Faculty Bibliography

Background - The use of bridge therapy with low-molecular-weight heparin during warfarin interruption for elective surgical and invasive diagnostic procedures leads to excess bleeding compared to interrupting warfarin alone. Other predictors of periprocedural bleeding during warfarin interruption are not well described. Aims - The purpose of this analysis was to identify predictors of major bleeding during and within 37 days after warfarin interruption for invasive procedures. Methods - BRIDGE was a double-blind, placebo controlled trial that randomized patients with atrial fibrillation requiring warfarin interruption to either bridge therapy with dalteparin 100IU/kg every 12 hours or matching placebo injections. Bleeding and thromboembolic outcomes were collected up to 37 days after the procedure. Multiple logistic regression models were used for baseline prediction of major bleeding. Time-dependent hazard models were used to add the effect of concomitant variables such as aspirin use and elevated INR values. Results - Nine hundred and fifty patients were assigned to placebo and 934 to dalteparin. Aspirin use at baseline was identified in 34.7% of the cohort (n=653) of which 60.5% (n=395) continued uninterrupted throughout the study period. The majority of procedures (89.4%) were considered low bleeding risk based on the planned surgical procedure. The median time to major bleeding was 7.0 days after surgery (interquartile range 4.0 to 18.0). Dalteparin administration was a baseline predictor of major bleeding (Odds Ratio (OR) = 2.5; 95% Confidence Interval (CI) 1.2-5.0, p=0.01), as was history of heart failure (OR=1.9; 95% CI 1.0-3.5, p=0.04) and major surgery (versus minor procedure) (OR=2.5; 95% CI 1.2-5.3, p=0.02). The current use of aspirin (OR=4.6; 95% CI 1.6-13.0, p=0.007) was significant as a time-dependent predictor of major bleeding. The presence of an elevated INR value (above 3.0) was not found to be significant when aspirin use was included in the model. Several factors known to contribute to bleeding risk during chronic anticoagulation were not found to predict bleeding around invasive procedures including age, history of hypertension, and history of gastrointestinal bleeding. The effect of history of diabetes, history of vascular disease, and gender were also evaluated but likewise these factors were not found to be significant predictors of bleeding. Conclusions - Major surgery, a history of heart failure and aspirin increase the risk of major bleeding during surgical and invasive diagnostic procedures requiring warfarin interruption. The risk and benefit of aspirin use during invasive procedures should be carefully assessed to minimize bleeding risk in this setting

BACKGROUND: Review patient and defect factors in which this donor site is an optimal choice for reconstruction and to discuss strategies to overcome the perceived drawbacks of this system of flaps. METHODS: A retrospective medical chart review was conducted on all patients who underwent the subscapular system of free flaps for head and neck reconstruction. RESULTS: Ninety-eight reconstructions were performed for mandibular defects, 4 for maxillary defects alone and 3 for combined mandible-maxilla defects. The overall success rate was 98%. CONCLUSION: The subscapular system of free flaps is an excellent option in patients for whom the alternative donor sites are either not usable or lack the associated soft tissue elements required for a successful reconstruction. This flap should also be considered as a first choice for patients with complex/extensive surgical defects requiring multiple, independently mobile, soft tissue components; in patients who will benefit from a large muscle flap placed over the vital structures in the neck; patients of advanced age; and patients in whom early mobilization is critical. (c) 2014 Wiley Periodicals, Inc. Head Neck, 2014.

Background: The management of patients with atrial fibrillation (AF) on warfarin who need treatment interruption for surgery/procedure is a common clinical problem. Bridging with low-molecular-weight heparin (LMWH) has been used to minimize the time that patients are not anticoagulated to mitigate the risk for arterial thromboembolism (ATE). The efficacy of bridging has not been validated, and bridging may increase bleeding. Aims: We aimed to determine the efficacy and safety of bridging anticoagulation. Methods: BRIDGE is a randomized, double-blind, placebo-controlled trial comparing bridging vs. no bridging in adults with non-valvular/ valvular AF or atrial flutter who required warfarin interruption for elective surgery/procedure. Patients with a mechanical heart valve or creatinine clearance < 30 mL min^-1 were excluded. After stopping warfarin 5 days pre-procedure, patients received dalteparin, 100 IU kg^-1, or matching placebo, both subcutaneous twice daily, for 3 days pre- and 5-9 days post-procedure. Dalteparin/placebo was resumed 12-24 h after minor and 48-72 h after major surgery/procedure. Warfarin was resumed < 24 h post-procedure. Follow-up was for 30 +/- 7 days post-procedure. Primary outcomes were ATE and major bleeding; secondary outcomes were minor bleeding, death, myocardial infarction, and venous thromboembolism. Results: We enrolled 1884 patients: median age was 72.7 (IQR 65.8- 78.2) years; 73.4% were male; median CHADS2 score = 2.0 (IQR 2.0- 3.0); and 336 (17.7%) had prior stroke or transient ischemic attack. Protocol adherence occurred in pre- and post-procedure periods in 1432 (81.0%) and 1669 (94.5%) patients, respectively. We lost 5 (0.3%) patients to follow-up. Trial enrollment ended in Dec. 2014, with results to be presented at the Congress. Conclusion: BRIDGE is the first randomized trial comparing the efficacy and safety of LMWH bridging vs. no bridging in patients with AF who require warfarin interruption for an elective surgery/procedure

