Skull Base Dural Thickness and Relationship to Demographic Features: A Postmortem Study and Literature Review.

Dural membrane is an important anatomic structure that surrounds and protects the entire central nervous system. Physical properties of the dura have many pathophysiological and therapeutic implications in cranial surgery, especially skull base disorders. The aim of this study is to investigate variation in skull base dural thickness and correlation with different demographic parameters. At the time of autopsy, the petrous apex dura with the underlying bone of 20 cadavers was harvested. Dural thickness was independently measured by two pathologists at the thinnest and thickest segments in the specimen. Correlational analyses were then performed to compare dural thickness with gender, age, neck circumference, height, weight, and body mass index (BMI). Mean, minimum, and maximum skull base dural thickness in our study was 0.36, 0.27, and 0.46 mm, respectively. Age demonstrated a negative correlation with dural thickness with significantly thinner dura in the older subjects, p = 0.01. There was a trend toward thinner dura in females that approached statistical significance, p = 0.06. No strong correlation could be found with body weight, height, neck circumference, or BMI. Our findings show a considerable intersubject and intrasubject variability in skull base dural thickness. Some demographic parameters also seem to impact dural thickness. Additional histological studies are needed for better understanding of the pathophysiological mechanisms pertaining to the tensile properties of the dural membrane.

Health-Related Internet Use Among Otolaryngology Patients.

OBJECTIVE: The association between online health resources use in specific otolaryngology patients is poorly understood. To better understand health-related Internet use by otolaryngology patients, we surveyed first-visit patients at academic and private practice clinics in Iowa. METHODS: Data on socioeconomic status, access, and utilization of online resources were collected. Age distributions were compared by t test, and categorical variables were compared by chi-square analysis. Multivariate logistic regression was used to estimate odds ratios for association between independent variables (age, sex, educational attainment, otolaryngology subspecialty, etc). RESULTS: Data showed that 8.7% lacked Internet access; an additional 5.4% reported access only in a public place or at work. Younger, more educated, and more urban patients reported higher rates of Internet access. Among university patients, patients seeing head and neck oncologists were most likely to report no Internet access (10.9%). Just over one-third of patients used the Internet to research their health condition prior to their appointment. CONCLUSIONS: Internet access was far from universal among this large cohort of otolaryngology outpatients. Head and neck cancer (HNC) patients report the least online access among all otolaryngology subspecialties. Providers should consider nonelectronic patient resources for older, more rural, less educated, and HNC patient populations as online/electronic methods of communication may not be accessible to these groups.

Screening for Behavioral Health Conditions in Primary Care Settings: A Systematic Review of the Literature.

BACKGROUND: Mounting evidence indicates that early recognition and treatment of behavioral health disorders can prevent complications, improve quality of life, and help reduce health care costs. The aim of this systematic literature review was to identify and evaluate publicly available, psychometrically tested tools that primary care physicians (PCPs) can use to screen adult patients for common mental and substance use disorders such as depression, anxiety, and alcohol use disorders. METHODS: We followed the Institute of Medicine (IOM) systematic review guidelines and searched PubMed, PsycINFO, Applied Social Sciences Index and Abstracts, Cumulative Index to Nursing and Allied Health Literature, and Health and Psychosocial Instruments databases to identify literature addressing tools for screening of behavioral health conditions. We gathered information on each tool's psychometrics, applicability in primary care, and characteristics such as number of items and mode of administration. We included tools focused on adults and the most common behavioral health conditions; we excluded tools designed for children, youth, or older adults; holistic health scales; and tools screening for serious but less frequently encountered disorders, such as bipolar disorder. RESULTS: We identified 24 screening tools that met the inclusion criteria. Fifteen tools were subscales stemming from multiple-disorder assessments or tools that assessed more than one mental disorder or more than one substance use disorder in a single instrument. Nine were ultra-short, single-disorder tools. The tools varied in psychometrics and the extent to which they had been administered and studied in primary care settings. DISCUSSION: Tools stemming from the Patient Health Questionnaire had the most testing and application in primary care settings. However, numerous other tools could meet the needs of primary care practices. This review provides information that PCPs can use to select appropriate tools to incorporate into a screening protocol.

