Implementing an Interprofessional Difficult Airway Response Team to Identify and Manage High-Risk Airways.

OBJECTIVE: To describe a multidisciplinary approach to and results from the creation of a difficult airway response team (DART) to address the management of inpatient loss of airway events. METHODS: Description of an interprofessional process to establish and sustain a DART program at a tertiary care hospital. An Institutional Review Board-approved retrospective review of the quantitative results was conducted from November 2019 through March 2021. RESULTS: After establishing the existing processes for difficult airway management, a focus on "work as imagined" identified 4 pillars to address the goal for the project of bringing the right providers with the right equipment to the right patients at the right time through DART equipment carts, an expanded DART code team, a screening tool to identify patients with at-risk airways and unique messaging for DART code alerts. "Work as done" was assessed through simulations. Educational efforts included further simulations and group teaching. Sustainability was achieved through ongoing e-learning and bidirectional feedback. During the period of study, there were 40,752 patients admitted and 28,013 (69%) screens completed. At-risk airways were identified in 4282 admissions (11%), most commonly due to a history of a difficult airway (19%) and elevated body mass index (16%). The DART responded to 126 codes. There were no airway-related deaths or serious adverse events. DISCUSSION: A successful DART program was created, optimized, and sustained using components of interprofessional meetings, simulation, bidirectional feedback, and quantitative analysis. IMPLICATIONS FOR PRACTICE: The techniques described can serve to guide groups who identify a quality improvement project that involves interactions between multiple stakeholders.

Survival, Outcomes, and Use of Acuity Scoring Systems Following Tracheotomy in Veteran Patients.

OBJECTIVES: To determine whether established prognosis tools used in the general population of critically ill patients will accurately predict tracheotomy-related outcomes and survival outcomes in critically ill patients undergoing tracheotomy. METHODS: Retrospective chart review of 94 consecutive critically ill patients undergoing isolated tracheotomy. RESULTS: Logistic Organ Dysfunction System (LODS) and sepsis-related organ failure assessment (SOFA) scores, 2 validated measures of acuity in critically ill patients, were calculated for all patients. The only tracheotomy-related outcome of significance was the finding that patients with an LODS score ≤6 were more likely to become ventilator independent (P < .015). Higher LODS or SOFA scores were associated with in-house death (LODS, P = .001, SOFA, P = .008) and death within 90 days (LODS, P = .009, SOFA, P = .031), while death within 180 days was associated only with a higher LODS score (LODS, P = .018). When controlling for age, there was an association between both LODS (P = .015) and SOFA (P = .019) scores and death within 90 days of tracheotomy. CONCLUSIONS: The survival outcome for critically ill patients undergoing tracheotomy seems accurately predicted based on scoring systems designed for use in the general population of critically ill patients. Logistic Organ Dysfunction System may also be useful to predict the likelihood of the tracheotomy-related outcome of ventilator independence. This suggests that LODS scores may be helpful to palliative care clinicians as part of a shared decision-making aid in critically ill, ventilated patients for whom tracheotomy is being considered.

Candidate Biomarkers for HPV-Negative Head and Neck Cancer Identified via Gene Expression Barcode Analysis.

OBJECTIVES: (1) Reanalyze publicly available genomic data for HPV-negative oral cavity squamous cell carcinoma to look for candidate biomarkers. (2) Evaluate the association of the identified biomarkers with survival. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary care. SUBJECTS AND METHODS: Gene expression barcode analysis was applied to an existing publicly available data set of 54 HPV-negative oral cavity squamous cell carcinoma tumor samples to identify candidate genes associated with poor prognosis. Genes identified were evaluated for their association with survival on the basis of univariable and multivariable Cox proportional hazards models. RESULTS: Three genes were found to be associated with poor prognosis. The most significant association was seen with spectrin expression. Subjects whose tumors expressed spectrin were 4.60 times more likely (hazard ratio; 95% confidence interval: 1.88-11.25) to die at any given time when compared with those without spectrin (P = .001). On univariable analysis, subjects with late-stage cancer were 6.34 times more likely (hazard ratio; 95% confidence interval: 1.41-28.53; P = .02) to die at any given time, but interestingly, after controlling for spectrin, this effect was attenuated (P = .07). Despite controlling for several possible confounding effects, the effect of spectrin remained hazardous throughout all multivariable models. This was true even after controlling for cancer stage and extracapsular extension (P = .004). CONCLUSION: Our analysis of public genomic data shows promise in identifying biomarkers that may allow clinicians to make more accurate survival predictions. Spectrin is a strong candidate for further biomarker testing.

11q21.1-11q23.3 Is a site of intrinsic genomic instability triggered by irradiation.

