Skull base surgery for malignant tumors: The 2nd international collaborative study (1995-2015).

BACKGROUND: The current study presents the effort of a global collaborative group to review the management and outcomes of malignant tumors of the skull base worldwide. PATIENTS AND METHODS: A total of 28 institutions contributed data on 3061 patients. Analysis evaluated clinical variables, survival outcomes, and multivariable factors associated with outcomes. RESULTS: The median age was 56 years (IQR 44-67). The open surgical approach was used in 55% (n = 1680) of cases, endoscopic resection was performed in 36% (n = 1087), and the combined approach in 9.6% (n = 294). With a median follow-up of 7.1 years, the 5-year OS DSS and RFS were 65%, 71.7% and 53%, respectively. On multivariable analysis, older age, comorbidities, histology, dural/intracranial involvement, positive margins, advanced stage, and primary site were independent prognostic factors for OS, DSS, and RFS. Adjuvant RT was a protective prognostic factor. CONCLUSION: The progress across various disciplines may have contributed to improved OS and DSS in this study compared to previous reports.

Developing a Memory and Communication App for Persons Living With Dementia: An 8-Step Process.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.3928/19404921-20210825-02.

Functional Outcomes Following Delayed Laryngeal Reinnervation Of Patients with Vagal Paralysis After Paraganglioma and Schwannoma Surgery.

PURPOSE: We present a prospective case series that aimed to report the functional (voice and swallowing) outcomes of delayed laryngeal reinnervation following vagal interruption by resection of vagal paraganglioma and schwannoma. MATERIALS AND METHODS: A dedicated, anonymized database was established in 2012 with a minimum eighteen-month follow up set for this report. Internationally validated self- and observer-reported measures were recorded preoperatively and at six, 12 and, 18 months together with demographics, diagnoses, and operative details. RESULTS: A total of eight patients with a median age of 46 (37-54) underwent excision of vagal paraganglioma (five) and schwannoma (three) with few mild complications. Three underwent selective and five non selective reinnervation. Seven out of eight patients underwent synchronous injection medialization. The voice handicap index (VHI-30) improved from a baseline median 83 (range 52-102) to 7.5 (5-58) at 18 months; maximum phonation time improved from median 8 (range 5-15) to 10.5 (8.5-11); voice grade ("G" in grade, roughness, breathiness, asthenia, and strain [GRBAS] scoring) improved from median three (severe impairment, range 0-3) to one (mild impairment, 0-2); Eating Assessment Tool (EAT-10) score improved from median 12 (range 3.5-27) preoperatively to one (0-16); and reflux symptom index (RSI) improved from median 25 (range 17-36) to 7 (0-36). One patient exhibited no discernible reinnervation, while the remainder exhibited good cord bulk and tone, though without purposive abduction. CONCLUSION: Delayed laryngeal reinnervation for high vagal paralysis is a safe technique associated with good voice and swallowing outcomes by 12-18 months. Potential confounders in this small series and the absence of a control arm both limit conclusions, but this study suggests that further prospective, controlled studies, and/or case registration are merited.

A novel technique to repair orbital roof defects: irradiated homologous cadaveric rib (Tutoplast ®) graft in a recurrent frontal sinus ossifying fibroma.

Ossifying fibroma in the fronto-ethmoidal sinuses is a rare, benign condition. In symptomatic cases, surgical excision is often undertaken and bony defects may be repaired using alloplastic grafts. We present a novel method of repairing an orbital roof defect using irradiated homologous cadaveric rib (Tutoplast ®) graft, overlaid with a pericranial flap. The patient made an excellent recovery, concluding that it is a viable and safe option with lower morbidity.

Eagle syndrome and carotid artery dissection: a rare skull base cause of stroke.

Eagle's syndrome is a rare collection of symptoms that occur secondary to an elongated styloid process or calcified stylohyoid ligament irritating its surrounding structures. Classically, this presents as unilateral throat pain or rarely, as acute neurological symptoms secondary to compression of the internal carotid artery: so called 'stylocarotid syndrome'. Significant neurological events in teenagers, secondary to Eagle syndrome have not been reported. We discuss the rare case of a teenage boy, diagnosed with right internal carotid artery dissection and middle cerebral artery infarction, with no cause initially identified. Following further admission with a transient neurological episode, he was noted to have elongated styloid processes with the right abutting the site of carotid dissection. He underwent styloidectomy and has since remained symptom free. This case highlights the importance of considering anatomical variants when assessing young patients with neurological symptoms, and the potential morbidity and mortality benefit that early surgical intervention may have.

