Characterization of cerebral radiation necrosis following the treatment of sinonasal malignancies.

Objectives: Our study aims to determine the incidence and potential risk factors for cerebral radiation necrosis (CRN) following treatment of sinonasal malignancies. Methods: One hundred thirty-two patients diagnosed with sinonasal malignancies over an 18-year period were identified at two institutions. Forty-six patients meeting inclusion criteria and treated with radiation therapy were included for analysis. Demographic and clinical-pathologic characteristics were collected and reviewed. Post-treatment magnetic resonance imaging (MRI) at least 1 year following treatment was reviewed to determine presence or absence of CRN. Results: CRN was identified on MRI in 8 of 46 patients (17.4%) following radiation treatment. Patients with a history of reirradiation were more likely to develop CRN (50% vs. 10.5%, p < .05). The BEDs of radiation were also higher in CRN patients compared to non-CRN patients, but this difference was not significant (p > .05). CRN patients had a higher proportion of tumors with skull base involvement than non-CRN patients (100% vs. 57.9%, p = .037). Demographics, comorbidities, pathology, primary tumor subsite, chemotherapy use, and stage of disease demonstrated no significant increase in risk of CRN. Conclusions: Reirradiation and tumor skull base involvement were significant risk factors associated with CRN. Higher average total prescribed and BEDs of radiation were seen in the CRN groups, but these differences were not statistically significant. Gender, comorbidities, tumor subsite, tumor location, and treatment type were not significantly different between groups. Level of evidence: Level 3.

Management of Adult Inpatient Otolaryngologic Consultations During the COVID-19 Pandemic: A Proposed Tier-Based Triage System.

The coronavirus disease 2019 (COVID-19) pandemic has placed tremendous strain on health care systems, leading to unprecedented challenges and obstacles in the delivery of patient care. Otolaryngologists are frequently called on for inpatient consultations for an array of pathologies, ranging from chronic benign conditions to acutely life-threatening processes. Professional otolaryngologic societies across the world have proposed limiting patient care to time-sensitive and urgent matters; however, limited literature is available to describe how this transient change in philosophy may translate to clinical practice. Here we present a structured algorithm that allows for rapid triage of otolaryngologic consults during the ongoing pandemic, in efforts to minimize infectious spread and protect clinicians while preserving high-quality patient care. Considerations for managing these consults are presented, with a commentary on practical and ethical considerations.

Three-dimensional, extended field-of-view ultrasound method for estimating large strain mechanical properties of the cervix during pregnancy.

Cervical shortening and cervical insufficiency contribute to a significant number of preterm births. However, the deformation mechanisms that control how the cervix changes its shape from long and closed to short and dilated are not clear. Investigation of the biomechanical problem is limited by (1) lack of thorough characterization of the three-dimensional anatomical changes associated with cervical deformation and (2) difficulty measuring cervical tissue properties in vivo. The objective of the present study was to explore the feasibility of using three-dimensional ultrasound and fundal pressure to obtain anatomically-accurate numerical models of large-strain cervical deformation during pregnancy and enable noninvasive assessment of cervical-tissue compliance. Healthy subjects (n = 6) and one subject with acute cervical insufficiency in the midtrimester were studied. Extended field-of-view ultrasound images were obtained of the entire uterus and cervix. These images aided construction of anatomically accurate numerical models. Cervical loading was achieved with fundal pressure, which was quantified with a vaginal pressure catheter. In one subject, the anatomical response to fundal pressure was matched by a model-based simulation of the deformation response, thereby deriving the corresponding cervical mechanical properties and showing the feasibility of noninvasive assessment of compliance. The results of this pilot study demonstrate the feasibility of a biomechanical modeling framework for estimating cervical mechanical properties in vivo. An improved understanding of cervical biomechanical function will clarify the pathophysiology of cervical shortening.

How the cervix shortens: an anatomic study using 3-dimensional transperineal sonography and image registration in singletons and twins.

