD risk profile that can manifest in prediabetes.

Olfactory dysfunction incidence and resolution amongst 608 patients with COVID-19 infection

PURPOSE

Olfactory dysfunction (OD) is a common presenting sign of coronavirus-19 (COVID-19) infection and remains persistent in up to 7 % of patients one year after diagnosis. However, demographic, socioeconomic, and medical risk factors for persistent OD are not well understood. This study aims to determine risk factors for development and persistence of OD amongst patients with COVID-19 infection.

MATERIALS AND METHODS

This prospective, observational questionnaire study was performed at a tertiary-level, academic center. Patients with history of a positive COVID-19 diagnosis were sent an online questionnaire. Patients' self-reported survey responses for OD and resolution were assessed for associations with demographic variables, socioeconomic factors, and clinical data.

RESULTS

In total, 608 of 26,094 patients (77.6 % women, mean age 42.7 ± 17.4 years, range 9 months-92 years) completed the survey. OD was reported by 220 (36.2 %) patients, and 139 (63.2 %) patients achieved resolution. Patients with OD were more likely to have other sinonasal and flu-like symptoms, and had a hospitalization rate of 2.7 %. There were no significant differences in age, gender, occupational or residential factors, or medical comorbidities incidence of OD development. Women reported higher rates of persistent OD (88.9 % vs 77.0 %, p = 0.045). The OD recovery rates amongst active and resolved COVID-19 infections was 27.0 % and 70.0 %, respectively (p < 0.001).

CONCLUSIONS

There was a low hospitalization rate amongst patients reporting OD. One-third of patients with COVID-19 self-reported OD, and two-thirds of patients achieve OD resolution. Survey respondents with active COVID-19 infection and female gender were more likely to report persistent OD.

Auditory Outcomes in Children Who Undergo Cochlear Implantation Before 12 Months of Age: A Systematic Review

OBJECTIVE

To systematically review the literature to determine auditory outcomes of cochlear implantation in children ≤12 months old.

DATA SOURCE

PubMed, EMBASE, Medline, CINAHL, Cochrane, Scopus, and Web of Science databases were searched from inception to 9/1/2021 using PRISMA guidelines.

REVIEW METHODS

Studies analyzing auditory outcomes after cochlear implantation (CI) in children ≤12 months of age were included. Non-English studies and case reports were excluded. Outcome measures included functional and objective auditory results. Two independent reviewers evaluated each abstract and article. Heterogeneity and bias across studies were evaluated.

RESULTS

Of 305 articles identified, 17 met inclusion criteria. There were 642 children ages 2 to 12 months at CI. The most common etiologies of hearing loss were congenital CMV, meningitis, idiopathic hearing loss, and GJB2 mutations and other genetic causes. All studies concluded that early CI was safe. Overall, outcomes improved following early CI: IT-MAIS (9 studies), LittlEARS (4 studies), PTA (3 studies), CAP (3 studies), GASP (3 studies), and LNT (3 studies). Nine studies compared outcomes to an older implantation group (>12 months); of these (n = 450 early CI, n = 1189 late CI), 8 studies showed earlier CI achieved comparable or better auditory outcomes than later implantation, whereas 1 study (n = 120) concluded no differences in speech perception improvement.

CONCLUSION

Auditory outcomes were overall improved in children ≤12 months old undergoing CI. Studies that compared early to late CI demonstrated similar or better auditory outcomes in early implantation group. Given the comparable safety profile and critical time period of speech and language acquisition, earlier CI should be considered for infants with hearing loss.

Rates of osteoradionecrosis in resected oral cavity cancer reconstructed with free tissue transfer in the intensity-modulated radiotherapy era

BACKGROUND

Resected oral cavity carcinoma defects are often reconstructed with osteocutaneous or soft-tissue free flaps, but risk of osteoradionecrosis (ORN) is unknown.

METHODS

This retrospective study included oral cavity carcinoma treated with free-tissue reconstruction and postoperative IMRT between 2000 and 2019. Risk-regression assessed risk factors for grade ≥2 ORN.

RESULTS

One hundred fifty-five patients (51% male, 28% current smokers, mean age 62 ± 11 years) were included. Median follow-up was 32.6 months (range, 1.0-190.6). Thirty-eight (25%) patients had fibular free flap for mandibular reconstruction, whereas 117 (76%) had soft-tissue reconstruction. Grade ≥2 ORN occurred in 14 (9.0%) patients, at a median 9.8 months (range, 2.4-61.5) after IMRT. Post-radiation teeth extraction was significantly associated with ORN. One-year and 10-year ORN rates were 5.2% and 10%, respectively.

CONCLUSIONS

ORN risk was comparable between osteocutaneous and soft-tissue reconstruction for resected oral cavity carcinoma. Osteocutaneous flaps can be safely performed with no excess concern for mandibular ORN.

Association of Ear Anomalies and Hearing Loss Among Children With 22q11.2 Deletion Syndrome

OBJECTIVE

To identify inner and middle ear anomalies in children with 22q11.2 deletion syndrome (22q11DS) and determine associations with hearing thresholds.

STUDY DESIGN

Retrospective study.

SETTING

Two tertiary care academic centers.

METHODS

Children presenting with 22q11DS between 2010 and 2020 were included. Temporal bone imaging with computed tomography or magnetic resonance imaging was reviewed by 2 neuroradiologists.

RESULTS

Twenty-two patients (12 female, 10 male) were identified. Forty-four ears were evaluated on imaging. There were 15 (34%) ears with abnormal semicircular canals, 14 (32%) with abnormal vestibules, 8 (18%) with abnormal ossicles, 6 (14%) with enlarged vestibular aqueducts, 4 (9.1%) with abnormal facial nerve canals, and 4 (9.1%) with cochlear anomalies. There were 25 ears with imaging and audiometric data. The median pure tone average (PTA) for ears with any structural abnormality was 41.0 dB, as compared with 28.5 dB for ears without any structural abnormality (P = .21). Of 23 ears with normal imaging, 6 (26%) had hearing loss in comparison with 13 (62%) of 21 ears with abnormalities (P = .02). Total number of anomalies per ear was positively correlated with PTA (Pearson correlation coefficient, R = 0.479, P = .01). PTA was significantly higher in patients with facial nerve canal anomalies (P = .002), vestibular aqueduct anomalies (P = .05), and vestibule anomalies (P = .02).

CONCLUSIONS

Semicircular canal, ossicular, vestibular aqueduct, and vestibular anomalies were detected in children with 22q11DS, especially in the setting of hearing loss. Careful evaluation of anatomic anomalies is needed prior to surgical intervention in these patients.

Association of Treatment Strategies and Tumor Characteristics With Overall Survival Among Patients With Anaplastic Thyroid Cancer: A Single-Institution 21-Year Experience

Importance

Survival outcomes for anaplastic thyroid cancer (ATC), the most aggressive subtype of thyroid cancers, have remained poor. However, targeted therapies and immunotherapies present new opportunities for treatment of this disease. Evaluations of survival outcomes over time with new multimodal therapies are needed for optimizing treatment plans.