Integration of Health Information Technology and Promotion of Personhood in Family-Centered Dementia Care: Intervention Trial.

Alzheimer's disease and related dementias (ADRD) often result in communication deficits that can lead to negative health outcomes as well as complications for caregiving and clinical care. Although augmentative and alternative communication (AAC) devices have demonstrated efficacy in assisting persons living with dementia (PLWD) in communicating, few devices offer customization for the person's care preferences (e.g., clothing, food, activities) or are designed for integration into clinical care and caregiving. To address this issue, our research team is developing a novel electronic AAC prototype with a touchscreen to promote communication and personhood for PLWD. The current article describes the development of this technology and uses the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) 2013 Statement to describe the clinical trial that is planned to test its efficacy. TARGETS: PLWD and their care partners. INTERVENTION DESCRIPTION: Use of AAC Plus to promote communication and personhood for PLWD. MECHANISMS OF ACTION: AAC Plus will provide PLWD and care partners a way to communicate PLWD's daily preferences and provide clinical data for health care providers. OUTCOMES: Determine whether enhanced communication of daily preferences of PLWD will improve quality of life of PLWD and their care partners. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04571502 (Date of registration October 1, 2020). [Research in Gerontological Nursing, 14(5), 225-234.].

Athlete Experiences of Shame and Guilt: Initial Psychometric Properties of the Athletic Perceptions of Performance Scale Within Junior Elite Cricketers.

Guilt and shame are self-conscious emotions with implications for mental health, social and occupational functioning, and the effectiveness of sports practice. To date, the assessment and role of athlete-specific guilt and shame has been under-researched. Reporting data from 174 junior elite cricketers (M = 17.34 years; females n = 85), the present study utilized exploratory factor analysis in validating the Athletic Perceptions of Performance Scale (APPS), assessing three distinct and statistically reliable factors: athletic shame-proneness, guilt-proneness, and no-concern. Conditional process analysis indicated that APPS shame-proneness mediated the relationship between general and athlete-specific distress (p < 0.01), with this pathway non-contingent on sex or past 12-month help-seeking for mental health concerns (p's > 0.05). While APPS domains of guilt-proneness and no-concern were not significant mediators, they exhibited correlations in the expected direction with indices of psychological distress and well-being. The APPS may assist coaches and support staff identify players who may benefit from targeted interventions to reduce the likelihood of experiencing shame-prone states.

Midfacial degloving for juvenile angiofibroma: A case-series of 21 adult males: An alternative to the endoscopic approach and when it should be considered.

OBJECTIVES: To describe the midfacial degloving approach and compare the varying surgical approaches to juvenile angiofibromas. To demonstrate the efficacy of midfacial degloving in treating large juvenile angiofibromas in a unique patient cohort. DESIGN: A retrospective case-series between 2006 and 2019. SETTING: All patient care was undertaken at a regional skull base referral centre. PARTICIPANTS: Twenty-one male patients with a median age of 18 (range 16-45 years). MAIN OUTCOME MEASURES: Presenting symptoms, imaging, stage, age at operation, residual disease, estimated blood loss and operative time were all recorded. Postoperative outcomes included complications, length of stay and recurrence. RESULTS: The median surgical time was 105 minutes (range 55-219 minutes), median estimated blood loss 600 mls (range 150-900 mls) and median length of stay was 4 days (range 2-13 days.). Complications included two episodes of epistaxis, one requiring packing and one return to theatre. 14% (3/21) of patients had residual disease, none requiring further treatment and one patient had recurrence. CONCLUSIONS: MFD for JNA in our series resulted in low recurrence rate and no progression of residual disease. The approach has been successful in our cohort of patients and is an option in males over the age of 16 years, with JA extending beyond the nasopharynx and sinuses, involving the infratemporal fossa, cavernous sinus or orbital region.

