SARS-CoV-2 exposures among healthcare workers in New York City.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has had a significant impact on hospitals, including the occupational health departments in charge of handling healthcare worker (HCW) staffing during high rates of exposure and infection of HCWs. HCWs who were exposed to a patient or community member infected with SARS-CoV-2 were required to isolate from work for a minimum of 14 days from the date of exposure. AIMS: This study was aimed to assess the relative risk of SARS-CoV-2 infection following different types of workplace and community exposures. METHODS: We analyzed the details of workplace and community exposures of HCWs to SARS-CoV-2 at Montefiore Medical Center in New York between 22 June 2020 and 22 November 2020. RESULTS: Of 562 HCW SARS-CoV-2 exposures analyzed, 218 were from the community and 345 were from the workplace. Twenty-nine per cent of community exposures resulted in infection, which was significantly greater than workplace exposure infection (2%). Household community exposures resulted in a larger frequency of infection than non-household community exposures. Of the seven infections after workplace exposures, five had qualifying exposures to a co-worker and two were exposed to an infected patient during a non-aerosolized procedure. CONCLUSIONS: HCW exposure to SARS-CoV-2 continues to present staffing challenges to healthcare systems. Even with deviations from standard personal protective equipment protocol, workplace exposures resulted in low frequencies of infection. In our study, the primary source of HCW infection was exposure in the community. Our findings support investing in efforts to educate around continued masking and social distancing in the community in addition to interventions targeted at addressing vaccine hesitancy.

Analysis of the prognostic significance of lymph node related characteristics in papillary thyroid carcinoma patients presenting with pre- or intra-operative evidence of cervical lymph node metastases.

OBJECTIVE: To identify the prognostic significance of specific lymph node related characteristics for disease persistence and recurrence in patients with pre- or intra-operative evidence of neck metastases and no other risk factors. METHOD AND RESULTS: Sixty-eight patients were identified; 50 per cent had persistent or recurrent disease. All underwent the same treatment strategy. There were no statistically significant differences in any of the patient- or tumour-related parameters when patients with and without persistence or recurrence were compared. Patients with recurrent or persistent disease had significantly larger (>3 cm) metastatic lymph nodes, but there were no differences regarding other lymph node related parameters (i.e. number, extracapsular extension, number of lymph nodes with extracapsular extension, and central vs lateral neck location). On multivariate analysis, however, none of the parameters were predictive of persistent or recurrent disease. CONCLUSION: In papillary thyroid carcinoma patients with no other risk factors, pre- or intra-operative evidence of cervical metastases was associated with a very high rate of disease persistence or recurrence. Specific lymph node characteristics were not shown to have prognostic significance.

The impact of positive resection margins in partial laryngectomy for advanced laryngeal carcinomas and radiation failures.

OBJECTIVES: To investigate the prognostic significance of positive margin and disease course in partial laryngectomy for advanced laryngeal carcinoma and radiation failure. DESIGN: Retrospective case control study. SETTING: A major tertiary referral centre. PARTICIPANTS: Patients who underwent partial laryngectomy for advanced laryngeal carcinoma or for radiation failure with at least 2 years of follow-up. MAIN OUTCOME MEASURES: Margin status versus primary treatment and salvage treatment versus disease-free survival and overall survival. RESULTS: Twenty nine patients with sufficient follow-up data were found. Twelve patients had histological positive margin. Five of the 12 patients with a histological positive margin failed surgery as did four patients with clear margins. A positive margin had no effect on disease-free survival (P = 0.287) but was associated with poorer overall survival (P = 0.051). Of 11 patients treated primarily with surgery, recurrence was documented in one of eight with a positive margin and none of three with clear margins. Of 18 patients who underwent surgery secondary to radiation failure, recurrence was documented in all four with a positive margin and 4 of 14 with negative margins. Extended frontolateral resection, performed only in radiation failures, was associated with worse disease-free survival. CONCLUSIONS: Non-irradiated patients with involvement of a single margin after partial laryngectomy may be spared total laryngectomy if adjuvant radiation is administered. Patients who fail radiation should undergo radical partial laryngectomy, with conversion to total laryngectomy in those with a positive margin.