Objective

To evaluate the association of treatment strategies and tumor characteristics with overall survival (OS) among patients with ATC.

Design, Setting, and Participants

This retrospective case series study evaluated the survival outcomes stratified by treatment strategies and tumor characteristics among patients with ATC treated at a tertiary level academic institution from January 1, 2000, to December 31, 2021. Demographic, tumor, treatment, and outcome characteristics were analyzed. Kaplan-Meier method and log rank test modeled OS by treatment type and tumor characteristics. Data were analyzed in May 2022.

Main Outcomes and Measures

Overall survival (OS).

Results

The study cohort comprised 97 patients with biopsy-proven ATC (median [range] age at diagnosis, 70 [38-93] years; 60 (62%) female and 85 [88%] White individuals; 59 [61%] never smokers). At ATC diagnosis, 18 (19%) patients had stage IVA, 19 (20%) had stage IVB, and 53 (55%) had stage IVC disease. BRAF status was assessed in 38 patients; 18 (47%) had BRAF-V600E variations and 20 (53%), BRAF wild type. Treatment during clinical course included surgery for 44 (45%) patients; chemotherapy, 41 (43%); definitive or adjuvant radiation therapy, 34 (RT; 35%); and targeted therapy, 28 (29%). Median OS for the total cohort was 6.5 (95% CI, 4.3-10.0) months. Inferior OS was found in patients who did not receive surgery (hazard ratio [HR], 2.12; 95% CI, 1.35-3.34; reference, received surgery), chemotherapy (HR, 3.28; 95% CI, 1.99-5.39; reference, received chemotherapy), and definitive or adjuvant RT (HR, 2.47; 95% CI, 1.52-4.02; reference, received definitive/adjuvant RT). On multivariable analysis, age at diagnosis (HR, 1.03; 95% CI, 1.01-1.06), tumor stage IVC (HR, 2.65; 95% CI, 1.35-5.18), and absence of definitive or adjuvant RT (HR, 1.90; 95% CI, 1.01-3.59) were associated with worse OS.

Conclusions and Relevance

This retrospective single-institution study found that lower tumor stage, younger age, and the ability to receive definitive or adjuvant RT were associated with improved OS in patients with ATC.

[Analysis on infection sources and transmission chains of three outbreaks caused by 2019-nCoV Omicron variant in Beijing, China]

Objective: To investigate the infection sources and the transmission chains of three outbreaks caused by 2019-nCoV Omicron variant possibly spread through cross-border logistics in Beijing. Methods: Epidemiological investigation and big data were used to identify the exposure points of the cases. Close contacts were traced from the exposure points, and the cases' and environmental samples were collected for nucleic acid tests. Positive samples were analyzed by gene sequencing. Results: The Omicron variant causing 3 outbreaks in Beijing from January to April, 2022 belonged to BA.1, BA.1.1 and BA.2. The outbreaks lasted for 8, 12 and 8 days respectively, and 6, 42 and 32 cases infected with 2019-nCoV were reported respectively. International mail might be the infection source for 1 outbreak, and imported clothes might be the infection sources for another 2 outbreaks. The interval between the shipment start time of the imported goods and the infection time of the index case was 3-4 days. The mean incubation period (Q₁, Q₃) was 3 (2,4) days and the mean serial interval (Q₁, Q₃) was 3 (2,4)days. Conclusions: The 3 outbreaks highlighted the risk of infection by Omicron variant from international logistics-related imported goods at normal temperature. Omicron variant has stronger transmissibility, indicating that rapid epidemiological investigation and strict management are needed.

Voice outcomes following surgical treatment for pediatric vocal fold nodules: A systematic review and meta-analysis

OBJECTIVES

This study aimed to systematically review the literature to determine outcomes following surgical treatment of pediatric vocal fold nodules.

METHODS

Studies with patients ≤18 years with nodules who underwent surgery were reviewed for dysphonia improvement and recurrence in PubMed, EMBASE, Medline, CINAHL, Cochrane, Scopus, and Web of Science databases, searched from inception to November 1, 2022 using PRISMA guidelines. Non-English studies and case reports were excluded. Two evaluators independently reviewed each abstract and article. Heterogeneity and bias across studies were evaluated and meta-analysis was performed.

RESULTS

The literature search yielded 655 articles; 145 underwent full-text screening and eight were selected for systematic review and meta-analysis. There were 311 children with nodules, aged 2-18 years, with male-to-female ratio of 3.6:1. There were no surgical complications. Voice therapy was inconsistently reported. Follow-up time ranged from 1 month to 10 years. One study concluded that neither surgery nor voice therapy was effective, while five studies concluded that dysphonia improved with surgery. Voice grading by GRBAS, objective voice measures, and lesion size were improved following surgery, when reported. Meta-analysis of six studies demonstrated improvement in dysphonia in 90% of children post-operatively (95% CI: 74-99%). Meta-analysis of four studies showed that recurrence occurred in 19% of children (95% CI: 13-23%).

CONCLUSION

This systematic review suggests possible post-operative improvement in dysphonia for pediatric patients with vocal fold nodules; however, study measures, methods, and surgery utilized were heterogeneous and results should be interpreted cautiously. In order to better understand surgical outcomes, future studies should include standardized definition of nodules and objective measures of voice.

Intraoperative Neural Response Telemetry and Auditory Outcomes in Pediatric Cochlear Implantation

OBJECTIVE

To evaluate the relationship between intraoperative neural response telemetry (NRT) and postoperative auditory testing outcomes in children.

STUDY DESIGN

Retrospective study.

SETTING

Tertiary-care academic center.

METHODS

Children who underwent cochlear implantation using the Cochlear Corporation device between 2010 and 2019 were included. Associations of average NRT and the slope of amplitude with postoperative auditory outcomes including functional auditory measure Infant-Toddler Meaningful Auditory Integration Scale (IT-MAIS), and speech perception testing (consonant-nucleus-consonant [CNC], Pediatric AzBio [BABY BIO], Hearing In Noise Test [HINT], and Northwestern University Children's Perception of Speech [NU-CHIPS]), measured between 6 and 57 months after implantation, were assessed using Spearman's rank correlation (ρ).

RESULTS

Thirty-eight patients (19 female, 19 male) and 54 ears were included. The median age of implantation was 20.6 months (range 9.6 months to 10.6 years). Eight (21%) children had neurologic disorders such as stroke, epilepsy, cerebral palsy, and other causes. Thirteen (34%) children had connexin mutations. Average NRT was not significantly correlated with postoperative auditory outcomes (IT-MAIS [ρ = -0.08, p = .74], CNC [ρ = 0.19, p = .32], BABY BIO [ρ = 0.21, p = .29], HINT [ρ = 0.05, p = .83]) and NU-CHIPS (ρ = 0.21, p = .28). The average slopes of amplitude and comfort level were not strongly correlated with any auditory outcomes (p > .05).