Prescribing of benzodiazepines and opioids to individuals with substance use disorders.

BACKGROUND: Benzodiazepines are recommended for short-term use due to risk of dependence. This study examined characteristics associated with benzodiazepine and opioid dispensing of 7+ days in a Medicaid population with substance use disorder (SUD). METHODS: Using 2014 MarketScan® data, we performed zero-inflated negative binomial regression to ascertain characteristics associated with longer-term use of these medications. RESULTS: Nearly 14% of those with SUDs received 1+ fills of benzodiazepines of 7+ days. The highest rates were among those aged 45-64 (IRR=2.38, p<0.0001) and with non-alcohol SUDs (IRR=1.12, p<0.0001). Individuals with co-occurring psychiatric disorders, particularly anxiety and depression (IRR=1.41, p<0.0001), had high rates of benzodiazepine fills. Receiving a 7+ day oral opioid fill (IRR=1.30, p<0.0001) coincided with increased benzodiazepine dispensing. Similar results occurred for longer-term prescribing of opioids, with higher rates among those with non-alcohol SUDs (IRR=1.23, p< 0.0001). CONCLUSIONS: For many people with SUDs, receiving a benzodiazepine or opioid prescription of 7+ days is not a single occurrence; patients in our sample were more likely to receive 2+ fills than to receive one. Longer-term prescribing is most pronounced among those with co-occurring anxiety disorders. This suggests that anxiety in those with SUD should preferentially not be treated using benzodiazepines. Longer-term polypharmacy with benzodiazepines and opioids coincided. Overdoses among those using both drugs are growing and this study provides evidence that attention to the opioid epidemic should include attention to polypharmacy that includes benzodiazepines.

Differences in Use of High-quality and Low-quality Hospitals Among Working-age Individuals by Insurance Type.

BACKGROUND: Research suggests that individuals with Medicaid or no insurance receive fewer evidence-based treatments and have worse outcomes than those with private insurance for a broad range of conditions. These differences may be due to patients' receiving care in hospitals of different quality. RESEARCH DESIGN: We used the Healthcare Cost and Utilization Project State Inpatient Databases 2009-2010 data to identify patients aged 18-64 years with private insurance, Medicaid, or no insurance who were hospitalized with acute myocardial infarction, heart failure, pneumonia, stroke, or gastrointestinal hemorrhage. Multinomial logit regressions estimated the probability of admissions to hospitals classified as high, medium, or low quality on the basis of risk-adjusted, in-hospital mortality. RESULTS: Compared with patients who have private insurance, those with Medicaid or no insurance were more likely to be minorities and to reside in areas with low-socioeconomic status. The probability of admission to high-quality hospitals was similar for patients with Medicaid (23.3%) and private insurance (23.0%) but was significantly lower for patients without insurance (19.8%, P<0.01) compared with the other 2 insurance groups. Accounting for demographic, socioeconomic, and clinical characteristics did not influence the results. CONCLUSIONS: Previously noted disparities in hospital quality of care for Medicaid recipients are not explained by differences in the quality of hospitals they use. Patients without insurance have lower use of high-quality hospitals, a finding that needs exploration with data after 2013 in light of the Affordable Care Act, which is designed to improve access to medical care for patients without insurance.

Effect of Having a Usual Source of Care on Health Care Outcomes Among Children With Serious Emotional Disturbance.

OBJECTIVE: To determine the influence of a usual source of care (USC) on health care utilization, expenditures, and quality for Medicaid-insured children and adolescents with a serious emotional disturbance (SED). METHODS: Administrative claims data for 2011-2012 were extracted from the Truven Health MarketScan Multi-State Medicaid Research Database for 286,585 children and adolescents with a primary diagnosis of SED. We used propensity score-adjusted multivariate regressions to determine whether having a USC had a significant effect on utilization and expenditures for high-cost services that are considered potentially avoidable with appropriate outpatient care: physical and behavioral health inpatient admissions, emergency department (ED) visits, and hospital readmissions. RESULTS: Propensity score-adjusted regressions indicated that children with a USC had fewer inpatient admissions related to behavioral health (adjusted odds ratio [AOR] = 0.87; 95% confidence interval [CI], 0.79-0.97) and physical health (AOR = 0.91; 95% CI, 0.89-0.93) and lower expenditures for behavioral health inpatient admissions, physical health ED visits, and readmissions. Having a USC also was associated with a higher likelihood of receiving quality health care for 4 physical health and 2 behavioral health measures. CONCLUSIONS: Having a USC improved the health care of Medicaid-insured children and adolescents with an SED. However, despite having insurance, approximately one-fourth of this patient population did not appear to have a USC. This information can be used in developing programs that encourage connections with comprehensive health care that provides coordination among various providers.