Laser posterior ventriculocordectomy with partial arytenoidectomy for the treatment of bilateral vocal fold immobility.

Bilateral vocal fold immobility in adduction usually creates severe dyspnoea. Many surgical procedures have been established to improve the airway insufficiency in affected patients. Over the last six years 22 patients with bilateral vocal fold immobility in our department have undergone CO(2) laser posterior ventriculocordectomy with partial arytenoidectomy (PVCPA). None had dyspnoea or a disturbance in the immediate post-operative period or during follow up, which ranged from five months to six years. Only one patient required a second procedure. Laser PVCPA appears to be an effective and reliable method for the treatment of bilateral vocal fold immobility in selected patients.

Predictive value of early weight loss in obesity management with orlistat: an evidence-based assessment of prescribing guidelines.

OBJECTIVE: To assess the clinical usefulness of published guidelines for the use of orlistat, by studying whether weight loss >/=2.5 kg during a 4 week dietary lead-in period, and weight losses of >/=5% after 12 weeks and >/=10% after 6 months of drug therapy predict weight loss and risk factor changes after 2 years. DESIGN: A retrospective analysis of pooled data from 2 multicentre, randomised, placebo-controlled clinical trials with similar design. SETTING: Twenty-nine centres throughout Europe. PARTICIPANTS: Two hundred and twenty men and women (BMI 28-43 kg/m(2)) who completed 2 years of treatment. INTERVENTION: After a 4 week hypocaloric diet plus placebo, 2 years of treatment with orlistat 120 mg tid, plus a hypocaloric diet for the first year and a weight maintenance diet in year two. MAIN OUTCOME MEASURES: Weight loss and obesity-related risk factor changes. RESULTS: Weight loss >/=5% body weight after 12 weeks of diet plus orlistat therapy was a good indicator of 2 year weight loss, whereas weight loss of >/=2.5 kg during the 4 week lead-in and >/=10% after 6 months did not add significantly to the prediction of 2 year outcomes. Patients who lost >/=5% of their weight at 12 weeks (n=104, 47.3%) lost significantly more weight after 2 years than others: -11.9% (95% confidence interval (CI) -13.4% to -10.3%) vs -4.7% (-5.7% to -3.7%) (P=0.0001), and had significantly greater reductions in total cholesterol, LDL-cholesterol, triglycerides, glucose, insulin, and blood pressure. Among those who achieved >/=5% weight loss at 12 weeks, the overall health benefits were not significantly greater in patients who went on to lose >/=10% body weight at 6 months compared with those who did not achieve >/=10% weight loss by month 6. CONCLUSIONS: Of the criteria currently suggested for assessing response to orlistat treatment, weight loss of >/=5% at 12 weeks accurately predicts sustained improvements in weight and major risk factors at 2 years, while other suggested criteria are less useful.

Metabolic and hemodynamic responses to exercise in subcutaneous adipose tissue and skeletal muscle.

This study evaluated the effect of standardized bicycle exercise on metabolism and blood flow in abdominal ( aSAT) and femoral subcutaneous adipose tissue ( fSAT) and skeletal muscle in eleven women and nine men. Using microdialysis, the respective tissues were perfused with Ringer's solution (+ 50 mM ethanol) and dialysate [ethanol], [glycerol], [lactate] and [pyruvate] were measured in order to estimate blood flow (ethanol dilution technique), lipolysis and glycolysis, respectively. At rest, blood flow tended to be higher in the respective tissues of women when compared to men. During exercise, blood flow was increased significantly in fSAT and muscle, but not in aSAT. Dialysate [glycerol] was increased two- to three-fold in aSAT and fSAT, similarly in men and women. However, in muscle, dialysate [glycerol] was increased five-fold in women and four-fold in men without reaching a steady state in women. Corrected for blood flow, the increase in lipolysis was greater in muscle than in fSAT, and greater in fSAT than in aSAT, and in muscle the increase was greater for women compared with men. Dialysate [lactate] and [lactate]/[pyruvate] ratio were much more increased in muscle compared with aSAT and fSAT. It is concluded that lipids stored in muscle are rather used than lipids stored in adipose tissue for fueling the energy metabolism of muscle during exercise. During exercise, lipid mobilization is much greater in women than in men.