CONCLUSIONS

Intraoperative NRT was not correlated with any postoperative functional auditory outcomes. Patient counseling should include discussions that a subpar intraoperative cochlear response does not preclude favorable speech and auditory outcomes.

Readmission Rates Following Major Head and Neck Surgery With Concurrent Tracheostomy

OBJECTIVES

To determine the influence of major head and neck procedures on readmission and complication rates following tracheostomy.

METHODS

A retrospective cohort study using the 2005 to 2017 National Surgical Quality Improvement Program (NSQIP) database. Current Procedural Terminology codes were used to identify tracheostomy patients and to define the underlying head and neck procedure. Patients under the age of 18 and with unknown pre-operative variables were excluded. Univariate and multivariable analyses were performed.

RESULTS

A total of 3240 tracheostomy patients undergoing major head and neck surgery were identified in NSQIP. The 30-day mortality rate was 104 (3.2%) and 258 (9.0%) patients were readmitted. 637 (19.7%) patients had an unplanned return to the operating room. There were 1606 (49.6%) non-tracheostomy specific complications, which included 850 (26.2%) medical and 1142 (35.2%) surgical complications. On multivariable analysis, we found that the underlying procedures did not impact the risk of readmission (P > .05 for all). The underlying procedure was also not associated with unplanned return to the operating room except for thyroidectomies, which had a lower risk than free tissue graft reconstruction (OR = 0.53 (95%CI 0.31, 0.88), P = .018).

CONCLUSION

While almost 1 in every 2 patients had a complication following major head and neck surgery that included creation of a tracheostomy, the rate of readmission is comparatively low and is not associated with the underlying procedure. These findings should reassure head and neck surgeons that properly managed tracheostomies do not constitute a disproportionate risk of readmission.

Risk Factors Associated With Recurrence and Death in Patients With Tall Cell Papillary Thyroid Cancer: A Single-Institution Cohort Study With Predictive Nomogram

Importance

Tall cell morphology (TCM) is a rare and aggressive variant of papillary thyroid carcinoma (PTC) that has been associated with poor outcomes; however, the risk factors for worse survival are not well characterized.

Objective

To identify prognostic factors associated with cancer recurrence and death in patients with PTC-TCM.

Design, Setting, and Participants

All patients treated for PTC-TCM at a single tertiary-level academic health care institution from January 1, 1997, through July 31, 2018, were included. Tall cell variant (TCV) was defined as PTC with TCM of 30% or more; and tall cell features (TCF) was defined as PTC with TCM of less than 30%. Patients with other coexisting histologic findings and/or nonsurgical management were excluded. Clinicopathologic features associated with worse outcomes were identified using Kaplan-Meier and Cox proportional-hazards model. Data were analyzed from March 1, 2018, to August 15, 2018.

Main Outcomes and Measures

Locoregional recurrence-free survival (LRRFS), distant recurrence-free survival (DRFS), and overall survival (OS) after surgery.

Results

A total of 365 patients (median [range] age, 51.8 [15.9-91.6] years; 242 [66.3%] female) with PTC-TCM (TCV, 32%; TCF, 68%) were evaluable. Total thyroidectomy was performed in 336 (92%) patients; 19 (5.2%) received radiotherapy; and 15 (4.1%) received radioactive iodine. Clinical features were pT3 or T4, 65%; node-positive, 53%; and positive surgical margins, 24%. LRRFS at 1-, 3-, 5-, and 10-year was 95%, 87%, 82%, and 73%, respectively. On multivariable analysis, male sex and age were not independent predictors of inferior 5-year LRRFS, whereas positive surgical margins (HR, 3.5; 95% CI, 2.0-6.3), positive lymph nodes (HR, 2.8; 95% CI, 1.4-5.8), and primary tumor size of 3 cm or more (HR, 3.3; 95% CI, 1.4-7.8) were strongly associated with worse LRRFS. Age 55 years or older (HR, 3.2; 95% CI, 1.5-7.0), male sex (HR 4.5; 95% CI, 2.1-10.0), positive surgical margins (HR, 2.7; 95% CI, 1.2-6.0), nodal positivity (HR, 3.1; 95% CI, 1.3-7.7), tumor diameter of 1.5 cm or more (HR, 20.6; 95% CI, 2.8-152.1), and TCV vs TCF (HR, 3.1; 95% CI, 1.5-6.7) were associated with worse DRFS. Male sex (HR, 3.1; 95% 1.4-6.8) and tumor diameter of 1.5 cm or more (HR, 2.8; 95% CI, 1.0-7.4) were associated with worse OS. A findings-based nomogram was constructed to predict 10-year LRRFS (C index, 0.8).

Conclusions and Relevance

This retrospective cohort study found that in patients with PTC-TCM, positive surgical margins, node positive disease, and tumor size of 3 cm or more were risk factors for worse LRRFS. Intensified locoregional therapy, including adjuvant radiation, may be considered for treating these patients.

Laryngology Outcomes Following Implantable Vagus Nerve Stimulation

Importance

Vagus nerve stimulation (VNS) devices have gained widespread acceptance for treatment of resistant epilepsy and depression. The increasing number of procedures has resulted in an increasing number of iatrogenic injuries to the vagus nerve, which can have a significant effect on vocalization and quality of life.

Objective

To determine the relative frequency of laryngeal adverse effects reported to the US Food and Drug Administration (FDA) after VNS implantation and to analyze associated VNS device problems.

Design, Setting, and Participants

This retrospective cross-sectional analysis queried the FDA Manufacturer and User Facility Device Experience database of adverse events in the US between 1996 and 2020.

Main Outcomes and Measures

The primary outcome was the percent of adverse events reported to the FDA that included patients who received VNS with laryngeal adverse effects and the associated proportion of device problems after VNS surgery.

Results

A total of 12 725 iatrogenic vagus nerve issues were documented after VNS implantation, with apnea (n = 395; 3.1%) being the most common patient problem. Overall, 187 reports of laryngeal adverse effects associated with VNS devices were identified and represented the eighth most common iatrogenic vagus nerve problem reported to the FDA. Laryngeal adverse effects included 78 reports of voice alteration and 57 reports of paresis/paralysis. The VNS device problems frequently associated with laryngeal adverse effects were high impedance (n = 15, 8.02%), incorrect frequency delivery (n = 10, 5.35%), and battery problems (n = 11, 5.88%). The number of laryngeal adverse effect reports per year peaked in 2012 with 43 cases.