Weight loss after head and neck cancer: A dynamic relationship with depressive symptoms.

BACKGROUND: Weight loss and depressive symptoms are critical head and neck cancer outcomes, yet their relation over the illness course is unclear. METHODS: Associations between self-reported depressive symptoms and objective weight loss across the year after head and neck cancer diagnosis were examined using growth curve modeling techniques (n = 564). RESULTS: A reciprocal covariation pattern emerged-changes in depressive symptoms over time were associated with same-month changes in weight loss (t [1148] = 2.05; p = .041), and changes in weight loss were associated with same-month changes in depressive symptoms (t [556] = 2.43; p = .015). To the extent that depressive symptoms increased, patients lost incrementally more weight than was lost due to the passage of time and vice versa. Results also suggested that pain and eating-related quality of life might explain the reciprocal association between depressive symptoms and weight loss. CONCLUSION: In head and neck cancer, a transactional interplay between depressive symptoms and weight loss unfolds over time. © 2016 Wiley Periodicals, Inc. Head Neck 39: 370-379, 2017.

Influence of body composition on survival in patients with head and neck cancer.

BACKGROUND: Recent evidence has suggested links between obesity and outcomes for various types of cancer. This study investigates the impact that body composition has on survival in patients with head and neck cancer. METHODS: Data prospectively collected from 578 patients were analyzed using Cox regression models to determine independent associations that pretreatment body mass index (BMI) and 3-month weight change have on observed survival. RESULTS: Higher BMIs were associated with better survival (p < .001). Five-year rates ranged from 33.8% for underweight to 75.3% for overweight/obese patients. Patients with stable weight had the highest 5-year rate (72.6%; p = .019), whereas patients who gained ≥5% had worse survival (45.8%) than those who lost ≥5% (65.8%). BMI independently predicted survival, whereas weight change was not an independent predictor. CONCLUSION: This demonstrated association between BMI and survival provides useful information when offering prognoses and investigating optimal treatments © 2015 Wiley Periodicals, Inc. Head Neck 38: E261-E267, 2016.

Fear of recurrence impacts health-related quality of life and continued tobacco use in head and neck cancer survivors.

OBJECTIVE: To examine the impact of fear of recurrence (FOR) on health-related quality of life (HRQOL) and tobacco use among head and neck cancer (HNC) survivors. METHODS: A cross-sectional subset of patients (N = 138) from a large, prospective study of oncologic outcomes in HNC was assessed for FOR, in addition to the parent study's ongoing assessments of HRQOL and tobacco use. FOR was measured using the Fear of Cancer Recurrence Inventory and HNC-specific HRQOL was assessed with the Head and Neck Cancer Inventory (HNCI). Tobacco use was patient-reported as "Current," "Previous," or "Never." RESULTS: After controlling for relevant clinical and demographic variables, hierarchical regression analyses revealed that higher FOR significantly predicted lower HRQOL across all HNCI domains (eating (p < .05), aesthetics (p < .01), speech (p < .01), and social disruption (p = .001)) and increased tobacco use (p < .01). A total of 60.1% of the sample expressed clinically significant levels of FOR. These patients reported lower HRQOL (eating: p < .05, aesthetics: p < .05, social disruption: p < .05) and were more likely to be using tobacco compared with patients with subclinical FOR (26.6% and 4.9%, respectively; p < .01). CONCLUSIONS: Results suggest that FOR is prevalent among HNC survivors and is related to decreased HRQOL and increased tobacco use.