[The current approach to hemangiomas and vascular malformations of the head and neck].

Though most hemangiomas do not need treatment, a significant minority are associated with complications and external deformities that demand intervention. Steroids play an important role in therapy, but not infrequently afford only partial and temporary benefit. Thanks to improvements in the surgical approach and equipment, hemostasis control devices and laser techniques, we can now treat patients who would otherwise go untreated. Moreover, in certain cases, we can now recommend earlier intervention, saving patients from years of living with deformities and the concomitant psychosocial problems. Vascular anomalies of the head and neck include venular, venous and arteriovenous malformations. These lesions are slow growing vascular ectasia that never involute spontaneously and almost always require intervention. Treatment includes laser therapy, injection of sclerosing agents, embolization through angiography and surgery, which in many cases is the only definitive treatment. We present the current treatment approach and describe our experience in the treatment of 16 patients.

Effect of orlistat-assisted weight loss in decreasing coronary heart disease risk in patients with syndrome X.

This study describes the changes in risk factors for coronary heart disease in obese persons with syndrome X after orlistat-assisted weight loss. Data were available for 1,700 patients who completed 52 weeks of weight loss; 128 were defined as having syndrome X by being in the quintile with the highest plasma triglyceride levels (>2.2 mM/L) and the lowest high-density lipoprotein cholesterol (HDL, <1.0 mM/L) concentrations. Initial characteristics of those with syndrome X were similar to the 119 subjects (non-syndrome X) in the lowest quintile of plasma triglyceride (<0.975 mM/L) and highest quintile of HDL cholesterol (>1.5 mM/L). Subjects were placed on a calorie-restricted diet, and randomized to receive orlistat or placebo. Initial values were higher in those with syndrome X for diastolic blood pressure (p = 0.03), plasma insulin (p = 0.0001), triglyceride (p = 0.0001) concentrations, and ratio of low-density lipoprotein cholesterol to HDL cholesterol (p = 0.0001), and were lower for HDL cholesterol (p = 0.001) concentrations. Weight loss was greater in both groups of orlistat-treated patients (p = 0.026); in those with syndrome X, it was associated with a significant reduction in plasma insulin (p = 0.019) and triglyceride (p = 0.0001) concentrations, an increase in HDL cholesterol concentration, and a decrease in low-density lipoprotein/HDL cholesterol ratio (p = 0.0001). There were no significant changes in plasma insulin, triglycerides, or HDL cholesterol concentration in the non-syndrome X group. In conclusion, weight loss attenuates coronary heart disease risk factors in obese persons with syndrome X, and the risk factor reduction is enhanced with administration of orlistat.

Connections of the facial and vestibular nerves: an anatomic study.

The facial and vestibulocochlear nerves emanate from the brain stem and then run parallel to each other within the internal auditory canal prior to their more peripheral distribution. Although anatomic connections between the facial and cochlear nerves have been described, reports outlining facial-vestibular anastomoses are few and may be found primarily in the non-English literature. The present study documents the existence of vestibulofacial neural connections as part of an anatomic dissection of 17 fresh human temporal bones.

Effects of weight loss with orlistat on glucose tolerance and progression to type 2 diabetes in obese adults.