Conclusions and Relevance

This cross-sectional study found that although the literature demonstrates that vocal changes occur with nearly all VNS devices, the FDA receives adverse event reports of voice changes. Our results emphasize a potential need to improve patient counseling prior to VNS surgery to better set patient expectations regarding vocal changes and to prevent unnecessary patient concern. In addition, reports of vocal fold paresis/paralysis potentially suggest that patients may benefit from preoperative laryngeal assessment to differentiate preexisting vocal fold paralysis from that caused by VNS surgery.

Cancer Risk Associated with Continuous Positive Airway Pressure: A National Study

OBJECTIVE

In 2021 the U.S. FDA issued a Class 1 safety recall notice for specific devices due to a risk of carcinogen exposure. The objective of this study was to evaluate reports of cancer linked to CPAP devices to understand implications for the field of sleep medicine.

METHODS

Cases of cancer involving CPAP devices were retrieved from the MAUDE database from 2014 to 2021 and analyzed with descriptive statistics.

RESULTS

A total of 2571 patient injuries were associated with CPAP. Reports of cancer (n = 209; 4.62%) were the second most commonly documented patient problem associated with CPAP, although 1950 (43.13%) patients had a device problem without an associated injury. Of the 209 cancer cases associated with CPAP, 200 (95.7%) of the adverse event reports were received by the FDA in 2021. There were 174 (9.15%) descriptions of the CPAP polyurethane sound abatement foam degrading in association with a cancer diagnosis, but degradation was more commonly not associated with malignancy (n = 1728; 90.85%). Other frequently documented CPAP device problems included broken devices (n = 279; 6.92%), fire (n = 182; 4.51%), and patient-device incompatibility (n = 144; 3.57%).

CONCLUSION

Malignancy associated with CPAP devices has been reported; however, future studies are required to establish causation. Given 95.7% of those documented cases were reported in 2021, otolaryngologists should be prepared to discuss the risks of carcinogenesis associated with CPAP. The otolaryngology community should also be aware of the potential bandwagon effect and the implications for CPAP compliance.

LEVEL OF EVIDENCE

4 Laryngoscope, 132:2270-2274, 2022.

[Survey on infection source of a cold-chain product associated COVID-19 epidemic caused by 2019-nCoV Delta variant in Beijing]

Objective: To investigate the source and the transmission chain of a cold-chain product associated COVID-19 epidemic caused by 2019-nCoV Delta variant in Beijing. Methods: Epidemiological investigation were used to verify the exposure points of the cases. Close contacts were traced from the exposure points, and human and environmental samples were collected for nucleic acid tests. Positive samples were analyzed by gene sequencing. Results: A total of 112 cases of COVID-19 were reported in the epidemic from January 18 to February 6, 2022 in Beijing. Except for 1 case was uncertain, there were epidemiological links among 111 cases. The source of infection was the packages of imported cold-chain products from Southeast Asia, which were harvested and stored in a local cold-storage in January 2021, and packaged and sent to the cold-storage A in A district in June 2021, and then sold in batches in cold-storage B in B district from January 2022. The first case was infected in the handling of positive frozen products, and then 77 cases occurred due to working, eating and living together with the index case in the cold-storage B, cold-storage C and restaurant D. Besides the cold-storage B, C and the restaurant D, there were 16 sub-transmission chains, resulting in additional 35 cases. Conclusion: The epidemic indicated that the risk of 2019-nCoV infection from imported cold-chain products contaminated by package and highlighted the importance to strengthen the management of cold-chain industry in future.

Utility of the finance-electronic medical record digital dashboard in pediatric otolaryngology

BACKGROUND

The time and cost of data collection via chart review of the electronic medical record (EMR) is a research barrier. This study describes the development of a digital dashboard conjoining EMR and finance data and its application in a pediatric otolaryngology practice.

METHODS

The dashboard creates a common language crosswalk between surgeries via the EMR, financial data, and national Vizient database. First, all Otolaryngology procedures billed via ICD-10 or CPT codes were categorized into Procedure Groups, which constitute the common language that links all data sources. The joined dataset was inputted into a Tableau workbook supporting dynamic filtering and custom real-time analysis.

RESULTS

The dashboard includes 84 Procedure Groups within Otolaryngology. Examples for pediatrics include Sistrunk procedure and supraglottoplasty. User-friendly dynamic filtering by Procedure Group, surgery date range, age, insurance, hospital, surgeon, and discharge status were developed. Outcomes include length of stay, telephone callbacks, postoperative hemorrhage, reoperations, return to Emergency Department, readmissions, and mortality. National comparisons can be analyzed via embedded Vizient data. The usability of the dashboard was tested by evaluating pediatric tonsillectomy outcomes, which revealed a significantly higher rate of postoperative hemorrhages and reoperations during the COVID-19 pandemic.

CONCLUSION

The hybrid finance/EMR dashboard creates a crosswalk between data sources and shows utility for use in evaluating patient outcomes via real-time data analysis and dynamic filtering. This innovative dashboard expedites data extraction, promoting efficient implementation of quality improvement initiatives and surgical outcomes research.

Head and Neck Wound Reconstruction Using Biodegradable Temporizing Matrix Versus Collagen-Chondroitin Silicone Bilayer

BACKGROUND

Head and neck reconstruction is challenging because of the functional requirements of movement, sensation, and cosmesis of this highly visible region. This study is the first to compare Novosorb biodegradable temporizing matrix (BTM) and Integra collagen-chondroitin silicone (CCS) skin substitutes for reconstruction of soft tissue head and neck wounds.

METHODS

This retrospective review included adults who underwent wound reconstruction of the head/neck with either BTM or CCS between 2015 and 2020. Patient-level data, complications, and closure rates were compared.

RESULTS

The review identified 15 patients: 5 who received BTM and 10 who received CCS. Mean age at dermal template placement was 55 (range, 28-79) years. Race, sex, smoking status, medical comorbidities, defect size, radiation history, prior surgeries, and follow-up time were not significantly different between groups. Wound etiologies for BTM and CCS included burn (40% vs 60%), trauma (20% vs 20%), surgical wounds (20% vs 20%), and skin cancer (20% vs 0%), respectively (P = .026). Skin grafts were placed in 8 (80%) wounds after CCS placement, compared with 3 (60%) after BTM (P = .670). Template reapplication was required in 2 (40%) BTM wounds and 3 (30%) CCS wounds (P = 1.0). Infection, hematoma, and seroma were comparable between groups, although skin graft failure was higher in the CCS group at 3 (37.5%) compared with 0 for BTM (P = .506). More secondary procedures were required after CCS placement (CCS, 1.9 ± 2.2; BTM, 0.9 ± 0.8; P = .090). Definitive closure in patients not lost to follow-up occurred in 4 (100%) BTM and 6 (75%) CCS cases (P = 1.0).

CONCLUSIONS

Head and neck wounds treated with BTM had comparable closure and complication rates as CCS bilayer and required fewer secondary procedures and skin grafts. These findings suggest that BTM is safe and efficacious for application in head and neck wounds and may be considered as an economical alternative.