Psychological factors associated with head and neck cancer treatment and survivorship: evidence and opportunities for behavioral medicine.

Individuals diagnosed with head and neck cancer (HNC) not only face a potentially life-threatening diagnosis but must endure treatment that often results in significant, highly visible disfigurement and disruptions of essential functioning, such as deficits or complications in eating, swallowing, breathing, and speech. Each year, approximately 650,000 new cases are diagnosed, making HNC the 6th most common type of cancer in the world. Despite this, however, HNC remains understudied in behavioral medicine. In this article, the authors review available evidence regarding several important psychosocial and behavioral factors associated with HNC diagnosis, treatment, and recovery, as well as various psychosocial interventions conducted in this patient population, before concluding with opportunities for behavioral medicine research and practice.

Accuracy of fine-needle aspiration and imaging in the preoperative workup of salivary gland mass lesions treated surgically.

OBJECTIVES/HYPOTHESIS: Fine-needle aspiration (FNA) biopsy and imaging are commonly used in the preoperative assessment of salivary gland mass lesions. The goal of this retrospective study was to clarify the role of FNA and imaging in the workup of salivary gland masses. STUDY DESIGN: Retrospective cohort study. METHODS: A computer search identified patients with an FNA of a salivary gland lesion with subsequent excision during a 10-year study period. Chart review of study patients was performed, and information on site of lesion, age, gender, radiologic diagnosis, pain in the tumor area, and facial paralysis was recorded and analyzed. RESULTS: There were 543 patients who had an FNA and subsequent histopathology. The majority of the tumors were in the parotid gland (n = 492, 90.9%), followed by submandibular gland (n = 45, 8.3%). The incidence of malignancy across all sites was 29.7%. The mean patient age was 54.1 years, and 54.1% were female. The sensitivity and specificity of FNA were 85.7% and 99.5%, respectively. Positive predictive value (PPV) was 98.6%, and negative predictive value (NPV) was 94.3%. A total of 464 patients had available radiologic studies. For the radiological diagnoses, sensitivity was 81.8% and specificity was 67.3%, whereas PPV and NPV were 52.7% and 89.3%, respectively. CONCLUSIONS: FNA is a reliable method of preoperatively assessing both benign and malignant salivary gland lesions. Preoperative imaging has a lower sensitivity and specificity than FNA in differentiating malignant from benign tumors. Older age, pain, and facial paralysis are clinical features independently associated with malignancy.

Changing microbiology of pediatric neck abscesses in Iowa 2000-2010.

OBJECTIVES/HYPOTHESIS: To examine the changing microbiology of pediatric neck abscesses over a 10-year period with particular interest in methicillin-resistant Staphylococcus aureus (MRSA) infections and their associated antibacterial-resistance patterns, including resistance to clindamycin, a frequently used antibiotic for Staphylococcus aureus. STUDY DESIGN: Retrospective chart review at a tertiary academic medical center. METHODS: One hundred and twenty-two consecutive pediatric patients managed between January 2000 and June 2010 with incision and drainage of a proven neck abscess. RESULTS: Seventy-four patients with 76 abscesses were identified. A microorganism was found in 65 (85%) of the 76 abscesses. Forty-three percent grew Staphylococcus aureus (SA), 12% were methicillin-resistant Staphylococcus Aureus (MRSA), and 31% were methicillin-susceptible Staphylococcus aureus (MSSA). There was a significant increase in the incidence of MRSA infections during the study period, with only one case of MRSA diagnosed in the first half of the study (from 2000-2004) compared with seven in the second half (from 2005-2010) (P = 0.023). The second most common bacterial etiology or isolate was Streptococcus pyogenes in 27%, while the remaining 30% grew mixed oral flora and other microorganisms. CONCLUSIONS: These findings demonstrate a statistically significant rise in the proportion of MRSA neck infections in pediatric patients in Iowa. Resistance to clindamycin was highest among MSSA isolates. Clindamycin-resistant S. aureus and Streptococcus pyogenes are established pathogens in neck infections. In communities with similar microbiology patterns, empiric treatment with combination therapy of a beta lactam and vancomycin or trimethoprim/sulfamethoxazole should be initiated until culture results are available.