BACKGROUND: Orlistat is a gastrointestinal lipase inhibitor that reduces dietary fat absorption by approximately 30%, promotes weight loss, and may reduce the risk of developing impaired glucose tolerance and type 2 diabetes in obese subjects. OBJECTIVE: To test the hypothesis that orlistat combined with dietary intervention improves glucose tolerance status and prevents worsening of diabetes status more effectively than placebo. METHODS: We pooled data from 675 obese (body mass index, 30-43 kg/m2) adults at 39 US and European research centers in 3 randomized, double-blind, placebo-controlled multicenter clinical trials. Subjects received placebo plus a low-energy diet during a 4-week lead-in period. On study day 1, the diet was continued, and subjects were randomized to receive placebo 3 times a day (n=316) or treatment with orlistat, 120 mg 3 times a day (n=359), for 104 weeks. A standard 3-hour oral glucose tolerance test was performed on day 1 and at the end of treatment. MAIN OUTCOME MEASURES: The categorical assessment of glucose tolerance status (normal, impaired, diabetic) and changes in status from randomization to end of treatment were the primary efficacy measures. The secondary measures were fasting and postchallenge glucose and insulin levels. RESULTS: The mean length of follow-up was 582 days. Subjects who were treated with orlistat lost more weight (mean +/- SEM, 6.72 +/- 0.41 kg from initial weight) than subjects who received placebo (3.79+/-0.38 kg; P<.001). A smaller percentage of subjects with impaired glucose tolerance at baseline progressed to diabetic status in the orlistat (3.0%) vs placebo (7.6%) group. Conversely, among subjects with impaired glucose tolerance at baseline, glucose levels normalized in more subjects after orlistat treatment (71.6%) vs placebo (49.1%; P=.04). CONCLUSIONS: The addition of orlistat to a conventional weight loss regimen significantly improved oral glucose tolerance and diminished the rate of progression to the development of impaired glucose tolerance and type 2 diabetes.

Orlistat in the long-term treatment of obesity in primary care settings.

OBJECTIVE: To evaluate the long-term efficacy and tolerability within primary care settings of orlistat, a gastrointestinal lipase inhibitor, for the treatment of obesity. DESIGN: Randomized, double-blind, placebo-controlled, multicenter study. PARTICIPANTS: A group of 796 obese patients (body mass index, 30-44 kg/m2), treated with placebo 3 times a day (TID), 60 mg of orlistat TID, or 120 mg of orlistat TID, in conjunction with a reduced-energy diet for the first year and a weight-maintenance diet during the second year. SETTING: Seventeen primary care centers in the United States. MAIN OUTCOME MEASURES: Changes in body weight and obesity-related disease risk factors. RESULTS: Patients treated with orlistat lost significantly more weight (7.08 +/- 0.54 and 7.94 +/- 0.57 kg for the 60-mg and 120-mg orlistat groups, respectively) than those treated with placebo (4.14 +/- 0.56 kg) in year 1 (P<.001) and sustained more of this weight loss during year 2 (P<.001). More patients treated with orlistat lost 5% or more of their initial weight in year 1 (48.8% and 50.5% of patients in the 60-mg and 120-mg groups, respectively) compared with placebo (30.7%; P<.001), and approximately 34% of patients in the orlistat groups sustained weight loss of 5% or greater over 2 years compared with 24% in the placebo group (P<.001). Orlistat produced greater improvements than placebo in serum lipid levels and blood pressure and was well tolerated, although treatment resulted in a higher incidence of gastrointestinal events. CONCLUSIONS: This long-term study indicates that orlistat is an effective adjunct to dietary intervention in the treatment of obesity in primary care settings.

Reactive arthritis (Reiter's syndrome).