[Analysis of change in esophageal varices and clinical characteristics in hepatitis B virus-related cirrhosis after antiviral therapy]

Objective: To clarify the effect and related factors of antiviral therapy on the change of esophageal varices in patients with hepatitis B virus-related cirrhosis. Methods: Fifty-two cases with hepatitis B virus-related cirrhosis who underwent endoscopy before and after antiviral therapy were selected from prospective cohorts. Patients were divided into three groups: no, mild, and moderate-severe based on the degree of esophageal varices. The changes in the severity of esophageal varices in each group were compared after antiviral therapy. Clinical characteristics (platelet, liver and kidney function, liver stiffness, and virological response) of patients with different regressions were analyzed. Measurement data were analyzed by independent sample t-test, one-way ANOVA, Mann-Whitney U test and Kruskal-Wallis H test, and Chi-Square test was used for count data. Results: All patients received entecavir-based antiviral therapy. The median treatment time was 3.1 (2.5-4.4) years. The proportion of patients without esophageal varices increased from 30.8% to 51.9%, the proportion of mild esophageal varices decreased from 40.4% to 30.8%, and the proportion of patients with moderate-to-severe esophageal varices decreased from 28.8% to 17.3% (χ²=14.067, P=0.001). A total of 40.4% of patients had esophageal varices regression, and 13.5% had esophageal varices progression. The progression rate was significantly higher in patients with moderate-severe esophageal varices than patients with mild and no esophageal varices (χ²=28.126, P<0.001), and 60.0% of patients with moderate-severe esophageal varices still remained in moderate-severe state after antiviral treatment. Baseline platelet count and 5-year mean change rates were significantly lower in patients with progressive moderate-to-severe esophageal varices than in those without progression (+3.3% vs. +34.1%, Z=7.00, P=0.027). Conclusion: After effective antiviral treatment, 40.4% of patients with hepatitis B virus-related cirrhosis combined with esophageal varices has obtained esophageal varices regression, but those with moderate to severe esophageal varices still have a considerable risk of progression while receiving mono antiviral treatment only. Thrombocytopenia and without significant improving are the clinical signs of progression risk after receiving antiviral treatment.

The Effect of Preoperative Gender Affirming Hormone Therapy Use on Perioperative Adverse Events in Transmasculine Individuals Undergoing Masculinizing Chest Surgery for Gender Affirmation

BACKGROUND

Many providers require cessation of gender affirming hormone therapy (GAHT) for transgender patients prior to undergoing masculinizing chest surgery due to concern for increased adverse events in the presence of exogenous hormones. Evidence has suggested that continuation of GAHT for certain patients may be safe for gender affirming procedures.

OBJECTIVES

To compare adverse event rates in GAHT cessation versus GAHT continuation in patients undergoing masculinizing chest surgery.

METHODS

This multicenter, retrospective study included patients at the Cleveland Clinic and MetroHealth System who underwent masculinizing chest surgery between 2016 and 2020.

RESULTS

There were 236 patients who met inclusion criteria. Of these, 172 (72.9%) discontinued testosterone GAHT prior to surgery (T-GAHT cessation), and 64 (27.1%) patients continued testosterone GAHT prior to surgery (T-GAHT continuous). Mean (SD) age at surgery was 25 (8) years, and mean (SD) BMI was 29.5 (6.6). Average duration of testosterone therapy was 18 months (range 0-300). There was no significant difference in tobacco use (p=0.73), diabetes (p=0.54), thrombophilia (p=0.97), or history of thromboembolism (p=0.39). Most patients underwent double incision free nipple graft technique (77.9%). There was no significant difference in surgical time (p=0.12), intraoperative complications (p=0.54), or postoperative complications (p=0.34). The most common complication was postoperative bleeding/hematoma (7.2%). Other complications included seroma (2.1%), infection (1.3%), and nipple graft failure (0.4%). There were no thromboembolic complications.

CONCLUSIONS

There is no significant difference in the incidence of perioperative adverse events for patients who continue GAHT preoperatively versus patients who undergo GAHT cessation for masculinizing chest surgery.

Performance of biodegradable temporizing matrix vs collagen-chondroitin silicone bilayer dermal regeneration substitutes in soft tissue wound healing: a retrospective analysis

INTRODUCTION

This study compared outcomes of soft tissue reconstruction using biodegradable temporizing matrix (BTM) and collagen-chondroitin silicone (CCS) skin substitutes.

OBJECTIVE

In this study, the authors compared wound healing rates and complication rates between BTM and CCS.

MATERIALS AND METHODS

This retrospective study reviewed outcomes for adult patients who underwent soft tissue reconstruction with either BTM or CCS skin substitutes between 2015 and 2020. Demographics, wound characteristics, surgical details, and complications were recorded.

RESULTS

Ninety-seven patients were included, of whom 51 (52.6%) were treated with BTM graft and 46 (47.4%) with CCS bilayer graft. The mean patient age was 48.2 years (range, 18-93 years). Wound etiologies included burn, trauma, iatrogenic, compartment syndrome, skin cancer, and osteomyelitis. The median template size was 147 cm2 and 100 cm2 for BTM and CCS, respectively (P =.337). Skin grafts were applied to 39 patients (84.8%) treated with CCS compared with 28 (54.9%) treated with BTM (P =.006); the remaining wounds healing secondarily. The template-related and skin graft-related complications of infection, dehiscence, and hematoma or seroma were comparable between groups. The rate of skin graft failure was significantly higher in the CCS cohort (n = 9 [23.1%]) compared with the BTM group (n = 1 [3.6%]) (P =.006). More secondary procedures were required after CCS placement (mean ± standard deviation, 1.9 ± 1.8; range, 0-9) than after BTM (mean, 1.0 ± 0.9; range 0-4) (P =.002). There was no statistical significance in the frequency of definitive closure between BTM and CCS (n = 31 [60.8%] vs n = 28 [60.9%], respectively; P =.655).

CONCLUSIONS

Compared with CCS, BTM had comparable closure and complication rates and required fewer secondary procedures and/or subsequent skin grafting.

[Survey of possible aerosol transmission of a COVID-19 epidemic caused by 2019-nCoV Delta variant]

Objective: To investigate the epidemiological characteristics and the transmission chain of a family clustering of COVID-19 cases caused by severe acute respiratory 2019-nCoV Delta variant in Changping district of Beijing. Methods: Epidemiological investigation was conducted and big data were used to reveal the exposure history of the cases. Close contacts were screened according to the investigation results, and human and environmental samples were collected for nucleic acid tests. Positive samples were analyzed by gene sequencing. Results: On November 1, 2021, a total of 5 COVID-19 cases caused by 2019-nCoV Delta variant were reported in a family detected through active screening. The infection source was a person in the same designated isolation hotel where the first case of the family cluster was isolated from 22 to 27, October. The first case was possibly infected through aerosol particles in the ventilation duct system of the isolation hotel. After the isolation discharge on October 27, and the first case caused secondary infections of four family members while living together from October 27 to November 1, 2021. Conclusion: 2019-nCoV Delta variant is prone to cause family cluster, and close attention needs to be paid to virus transmission through ventilation duct system in isolation hotels.