"Food is something everyone should participate in": A positive deviance approach to understanding the use of a food and nutrition app in low-income, Latino homes.

OBJECTIVES: Latino families are among the most likely to be overweight or obese, which are conditions associated with numerous health risks and diseases. These families might lack know-how for preparing vegetables that fall outside cooks' culinary comfort zones and cultural traditions. Mobile apps are increasingly being developed for healthier cooking and eating, but research has not much explored how such apps are used among these families to help facilitate changes in eating patterns. This research seeks to identify behaviors and motivations that lead household cooks (i.e. mothers) in low-income Latino homes to use a food and nutrition app and create healthier eating environments for their families. METHODS: This study uses a positive deviance approach and individual interviews with mothers who were frequent app users and experienced beneficial food outcomes during their participation in a randomized controlled trial that tested the effects of an app on their cooking and family eating behaviors. Interviews were analyzed for themes using a framework analysis approach. RESULTS: Three themes emerged across interviews that were suggestive of approaches that led mothers to become frequent app users and prepare healthier meals: (1) mothers invited their children to use the app; (2) they involved both sons and daughters in the kitchen; and (3) they (cautiously) stepped outside their culinary comfort zones. CONCLUSION: Mobile apps and app-focused interventions should include features that invite: app co-use between mothers and children; opportunities for mothers to socialize boys, as well as girls into kitchen routines; and the use of culturally-familiar ingredients or recipes that are easily adaptable.

Transoral robotic surgery for recurrent cancers of the upper aerodigestive tract-Systematic review and meta-analysis.

BACKGROUND: Transoral robotic surgery (TORS) for recurrent head and neck (H&N) cancer is an emerging but relatively infrequent procedure. METHODS: Systematic review and meta-analysis of studies reporting survival data and functional outcomes for patients undergoing TORS for previously treated H&N cancers. RESULTS: Eight hundred seventy-eight records were identified, of which eight were eligible for inclusion, covering 161 cases (range 1-64). The pooled rates were as follows: 2-year overall survival 73.8% (4 studies, range 70.6-75.0, 95% confidence intervals (CI) 65.4 to 81.5, [I2 0.0%, P = 1.0]); 2-year disease-free survival 74.8% (4 studies, range 56.2-92.0, 95% CI 63.3 to 84.8, [I2 36.9%, P = .2]); postoperative hemorrhage 9.3% (4 studies, range 3.3-13.3, 95% CI 4.7 to 15.1, [I2 0.0%, P = .5]). CONCLUSIONS: Functional and oncological outcomes are favorable, although the follow-up is limited in the literature. Larger cohorts with longer follow-up are needed for definitive conclusions to be drawn.

Testing the clinical validity of the Bemelman Rib Fracture Management Guideline.

Whilst surgical stabilization of rib fractures (SSRF) results in better outcomes, selection algorithms are lacking. We aimed to validate the Rib Fracture Management Guideline proposed by Bemelman. From a cohort of 792 patients with multiple rib fractures, 2 sequential cohorts were selected: 48 patients who underwent SSRF and 48 patients who managed conservatively. Admission computed tomography scans and records were reviewed by an investigator blinded to the SSRF outcome. Adherence to the Bemelman guideline, revised to take account of consensus rib fracture definitions, was tested. Fifty-seven patients had multiple rib fractures only, and 39 patients also had a flail segment. Thirty-nine patients with flail segment underwent SSRF, and 18 patients were managed conservatively. Of the patients that the guideline predicted should have received surgery, 87% did. Of those that it predicted should not receive SSRF, 98% did not. The guideline displayed a sensitivity (95% confidence interval) and specificity for predicting the fixation of 0.98 (0.89-0.9995) and 0.83 (0.70-0.93), respectively. The positive and negative predictive values for surgical fixation were 0.87 (0.76-0.92) and 0.98 (0.85-0.99), respectively. The Bemelman guideline was thus a good predictor of SSRF in retrospective cohort but should be used in conjunction with clinical judgement. Further validation is indicated in a prospective study.

Body dysmorphic disorder and facial aesthetic treatments in dental practice.