OBJECTIVES: The purpose of this study was to use a fixed reference to study movement (displacement) of the cervical internal os from the second to the third trimester in singletons and twins. The rationale was to gain insight into anatomic changes associated with cervical shortening. METHODS: For each patient, 2 transperineal scans were performed 12 weeks apart (20 and 32 weeks). The internal os and symphysis pubis were visualized in the same field of view. Image registration techniques were used to align the 2 scans using the symphysis as a fixed reference. Total displacement, anterior displacement, and inferior displacement of the internal os were measured. Displacements were correlated with cervical shortening. Bland-Altman plots and interobserver intraclass correlation coefficients were calculated. RESULTS: A total of 42 healthy participants were studied: 28 with singletons and 14 with twins. The mean ± SD values for total displacement were 2.1 ± 1.2 and 2.0 ± 1.2 cm for singletons and twins, respectively (P = .75). The direction of displacement was significantly different. The mean anterior displacement was 1.1 cm greater for singletons than for twins (95% confidence interval, 0.29-2.0 cm, P = .01). Mean inferior displacement was 1.3 cm greater for twins than for singletons (95% confidence interval, 2.2-0.1 cm; P = .03). Only inferior displacement correlated with cervical shortening (P < .001; R(2) = 0.74). For every 2.2 cm of inferior displacement, the cervix shortened 1.0 cm. Assessments of reliability showed good agreement between 2 observers. CONCLUSIONS: The anatomic position of the internal cervical os depends on gestational age and fetal number. Cervical shortening correlated most strongly with inferior displacement.

Quantifying osteogenic cell degradation of silk biomaterials.

The degradation of silk protein films by human mesenchymal stem cells (hMSCs), osteoblasts and osteoclasts, cells involved in osteogenic functions in normal and diseased bone, was assessed in vitro. The involvement of specific matrix metalloproteinases (MMPs) and integrin signaling in the degradation process was determined. Scanning electron microscopy (SEM) and atomic force microscopy (AFM) were used to quantitatively compare degradation by the different cell types using surface patterned silk films. Osteoblasts and osteoclasts demonstrated significant degradation of the silk films in vitro in comparison to the hMSCs and the film controls without cells. The osteoclasts degraded the silk films the most and also generated the highest level of MMPs 1 and 2. The osteoblasts upregulated integrins α5 and ß1, while the osteoclasts upregulated integrins α2 and ß1. There was significant contrast in responses on the silk matrices between osteogenic cells versus undifferentiated hMSCs to illustrate in vitro the role of cell type on matrix remodeling. These are important issues in matching biomaterial matrix features and studies in vitro to remodeling in vivo, in both normal and disease tissue systems. Cell populations and niche factors impact tissue regeneration, wound healing, physiological state, and the ability to better understand the role of different cell types is critical to overall regenerative outcomes.

Hypoxia and amino acid supplementation synergistically promote the osteogenesis of human mesenchymal stem cells on silk protein scaffolds.

Tailoring tissue engineering strategies to match patient- and tissue-specific bone regeneration needs offers to improve clinical outcomes. As a step toward this goal, osteogenic outcomes and metabolic parameters were assessed when varying inputs into the bone formation process. Silk protein scaffolds seeded with human mesenchymal stem cells in osteogenic differentiation media were used to study in vitro osteogenesis under varied conditions of amino acid (lysine and proline) concentration and oxygen level. The cells were assessed to probe how the microenvironment impacted metabolic pathways and thus osteogenesis. The most favorable osteogenesis outcomes were found in the presence of low (5%) oxygen combined with high lysine and proline concentrations during in vitro cultivation. This same set of culture conditions also showed the highest glucose consumption, lactate synthesis, and certain amino acid consumption rates. On the basis of these results and known pathways, a holistic metabolic model was derived which shows that lysine and proline supplements as well as low (5%) oxygen levels regulate collagen matrix synthesis and thereby rates of osteogenesis. This study establishes early steps toward a foundation for patient- and tissue-specific matches between metabolism, repair site, and tissue engineering approaches toward optimized bone regeneration.