Nasopharyngeal cancer: Incidence and prognosis of human papillomavirus and Epstein-Barr virus association at a single North American institution

BACKGROUND

The prognostication of Epstein-Barr virus (EBV) and human papillomavirus (HPV) status in nasopharyngeal cancer (NPC) is unclear.

METHODS

This retrospective study analyzed NPC from 2000 to 2019.

RESULTS

Seventy-eight patients were included: 43 EBV⁺ , 12 HPV⁺ , 23 EBV^- /HPV^- , and 0 EBV⁺ /HPV⁺ . All p16⁺ tumors were also positive for HPV-CISH. Baseline characteristics were not different between groups except age, N-classification, and Karnofsky Performance Scale (KPS) (p < 0.05). For EBV⁺ , HPV⁺ , and EBV^- /HPV^- respectively, 3-year overall survival (OS) was 89.9%, 69.8%, and 52.5% (p = 0.006). EBV^- /HPV^- status was significantly associated with worse OS but not freedom from progression (FFP) on univariate analysis, and did not remain a significant predictor of OS after adjusting for KPS, age, and group stage.

CONCLUSIONS

EBV⁺ NPC tumors were seen in younger, healthier patients than HPV⁺ and EBV^- tumors, and there were no cases of coinfection. The association of viral status with OS was insignificant after adjusting for KPS and age.

[Study on flow field characteristics of dust airflow in vibrating screen and optimization of dust removal system]

In order to solve the problem of dust hazard of vibrating screen machine and difficult treatment in catalyst production process, computational fluid dynamics software Fluent was used to carry out numerical simulation calculation of the local exhaust dust removal system for the main dust dispersing points of the vibrating screen machine, including fine/coarse particles outlet and product outlet blowing and cleaning the dust points. The optimal design scheme and key technical parameters of local ventilation and dust removal system of vibrating screen machine were proposed. The results showed that the dust diffusion could be prevented by setting up an upper suction hood without air blowing, but the exhaust air volume needed to be calculated accurately. On the premise of purge, it is necessary to control the air volume to form a wind speed band of 8 m/s with a height of 15 cm at the feed port, so as to effectively remove the dust on the surface of solid particles of catalyst products and ensure that the catalyst products will not be blown away when falling into the feed barrel. The simulated design was applied to the vibrating sieve powder machine of a catalyst company, and the maximum dust concentration in the workplace was reduced from 45.80 mg/m(3) to 5.46mg/m(3), which effectively improved the working environment in the workplace.

Evaluating the Effects of Enhanced Recovery Pathways in Craniosynostosis: National Trends in Hospitalization Charges and Length of Stay in Craniosynostosis Surgery

BACKGROUND

Enhanced Recovery After Surgery (ERAS) pathways are multimodal approaches aimed at minimizing postoperative surgical stress, reducing hospitalization time, and lowering hospitalization charges. Enhanced Recovery After Surgery is broadly and increasingly implemented in hospitals across the country. Early reports have shown ERAS to reduce length of stay (LOS) after commonly performed pediatric surgeries. However, LOS and hospital charges after craniosynostosis have not been studied. We hypothesized that extended hospital LOS is correlated with increased hospitalization charges associated with open cranial vault surgery (CVS) and that over a multiyear timeframe, LOS and cost would decrease because of the increased adoption of ERAS in pediatric surgery.

METHODS

The Healthcare Cost and Utilization Project's National Inpatient Sample database was analyzed from January 2007 to December 2014. All patients who were diagnosed with craniosynostosis who underwent CVS were included. Variables of interest included demographic data, hospital characteristics, hospitalization data, and total hospital charges. Univariate and generalized linear regression models were used to examine associations between selected variables and the hospitalization charges.

RESULTS

There were 54,583 patients diagnosed with craniosynostosis between 2007 and 2014. Of these patients, 22,916 (41.9%) received CVS. The median total hospital charge was $66,605.77 (interquartile range, $44,095.60-$101,071.17). The median LOS was 3 days (interquartile range, 2-4 days), and there was no significant change in LOS by year (P = 0.979). However, despite a stable LOS, mean hospitalization charge increased significantly by year (P < 0.01). Regression analysis demonstrated the proportion of eligible patients who underwent CVS substantially increased over the selected timeframe (P < 0.01). Most procedures were performed in urban teaching hospitals and high-volume hospitals. There was no significant association between hospital volume and hospitalization charge (P = 0.331).

CONCLUSIONS

Increasing hospital charges despite constant LOS for craniosynostosis CVS procedures was observed between 2007 and 2014. Although ERAS has reduced LOS for common pediatric surgical procedures, no decrease in LOS for CVS has been observed. The charges significantly increased over the same period including high-volume centers. Further study to safely lower LOS and hospitalization charges for this procedure may reduce the overall health care burden.

[Correlation among age, sex, and liver diseases-related mortality risk in patients with hepatitis B virus-related liver cirrhosis]

Objective: To understand and compare the differences between age, sex and liver diseases-related mortality risk in patients with hepatitis B virus-related liver cirrhosis. Methods: Based on the front-page inpatient medical record database and the death registration system of Beijing patients with hepatitis B-related liver cirrhosis from 2008 to 2015 were included. The survival information of all patients were traced up to the occurrence of liver disease-related mortality event or until December 31, 2019. Kaplan-Meier method was used to calculate the cumulative incidence of liver disease-related mortality in patients with liver cirrhosis. Cox regression model was used to analyze the effect of age-gender interaction on liver disease-related mortality risk. Results: A total of 16 738 patients with hepatitis B-related liver cirrhosis were included, of which 13 969 cases (83.46%) were in compensated stage and 2 769 cases (16.54%) were in decompensated stage. Liver cirrhosis complications mortality risk in patients with compensated stage cirrhosis at 3, 5, and 8 years were 10.84%, 12.70%, and 14.37%, respectively; while in decompensated stage patients, the mortality risk was 16.70%, 19.02%, and 20.73%, respectively. The 3, 5, and 8-year liver cancer mortality rates of patients with compensated stage liver cirrhosis were 5.24%, 7.49%, and 10.25%, respectively; while those with decompensated stage liver cancer mortality rates were 9.01%, 11.16%, and 13.50%, respectively. Liver disease-related mortality risk was increased with age in patients with liver cirrhosis. Liver cirrhosis complications mortality risk in female patients with liver cirrhosis at age < 60 years was lower than that of male patients. Liver cirrhosis complications mortality risk in male and female patients aged 60-69 years were similar. Liver cirrhosis complications mortality risk in female patients aged ≥70 years was higher than that of male patients. However, female patients had a lower risk of liver cancer mortality than male patients in utmost age groups. Conclusion: Age is positively correlated with liver diseases-related mortality risk in patients with hepatitis B-related liver cirrhosis. Female sex is a protective factor for liver cancer mortality in patients with liver cirrhosis, and the protective effect on liver cirrhosis complications mortality risk gradually disappears with age.