There is a relatively high prevalence of body dysmorphic disorder (BDD) and it is known that this patient group regularly and frequently visit dental practitioners, especially those who advertise themselves as cosmetic or aesthetic practices. The market for facial aesthetics is hugely increasing both generally and within dental practices making it ever more likely that dentists will encounter this patient group frequently. Moreover, due to the nature of their concerns individuals within this group are likely to have contact with dentists (or other medical professionals in the physical health field) prior to any contact with mental health professionals. The aim of this paper is to give an overview of the presentation of BDD, to discuss the changing climate of facial aesthetic treatments and to highlight a care pathway for general dentists. Identification of patients with potential BDD is far more predictable with the use of a validated questionnaire, and the BDD Questionnaire and Dysmorphic Concern Questionnaire are described. A flowchart approach for the management of patients requesting aesthetic improvements is presented as the ideal method for identifying, referring and managing the aesthetic treatment desires of potential BDD patients.

Determining the clinical significance of the Chest Wall Injury Society taxonomy for multiple rib fractures.

BACKGROUND: The Chest Wall Injury Society (CWIS) proposals for standardized nomenclature for multiple rib fracture (MRF) classifications were derived by international expert Delphi consensus. This study aimed to validate the CWIS taxonomy using a single-instituion clinical database. METHODS: Computed tomography (CT) scans, of 539 consecutive patients with MRFs admitted to a regional major trauma center over a 33-month period, were reviewed (blinded for clinical outcomes). Every rib fracture in every patient was assessed according to each of the CWIS criteria (the degree of displacement, characterization of the fracture line, location of each fracture, and the relationship to neighboring fractures). The clinical significance of the proposed CWIS definitions were determined from independently coded, routinely collected Hospital Episodes Statistics data. RESULTS: The radiologic aspects of 3,944 individual rib fractures were assessed. Indicators of injury severity (severe displacement greater series length, and flail segment) were positively associated with other fractures (p < 0.001), hemopneumothorax (p < 0.001), pulmonary complications (p = 0.002), adverse outcomes (p = 0.006), mechanical ventilation (p < 0.001) and prolonged hospital and intensive therapy unit length of stay (p = 0.006, p = 0.007 respectively). Four of the CWIS-proposed definitions were correlated with pulmonary complications and adverse outcomes: the categories of displacement, the definition of individual fracture characterization, the presence of a flail segment. Two definitions for which there was CWIS consensus were not correlated with clinical outcomes: the definition of a series to describe associated fractures on neighboring ribs, the inclusion of a paravertebral sector for fracture localization. CONCLUSION: The CWIS rib fracture taxonomy demonstrates clinical relevance. There were associations between the severity of category groups within three of the proposed definitions, based on the clinical outcomes observed. Clinical outcome assessment proved inconclusive for four agreed definitions. Comprehensive, multiinstitutional data collection would be required to provide validation for all the CWIS-proposed definitions. LEVELS OF EVIDENCE: Level IV.

Secondary free tissue transfer in head and neck reconstruction.

BACKGROUND: The incidence of head and neck cancer (H&N) continues to increase together with the need for reconstructive surgery. Head and Neck microsurgeons are likely to encounter challenging secondary free flap surgery on the background of failed primary flaps, radiotherapy treatment or recurrence. The aim of this study was to review our experience of treating such cases in a tertiary referral centre in the United Kingdom. METHODS: We performed a retrospective analysis of all patients undergoing sequential free flap surgery for head and neck defects in our unit during 2010-2017. Parameters recorded included indication for surgery, type and sequence of reconstruction, recipient vessel use and post-operative complications. RESULTS: We identified 17 patients who underwent 39 free tissue transfers for the reconstruction of head and neck defects (five transfers were performed at other units). The radial forearm and anterolateral thigh flaps were most commonly used. Almost a quarter of patients underwent three or more free flap reconstructive procedures. In over a third, the same vein and artery were used for subsequent anastomoses, and we used five vein grafts over 68 anastomoses. There were no flap failures recorded. CONCLUSIONS: Secondary free flaps in the head and neck are required for a variety of aetiologies and can have success rates similar to those for primary free tissue transfers with minimal morbidity and mortality. Free tissue transfer is the best reconstructive option in H&N patients and should still be considered the first choice option in salvage cases until the patient's donor sites have been depleted.