Hypocalcemia is a well-known complication of total thyroidectomy. Patients who have previously undergone gastric bypass surgery may be at increased risk of hypocalcemia due to gastrointestinal malabsorption, secondary hyperparathyroidism, and an underlying vitamin D deficiency. We present the case of a 58-year-old woman who underwent a total thyroidectomy for the follicular variant of papillary thyroid carcinoma. Her history included Roux-en-Y gastric bypass surgery. Following the thyroid surgery, she developed postoperative hypocalcemia that required large doses of oral calcium carbonate (7.5 g/day), oral calcitriol (up to 4 mug/day), intravenous calcium gluconate (2.0 g/day), calcium citrate (2.0 g/day), and ergocalciferol (50,000 IU/day). Her serum calcium levels remained normal on this regimen after hospital discharge despite persistent hypoparathyroidism. Bariatric surgery patients who undergo thyroid surgery require aggressive supplementation to maintain normal serum calcium levels. Preoperative supplementation with calcium and vitamin D is strongly recommended.

Objectives: To study the MRI and PET/CT imaging of osteoradionecrosis of the sub-axial cervical spine, a serious long-term complication of radiation therapy for head and neck cancers that can lead to pain, vertebral instability, myelopathy, and cord compression. Methods and Materials: This is a single-institution retrospective review of patients diagnosed and treated for osteoradionecrosis of the sub-axial cervical spine following surgery and radiation for head and neck cancer. Results: We report PET/CT and MRI imaging for four patients, each with extensive treatment for recurrent head and neck cancer. Osteomyelitis and discitis are the end stage manifestations of osteoradionecrosis of sub-axial spine. Conclusions: Osteoradionecrosis of the sub-axial spine has variable imaging appearance and needs to be differentiated from recurrent or metastatic disease. Surgical violation of the posterior pharyngeal wall on top of compromised vasculature in patients treated heavily with radiation therapy may predispose the sub-axial cervical vertebrae to osteoradionecrosis, with possible resultant osteomyelitis and discitis. MRI and PET/CT imaging are complimentary in this setting. PET/CT images may be misinterpreted in view of history of head and neck cancer. MRI should be utilized for definitive diagnosis of osteomyelitis and discitis in view of its imaging specificity. Advances in Knowledge: We identify the end-stage manifestation of osteoradionecrosis in the sub-axial spine on PET/CT and MRI to facilitate its correct diagnosis.

Surgical resection in oral cancer patients can result in altered speech, swallowing, and patient perception of quality of life (QOL). Oral surgery can result in reduced lingual range of motion (ROM). However, few studies have quantified the degree of lingual restriction after surgery. This pilot study describes a new measurement system to define tongue ROM in surgically treated tongue cancer patients. This measurement system was validated by comparing results in these treated surgical patients versus healthy individuals. This scale was further validated by correlating ROM with performance status, oral outcomes, and patient-rated QOL. Thirty-six patients who underwent oral tongue surgery and 31 healthy individuals were included. Tongue ROM was assessed using a novel ROM assessment system. This novel system was examined in these patients versus healthy subjects. This measurement tool was further validated by correlating tongue ROM in treated patients with performance status, oral outcomes, and patient-rated QOL. Tongue ROM was found to be significantly lower in the surgically treated patients than in the healthy individuals (p = 0.0001). Tongue ROM correlated with performance status, oral outcomes, and all QOL measures. This new tongue ROM measurement system defined tongue deficits in surgically treated oral cancer patients. This tool was validated by comparing results to those in healthy individuals, as well as by correlating tongue ROM to performance status, oral outcomes, and QOL. This measurement tool can be used to define baseline and postsurgery tongue ROM in oral cancer patients, as well as track change over time with recovery and therapy. Future studies should examine use of this measurement tool with other populations demonstrating tongue deficits.