[Relationship between respiratory viral load of cases of COVID-19 and secondary attack risk in close contacts]

Objective: To analyze the relationship between the cycle threshold (Ct) values of N gene of COVID-19 cases and the secondary attack risk in close contacts, and identify the relationship between respiratory viral load and infectivity in COVID-19 cases. Methods: The COVID-19 cases with records of Ct values of N gene within 0-7 days of onset were selected, and their close contacts were recruited as the subjects of study. We collected the information of close contacts, including name, gender, age, isolation mode, exposure mode and outcome (whether they were infected with SARS-CoV-2 or not) and other variables. Multivariate logistic regression models were used to identify the relationship between Ct values of N gene of COVID-19 cases and secondary attack risk in close contacts. Results: A total of 1 618 close contacts were recruited, in whom 77 were confirmed as symptomatic or asymptomatic COVID-19 patients with overall secondary attack rate of 4.8%. The multivariate logistic regression analysis indicated that eating together (OR=2.741, P=0.054), living together (OR=9.721, P<0.001), non-centralized isolation (OR=18.437, P<0.001) and COVID-19 case's values of N gene within 0-7 days of onset being <20 (OR=8.998, P=0.004) or 20-25 (OR=3.547, P=0.032) were significantly associated with higher likelihood of being infected with SARS-CoV-2 in close contacts. Conclusion: The results indicated that positive relationship exists between respiratory viral load and infectivity in COVID-19 cases, suggesting that Ct values of N gene can be used as an early warning indicator for the management of close contacts of COVID-19 cases.

Measurement of the Cosmic Ray Helium Energy Spectrum from 70 GeV to 80 TeV with the DAMPE Space Mission

The measurement of the energy spectrum of cosmic ray helium nuclei from 70 GeV to 80 TeV using 4.5 years of data recorded by the Dark Matter Particle Explorer (DAMPE) is reported in this work. A hardening of the spectrum is observed at an energy of about 1.3 TeV, similar to previous observations. In addition, a spectral softening at about 34 TeV is revealed for the first time with large statistics and well controlled systematic uncertainties, with an overall significance of 4.3σ. The DAMPE spectral measurements of both cosmic protons and helium nuclei suggest a particle charge dependent softening energy, although with current uncertainties a dependence on the number of nucleons cannot be ruled out.

[Study on mental health status of pregnant women and its influencing factors in the third trimester]

Objective: To understand the mental health status of pregnant women in the third trimester of pregnancy, and explore the influencing factors. Methods: The general demographic information and pregnancy information of 575 pregnant women in the Chinese Pregnant Women Cohort Study were collected. The mental health status of pregnant women in the third trimester was investigated by using Edinburgh Postpartum Depression Scale, Self-Rating Anxiety Scale and University of California at Los Angeles. Multivariate unconditional logistic regression was used to analyze the influencing factors for mental health of pregnant women. Results: In the third trimester of pregnancy, the incidence of depression was 16.52%, the incidence of anxiety was 11.13%, and the incidence of feeling loneliness was 26.26%. Logistic regression analysis showed that compared with those with education level of junior high school below, those with education level of college or bachelor's degree (OR=0.418, 95%CI: 0.184-0.950) and master's degree or above (OR=0.116, 95%CI: 0.027-0.503) were less likely to feel loneliness. Pregnant women with higher annual family income (10 000 RMB yuan) were less likely to suffer from depression (≥20 vs. <10: OR=0.527, 95%CI: 0.279-0.998), anxiety (10-20 vs. <10: OR=0.363, 95%CI: 0.180-0.731; ≥20 vs. <10: OR=0.271, 95%CI: 0.132-0.554) and feeling loneliness (≥20 vs. <10: OR=0.477, 95%CI: 0.276-0.826). Conclusions: The education level and family income have impacts on the mental health status of pregnant women in the third trimester. Medical staff should give targeted psychological advice to pregnant women to improve their mental health status.

[Clinical application of single-port inflatable endoscopic nipple sparing mastectomy with immediate reconstruction using prosthesis implantation]

Objective: To examine the clinical application value of single-port inflatable endoscopic nipple sparing mastectomy with immediate reconstruction using prosthesis implantation in the treatment of early breast cancer. Methods: From February 2014 to July 2019, the clinic-pathological data of 34 early breast cancer patients received single-port inflatable endoscopic nipple sparing mastectomy with immediate reconstruction using prosthesis implantation at Department of General Surgery, Beijing Friendship Hospital, Capital Medical University were retrospectively analyzed and followed up. All the patients were female, with an age of 46(11) years (M(Q_R)) (range: 26 to 64 years). The radical cure degree of operation, cosmetic effect after operation were evaluated. The satisfaction to operation and personal quality of life after operation was accessed by BREAST-Q scale. Results: All surgical procedures were successfully completed. The operation time was (313.4±11.7) minutes (range: 200 to 485 minutes). The blooding-liquid was (33.8±3.3) ml (range: 10 to 100 ml). There were 5 cases (14.7%) of nipple areola necrosis after operation, of which 1 patient received taking the prosthesis out because of prosthesis exposure. There was no capsular contracture or postoperative bleeding case. The follow-up time was 35(17) months (range: 12 to 77 months), and there was one case suffering local recurrence and metastasis, and another suffering metastasis. The scores of postoperative breast satisfaction, psychosocial status, chest wall status and sexual health were 78.32±2.57 (range: 55 to 100), 89.12±2.30 (range: 82 to 100), 91.47±1.33 (range: 43 to 100), and 78.50±2.68 (range: 39 to 100). Conclusion: Single-port inflatable endoscopic nipple sparing mastectomy with immediate reconstruction using prosthesis implantation in the treatment of early breast cancer can achieve provided curative and cosmetic effect on patients with breast cancer, with good patients' postoperative quality of life and satisfaction.