Influence of pretreatment social support on health-related quality of life in head and neck cancer survivors: results from a prospective study.

BACKGROUND: Head and neck cancer and its treatment can have considerable impact on health-related quality of life (HRQOL). The present study investigated whether social support, assessed before treatment, predicted HRQOL outcomes up to 12 months later in head and neck cancer survivors. METHODS: Using a prospective longitudinal design, patients (n = 364) were assessed on several clinical and psychosocial characteristics at diagnosis and then at 3- and 12-month follow-up appointments. HRQOL was assessed with the Short Form Health Survey (SF-36) and the Head and Neck Cancer Inventory (HNCI). RESULTS: Hierarchical multiple regression analyses demonstrated that greater perceived support present at diagnosis significantly predicted more favorable global and head and neck cancer-specific HRQOL at 3- and 12-month follow-up. CONCLUSION: Results suggest that adequate social support at diagnosis can have a significant, positive impact on HRQOL in head and neck cancer survivors. Thus, it may be useful to evaluate support resources at diagnosis in order to identify individuals at risk for poor HRQOL outcomes.

Upper aerodigestive tract cancer in patients with chronic lymphocytic leukemia: incidence, stage, and outcome.

OBJECTIVE: To compare incidence, stage, and survival of upper aerodigestive tract (UADT) cancers in patients with and without chronic lymphocytic leukemia (CLL). DESIGN: Inception cohort. SETTING: National database. PATIENTS: Individuals with CLL and UADT cancers included in the Surveillance, Epidemiology, and End Results (SEER) database. MAIN OUTCOME MEASURES: Incidence was compared by computing standardized incidence ratio (SIR), the ratio of observed UADT cancers in patients with CLL, and the number of UADT cancers expected based on the characteristics of patients with CLL and population incidence of UADT cancers. The association between CLL and UADT cancer stage was measured using odds ratio (OR) calculations. Survival of patients with UADT cancer with and without CLL was compared. RESULTS: For the SIR calculation, 36 985 patients with CLL contributed a mean 6.36 years of follow-up each, for a total of 235 314 person-years of follow-up. The SIR was 1.18 (95% CI, 0.97-1.41) for UADT cancers; 1.52 (95% CI, 1.18-1.93) for laryngeal cancer; and 1.92 (95% CI, 1.05-3.23) for cancers of the nasal cavity and paranasal sinuses. In the stage and survival analyses, 253 patients with CLL followed by a UADT cancer were compared with 133 840 patients with 1 UADT cancer only. Cancers of the UADT in patients with CLL were more likely localized (OR, 0.50; 95% CI, 0.37-0.68). Relative survival was worse in patients with CLL. In multivariate analysis, CLL was independently associated with poorer observed survival (hazard ratio, 1.45; 95% CI, 1.24-1.70). CONCLUSIONS: Larynx and nasal cavity cancers were more common in patients with CLL. Overall incidence of UADT cancers was not significantly elevated. Cancers of the UADT in patients with CLL were more likely to be localized at diagnosis than those in patients without CLL. Finally, CLL was associated with poorer survival outcomes.

Long-term health-related quality of life in survivors of head and neck cancer.

OBJECTIVE: To examine health-related quality of life (HRQOL) reported by 5-year head and neck cancer survivors and factors that predicted these long-term scores. DESIGN: Prospective, observational outcomes study. SETTING: Tertiary care institution. PATIENTS: A total of 337 patients diagnosed as having head and neck carcinoma between January 1995 and December 2004, who enrolled in the Outcomes Assessment Project and survived at least 5 years. INTERVENTIONS: While participating in the longitudinal Outcomes Assessment Project, patients filled out surveys measuring HRQOL at numerous points in time. MAIN OUTCOME MEASURES: Outcomes included 5-year scores in eating, speech, aesthetics, social disruption, physical and mental health, depressive symptoms, and overall quality of life (QOL). In addition to analyzing patients' 5-year HRQOL outcomes, multivariate analyses were performed to determine which patient, clinical, treatment, and 1-year HRQOL factors independently predicted these 5-year outcomes. RESULTS: Overall, the cohort's long-term general health was similar to that to age-matched norms from the general population. But over 50% of these survivors had problems eating, 28.5% reported depressive symptoms, and 17.3% reported substantial pain. At long-term follow-up, 13.6% continued to smoke, and 38.9% used alcohol. Multivariate analyses demonstrated that 1-year pain and diet were the strongest independent predictors of 5-year HRQOL outcomes. CONCLUSIONS: Eating problems due to poor oropharyngeal functioning and persistent pain are the most prevalent problems that these survivors face. Early interventions addressing eating issues, swallowing problems, and pain management will be a crucial component in improving this patient population's long-term QOL, especially in those who are functioning poorly 1 year after diagnosis.

