Faculty Bibliography

IMPORTANCE: Posttreatment surveillance (PTS) is a key component in the treatment of patients with head and neck cancer. It is unclear how beneficial this is in improving patients' survival. OBJECTIVE: To determine how compliance with follow-up affects clinical outcomes in patients with head and neck squamous cell carcinoma. DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective cohort study at a tertiary academic center of a total of 332 patients with head and neck squamous cell carcinoma who had completed both treatment and follow-up at the University of Kansas Medical Center. Patient and tumor characteristics, socioeconomic status, and geographic data were collected. EXPOSURES: Compliance with PTS. MAIN OUTCOMES AND MEASURES: The effect of compliance with PTS on overall survival. RESULTS: Compliance with PTS, US Census tract income level, and the distance patients travel for follow-up had significant effects on survival (P = .001, P = .001, and P = .01, respectively). Cox proportional hazard models revealed that more advanced disease (hazard ratio [HR], 1.76 [95% CI, 1.21-2.58]; P = .003), middle (HR, 1.64 [95% CI, 1.13-2.39]; P = .009) and moderate (HR, 1.90 [95% CI, 1.18-3.06]; P = .008) census tract income level, and age (HR, 1.03 [95% CI, 1.01-1.04]; P < .001), were significantly associated with an increased risk of death. There was an association between compliance and tobacco cessation (P = .003), as well as the distance a patient lived from the medical center (P = .008). CONCLUSIONS AND RELEVANCE: Patients with head and neck squamous cell carcinoma were significantly more likely to survive with completion of follow-up and tobacco cessation. Compliance with PTS was associated with smoking cessation and traveling less than 200 miles for follow-up.

CONTEXT.: Approximately 30% of women report pain in the affected breast prior to breast cancer surgery. OBJECTIVES: The purpose of this secondary analysis of our prospective study was to determine how women who experienced both preoperative and persistent postsurgical breast pain (n=107) differed from women who did not report preoperative breast pain and did (n=158) or did not (n=122) experience persistent postsurgical breast pain. METHODS: Differences in demographic and clinical characteristics were evaluated. Linear mixed effects (LME) modeling was used to evaluate for group differences in symptom severity, function, sensation, and quality of life (QOL) over time. RESULTS: Between-group differences in demographic and clinical characteristics as well as trajectories of shoulder function and QOL were identified. Women with both preoperative and persistent postsurgical breast pain were younger; were more likely to report swelling, strange sensations, hardness, and numbness in the affected breast prior to surgery; and were more likely to have reconstruction at the time of surgery. Women with both preoperative and persistent postsurgical breast pain had more biopsies in the prior year, more lymph nodes removed, and reported more severe acute postsurgical pain than women without preoperative breast pain. LME modeling revealed significant group effects for the majority of outcomes evaluated. Over the six months of the study, women with both preoperative and persistent postsurgical pain had persistently poorer shoulder flexion and physical well-being than women without preoperative breast pain. CONCLUSION: Investigations of the etiology and molecular mechanisms of preoperative breast pain, as well as interventions for this high risk group, are needed.

BACKGROUND: The presence of olfactory cleft polyps in chronic rhinosinusitis with nasal polyposis is well documented, but the effect of endoscopic olfactory cleft polyp surgery on olfaction, versus observation, has not been well studied. This analysis assessed if microdebridement of olfactory cleft polyps yields significant objective smell improvements in those with anosmia or hyposmia. METHODS: A randomized prospective single-blinded study was performed on patients undergoing bilateral endoscopic sinus surgery with profound bilateral nasal polyposis, excluding those younger than 18 years or without olfactory polyps. A preoperative University of Pennsylvania Smell Identification Test (UPSIT), visual analog scale (VAS), and sinonasal outcomes 20 score (SNOT-20), and a follow-up at 6 months was performed. Two cohorts were created, including one with cleft polyp removal (group A) and one with cleft polyps left in place (group B). RESULTS: There were 10 patients in group A and 7 in group B. By using the Wilcoxon signed rank test, the two groups were individually analyzed for changes in the preoperative UPSIT, VAS, and SNOT-20 versus the 6-month test results. In group A, the improvement in the UPSIT, VAS, and SNOT-20 were statistically significant at p < 0.05. For group B only the improvement in the VAS was statistically significant, at p < 0.05. There was a statistically significant difference in clinical smell improvement between group A and B at 6 months (p = 0.00512). CONCLUSIONS: Evidence exists that olfactory cleft polyp surgery improves olfactory function outcomes. Long-term data beyond 6 months is needed to further validate these early promising outcomes.

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

The present study aims to determine the risk of early secondary nasal revisions in patients with complete unilateral and bilateral cleft lip and palate (U/BCLP) treated with and without nasoalveolar molding (NAM) and examine the associated costs of care. A retrospective cohort study from 1990 to 1999 was performed comparing the risk of early secondary nasal revision surgery in patients with a CLP treated with NAM and surgery (cleft lip repair and primary surgical nasal reconstruction) versus surgery alone in a private practice and tertiary level clinic. The NAM treatment group consisted of 172 patients with UCLP and 71 patients with BCLP, whereas the non-NAM-prepared group consisted of 28 patients with UCLP and 5 with BCLP. The risk of secondary nasal revision for patients with UCLP was 3% in the NAM group and 21% in the non-NAM group. The risk of secondary nasal revision for patients with BCLP was 7% in the NAM group compared with 40% in the non-NAM group. Using multicenter averages, the non-NAM revision rates were calculated at 37.8% and 48.5% for U/BCLP, respectively. Applying these risks of revision, NAM treatment led to an estimated savings of between $491 and $4893 depending on the type of cleft. In conclusion, NAM can reduce the number of early secondary nasal revision surgeries and, therefore, reduce the overall cost of care.

Cervical lymphadenopathy in adults has a broad differential diagnosis, including bacterial and viral infections, Kikuchi-Fujimoto disease, systemic lupus erythematosus, and various neoplasms. Many of its etiologies share similar symptomatology and presentations, which complicates the diagnosis. A thorough history and a comprehensive physical examination, to include nasopharyngoscopy and imaging as indicated by the specific case, are key to determining the origin of the lymphadenopathy and to avoid a missed or delayed diagnosis. Based on our review of the literature, we present the second reported case of anaplastic lymphoma kinase-positive anaplastic large-cell lymphoma presenting in an adult with an obstructing adenoid/nasopharyngeal mass and lymphadenopathy. The mass, which occurred in a 19-year-old woman of Asian descent, caused nasal airway obstruction in the setting of cervical lymphadenopathy that was initially ascribed to mononucleosis.