[Effect of levothyroxine treatment on pregnancy outcomes in euthyroid women with thyroid autoantibody positive: a Meta-analysis]

Objective: To conduct a systematic review of the association of levothyroxine treatment with pregnancy outcomes in euthyroid women who are thyroid autoantibody positive. Methods: Medline, Excerpta Medica (EMBASE), Cochrane Library, China National Knowledge Infrastructure (CNKI), China Biology Medicine (CBM), Wanfang data and VIP database were searched from inception until Jan. 28, 2020. All published randomized controlled trials assessing the association of levothyroxine treatment with pregnancy outcomes in euthyroid women with thyroid autoantibody-positive were included. STATA 11.0 and RevMan 5.3 softwares were used to perform this Meta-analysis. Results: A total of 6 studies met the inclusion criteria, with 2 188 women randomized. Meta-analysis showed that there was no significantly association between miscarriage (OR=0.85, 95%CI: 0.65-1.11, P=0.234) and preterm birth (OR=0.79, 95%CI: 0.54-1.16, P=0.224) with levothyroxine treatment. Conclusions: Levothyroxine therapy could not reduce the risk of miscarriage and preterm birth in euthyroid women with thyroid autoantibody-positive. Therefore, levothyroxine should be used with caution for these pregnant women.

Retrospective comparison of focused shockwave therapy and radial wave therapy for men with erectile dysfunction

Background

Low-intensity shockwave therapy (SWT) is an emerging treatment for erectile dysfunction (ED). Devices used for SWT include focused shockwave therapy (fSWT) or radial wave therapy (rWT), which differ in how the waves are generated, their tissue penetration, and the shape of their pressure waves. Most studies of SWT for ED to date have utilized fSWT. Although widely used, the efficacy of rWT for ED is unknown. Our objective is to compare the efficacy of rWT and fSWT for ED at our institution.

Methods

A retrospective chart review was performed to identify all men with ED treated by fSWT or rWT. Men with history suggesting non-vasculogenic ED were excluded. All men received 6 consecutive weekly treatments. The fSWT group received 3,000 shocks per treatment at 0.09 mJ/mm². The rWT group received 10,000 shocks per treatment at 90 mJ and 15 Hz. Pre-treatment and 6-week post-treatment Sexual Health Inventory in Men (SHIM) scores were measured. Treatment response was categorized on a scale of 1–3 (1 if no improvement, 2 if erections sufficient for intercourse with phosphodiesterase 5 inhibitors (PDE5i), or 3 if sufficient erections without PDE5i). Primary endpoint was self-reported improvement score of 2 or greater.

Results

A total of 48 men were included: 24 treated by fSWT and 24 by rWT. There were no significant differences in age, duration of ED, pre-treatment PDE5i use, or pre-treatment SHIM scores between the groups. Following treatment with rWT, the mean SHIM score improved from 9.3 to 16.1 (P<0.001). The mean SHIM following fSWT improved from 9.3 to 15.5 (P<0.001). The mean improvement in SHIM score did not differ between rWT (6.8) and fSWT (6.2) (P=0.42). 54% of men treated by fSWT experienced a significant clinical improvement (≥ grade 2 response) compared to 75% in the rWT group (P=0.42). There were no reported side effects with either device.

Conclusions

In our patient population, both fSWT and rWT were moderately effective treatments for arteriogenic ED with no observable difference in efficacy between the two modalities.

Geriatric syndrome risk factors among hospitalized postacute Medicare patients

OBJECTIVES

To assess the association of geriatric syndrome risk factors with postacute utilization among hospitalized Medicare patients (both Medicare Advantage [MA] and fee-for-service [FFS] cohorts) and to examine patterns of postacute care for MA and FFS cohorts with high geriatric syndrome risk.

STUDY DESIGN

Secondary data analysis using encounter-level data from the State Inpatient Databases (SID) of the Healthcare Cost and Utilization Project.

METHODS

The sample included 3.1 million Medicare hospitalizations from the Florida SID (2010 to 2014). We used multivariate linear regression to examine the impact of a geriatric syndrome risk measure, assessed as high risk, moderate risk, or nonrisk, on outcomes in MA and FFS cohorts. Outcome measures included postacute destination and inpatient utilization. We then examined if this risk measure was associated with differences in outcomes between MA and FFS cohorts.

RESULTS

Patients with high geriatric syndrome risk (in both MA and FFS cohorts) are less likely to be discharged to home or to home health care. They also have longer inpatient lengths of stay and higher inpatient costs. This risk measure also explains differences in postacute skilled nursing destination between MA and FFS cohorts.

CONCLUSIONS

Geriatric syndrome risk factors not only play a role in postacute care and inpatient utilization in MA and FFS cohorts but also explain different utilizations between MA and FFS cohorts. This study's results can be applied to guide discharge planning among a group of high-risk patients and evaluate alternative delivery models for this high-cost, high-need cohort.

[Interpretation for the group standards in guidelines for personal protection against coronavirus disease 2019 for diseases control person]

As an emerging infectious disease, the COVID-19 threatened the safety of personnel in the prevention and control during the COVID-19 pandemic. Beijing Association of Preventive Medicine organizes the Beijing CDC and other organizations drafted the group standard entitled "Guidelines for personal protection against coronavirus disease 2019 for diseases control person (T/BPMA 0002-2020)" , according to years of scientific research on personal protection. Based on the principles of emphasizing the scientific, normative and safe nature, the standard was drafted to put forward the reasonable selection and correct use of personal protective equipment for disease control personnel, as well as the procedures for personal protective equipment. The standard provided a standardized basis for ensuring the safety of disease control personnel in contacting and handling of the new coronary pneumonia outbreaks with high risks.

[Effects of changes in physical activities on depressive symptoms during pregnancy: a cohort study]

Objective: To investigate the effect of changes in physical activities on depressive symptoms in the second trimester of pregnancy. Methods: Data from the Chinese Pregnant Women Cohort Study, from July 25, 2017 to November 26, 2018, were used. Women who had effectively completed the survey of physical activity and depressive symptoms in the first and second trimesters of pregnancy, were recruited. Both International Physical Activity Questionnaire-short and Edinburgh Postnatal Depression Scale were used, respectively. Pregnant women who had completed two surveys were included in our study and were divided into two groups according to the depressive symptoms, measured at the baseline. Among the pregnant women without depressive symptoms at the baseline, logistic regression was used to analyze the effects of changes in physical activity on the prevention of depressive symptoms. Effect on the reduction of depressive symptoms was analyzed, using the same method. Results: The prevalence rates of depressive symptoms were 23.83% and 20.57% in the baseline and second trimester, respectively. After adjusting for age, education level, occupation, family annual income and pre-pregnancy BMI, data from the logistic regression showed that women without depressive symptoms and with increased and adequate physical activities in the baseline, were with lower risks to develop depressive symptoms in the second trimester (OR=0.479, 95%CI: 0.335-0.684;OR=0.566, 95%CI: 0.394-0.815). Among women with depressive symptoms in the baseline survey, association between physical activity and depressive symptoms was not statistically significant (P>0.05). Conclusions: Increased and adequate physical activities showed preventive effects on depressive symptoms during pregnancy, but the remission effect was not obvious in women with depressive symptoms. Pregnant women should be encouraged to increase their physical activities while screening programs should also be carried out to reduce the depressive symptoms during pregnancy.