The chromosome location, 11q21-23, is linked to loss of heterozygosity (LOH) in multiple tumors including those of breast, lung, and head and neck. To examine the process of LOH induction, the H292 cell line (human muco-epidermoid carcinoma) was irradiated or treated with anti-CD95 antibody, and individual clones isolated through two rounds of cloning. Regions of LOH were determined by screening a suite of eight polymorphic microsatellite markers covering 11p15-11q24 using fluorescent primers and genetic analyzer peak discrimination. LOH induction was observed extending through 11q21.1-11q23.3 in 6/49 of clones surviving 4 Gy and 8/50 after 8 Gy. Analysis of selected clones by Affymetrix 6.0 single nucleotide polymorphism (SNP) arrays confirmed the initial assessment indicating a consistent 27.3-27.7 Mbp deletion in multiple clones. The telomeric border of LOH mapped to a 1 Mbp region of elevated recombination. Whole genome analysis of SNP data indicated that site-restricted LOH also occurred across multiple additional genomic locations. These data indicate that 11q21.1-11q23.3, and potentially other regions of this cell line are sites of intrinsic cell-specific instability leading to LOH after irradiation. Such deletions may subsequently be propagated by genetic selection and clonal expansion.

A 25-year analysis of veterans treated for tonsillar squamous cell carcinoma.

OBJECTIVE: To determine the recurrence and survival outcome based on treatment date, type of treatment, stage of disease, and comorbidity and the recurrence and survival differences based on smoking status as a surrogate for human papillomavirus status in veterans treated for tonsillar squamous cell carcinoma (SCC). DESIGN: Outcome cohort study. SETTING: Tertiary care Department of Veterans Affairs hospital. PATIENTS: A consecutive sample from 1981 through 2006 of 683 patients treated for oropharyngeal SCC was screened, and 141 patients with tonsillar SCC without distant metastatic spread and a minimum of 2 years of follow-up were included. MAIN OUTCOME MEASURES: Disease-free survival (DFS), disease-specific survival (DSS), and overall survival (OS). RESULTS: Disease-free survival was significantly better in cohort II (treated during or after 1997) compared with cohort I (treated before 1997) (2- and 5-year DFS, 82% vs 64% and 67% vs 48%; P = .02). Disease-specific survival was better in the surgical vs nonsurgical group (2- and 5-year DSS, 77% vs 46% and 67% vs 30%; P < .001), as was the OS (2- and 5-year OS, 66% vs 41% and 45% vs 23%; P = .005). In subjects with early-stage disease, OS and DSS were not different regardless of treatment type. In subjects with late-stage disease treated most recently (time cohort II), there was significantly better DSS in those receiving surgical vs nonsurgical treatment (2-year DSS, 70% vs 43%; P = .045). Nonsmokers had better OS (94 months vs 41 months; P = .001) and lower incidence of recurrence (8% vs 44%; P = .02). CONCLUSION: In veterans treated for tonsillar SCC, we advocate the consideration of a treatment plan that includes surgery for patients presenting with advanced-stage SCC of the tonsil, even in patients with notable comorbidities.

Primary tumor thickness as a risk factor for contralateral cervical metastases in T1/T2 oral tongue squamous cell carcinoma.

OBJECTIVES/HYPOTHESIS: Contralateral cervical metastases represent an avoidable source of failure in squamous cell carcinoma (SCCa) of the oral tongue. We sought to identify risk factors for the development of contralateral cervical metastases in T1/T2 oral tongue SCCa. STUDY DESIGN: Retrospective review. METHODS: We reviewed the medical records of 50 sequential cases of Stage I/II SCCa of the oral tongue treated with surgery between 1983 and 2003 at Loyola University Medical Center and Hines VA Hospital. Clinical staging, primary tumor thickness, results of neck dissection, adjuvant treatment, site and date of recurrence, and final outcome were recorded. Follow-up ranged from 0.2 to 17 years, with a mean of 5 years. Data were analyzed using multivariate logistic, Cox regression analysis, and a classification and logistic regression tree analysis. RESULTS: The odds ratio for risk of developing contralateral neck metastasis was 5% for each 1 mm increase in tumor thickness (P = .68). The risk did not change when controlling for the presence of ipsilateral metastasis. There was a significant relationship between contralateral cervical metastases and the development of recurrent disease at any site (P = .005). Classification tree analysis determined the risk for contralateral metastases and was greatest for patients with tumors > 3.75 mm thick and < or = 9.5 mm thick. CONCLUSIONS: This report is the first to our knowledge that evaluates thickness as a risk factor for contralateral cervical metastasis in oral tongue SCCa. We recommend consideration be given to treating the contralateral neck in cases where the primary tumor is > 3.75 mm thick.