Association between severity of dysphagia and survival in patients with head and neck cancer.

BACKGROUND: This study examined risk factors for dysphagia, a common and serious condition in patients with head and neck cancer, and the association between severity of dysphagia and survival. METHODS: Chart reviews were performed on patients diagnosed with head and neck cancer between January 2001 and April 2003, who had dysphagia diagnoses or swallowing evaluations. Regression analyses determined factors associated with dysphagia and the association between observed survival and severity of dysphagia. RESULTS: Almost 50% of the 407 patients had dysphagia. Risk factors included advanced stage, older age, female sex, and hypopharyngeal tumors. The most severe dysphagia ([L.] nil per os or "nothing by mouth" status), which was associated with lower survival rates, was the strongest independent predictor of survival. CONCLUSIONS: Swallowing problems should be considered when determining appropriate cancer-directed treatment and posttreatment care. Because of dysphagia's high incidence rate and association with survival, a speech-language pathologist should be involved to ensure routine diagnostic and therapeutic swallowing interventions.

Factors associated with mortality in 2-year survivors of head and neck cancer.

OBJECTIVES: To determine conditional survival rates of 2-year survivors of head and neck cancer and to identify risk factors of increased mortality. DESIGN: Prospective, observational study conducted from September 1, 2001, through September 31, 2008. SETTING: Tertiary care institution. PATIENTS: Two hundred seventy-six patients who survived 2 years after the diagnosis of their upper aerodigestive carcinoma. INTERVENTION: Patients prospectively provided health-related information. MAIN OUTCOME MEASURES: The primary outcomes were observed (death from all causes) and disease-specific (cancer-related) survival for 2-year survivors. RESULTS: Five-year observed (90.8%) and disease-specific (94.8%) survival rates were 29.7 and 25.0 percentage points higher, respectively, than rates calculated for all patients at diagnosis. Older age and advanced stage were associated with poorer survival, whether death was due to the cancer or from all causes. Patients with pain or poor overall quality of life at 2 years were more likely to die from all causes, whereas those still smoking 2 years after diagnosis were more likely to die from their cancer. CONCLUSIONS: In addition to older age and advanced stage, pain, poor overall quality of life, and tobacco use 2 years after diagnosis characterize patients who might need longer and more intense follow-up care to improve their observed and disease-specific survival. This information is useful in developing management plans for patients transitioning from a focus on cancer surveillance into survivorship.

Outcomes after the use of gastrostomy tubes in patients whose head and neck cancer was managed with radiation therapy.

BACKGROUND: The purpose of this study was to examine the effect of continued oral intake and duration of gastrostomy tube placement on posttreatment nutritional outcomes in patients being irradiated for head and neck cancer. METHODS: Factors associated with continued oral intake and its association with posttreatment outcomes were analyzed. RESULTS: Patients with no oral intake (39.6% of 91) were more likely to have laryngeal tumors, advanced disease, and pretreatment gastrostomy tube placement. Of the 55 patients whose gastrostomy tubes had been removed, those with continued oral intake and shorter gastrostomy tube placement were more likely to maintain their weight and report eating scores in the higher-functioning category, but have more restricted diets. Observed survival was significantly better for the continued-oral-intake group (p = .001). CONCLUSION: The beneficial effects of continued oral intake and shorter gastrostomy tube placement on posttreatment outcomes shown in this study suggest that clinicians involved in these patients' care should emphasize oral intake during treatment.