Reactive arthritis, also called Reiter's syndrome, is the most common type of inflammatory polyarthritis in young men. It is sometimes the first manifestation of human immunodeficiency virus infection. An HLA-B27 genotype is a predisposing factor in over two thirds of patients with reactive arthritis. The syndrome most frequently follows genitourinary infection with Chlamydia trachomatis, but other organisms have also been implicated. Treatment with doxycycline or its analogs sometimes shortens the course or aborts the onset of the arthritis. Reactive arthritis may also follow enteric infections with some strains of Salmonella or Shigella, but use of antibiotics in these patients has not been shown to be effective. Reactive arthritis should always be considered in young men who present with polyarthritis. Symptoms may persist for long periods and may, in some cases, cause long-term disability. Initial treatment consists of high doses of potent nonsteroidal anti-inflammatory drugs. Patients with large-joint involvement may also benefit from intra-articular corticosteroid injection.

Surgery of thyroid cancer in children and adolescents.

BACKGROUND: Thyroid carcinoma in young patients under the age of 20 years is uncommon. Because of the slow progression of this disease, there is still a great deal of debate as to which operation strategy is best. METHODS: We undertook a retrospective study of 61 patients under 20 years of age with thyroid cancer treated at our institute between 1952 and 1995. They constitute 6.6% of the 921 thyroid cancer patients treated by us during the same period. Factors examined were: symptoms, metastases, treatment, complications, and survival. RESULTS: Total or near-total thyroidectomy was performed in 51 patients. Regional lymph node dissection was performed in 17 patients and modified radical neck dissection in 13. Fifty-one patients underwent pretracheal and paratracheal lymph node dissection. During the 43 years of this study, two patients died of thyroid cancer. CONCLUSIONS: Although most children are initially seen with more extensive disease than adults, the overall prognosis is excellent. The excellent prognosis is the product of initial aggressive treatment: near-total or total thyroidectomy and at least pre- and paratracheal lymph node dissection, followed by radioactive iodine therapy.

DNA ploidy in papillary carcinoma of the thyroid gland in children and adolescents.

OBJECTIVE: To evaluate DNA ploidy in papillary thyroid carcinoma in children in correlation to the clinical course of the disease. METHODS: Flow cytometric DNA ploidy measurements were performed on formalin-fixed, paraffin-embedded tumor specimens from 14 children and 14 adult patients with papillary carcinoma of the thyroid gland. Analysis of DNA content was performed blind to patient's age and clinical presentation. RESULTS: Seven patients presented with cervical metastasis, one patient had distal metastasis and four patients had local invasion. All patients underwent total thyroidectomy. Seven children underwent bilateral modified neck dissection. Twenty-five tumors expressed diploid DNA content. No statistically significant difference in DNA content was observed between the tumors from child and adult patients. No correlation was found between DNA content and aggressive presentation in the pediatric group. CONCLUSION: Our primary results indicate that diploid DNA content is common in papillary thyroid carcinoma in children and aggressive clinical presentation is not associated with DNA aneuploidy. Larger prospective studies and long-term clinical follow-up is warranted to document the clinical significance of these observations.

[Kimura's disease and angiolymphoid hyperplasia with eosinophilia-- on disease with different expressions?].

Kimura's disease is a rare angiolymphoid proliferative disorder of soft tissue characterized by subcutaneous swelling and a predilection for the head and neck. There are usually enlarged regional lymph nodes, eosinophilia and elevated sedimentation rate and IgE levels. A 26-year-old women with subcutaneous masses in the submandibular area is reported. The diagnosis of Kimura's disease versus angiolymphoid hyperplasia is discussed.

Supraglottic carcinoma: a retrospective study of 114 patients.

We retrospectively evaluated the management of supraglottic carcinoma at our centre during the last 35 years to determine the preferred mode of treatment. A review of the medical records yielded 114 patients with supraglottic T1 and T2 carcinoma who were diagnosed and treated in the Departments of Otolaryngology, Head and Neck Surgery, and Oncology between 1959 and 1993. Of these, 47 (41.2%) had T1 carcinoma (stage I) and 67 (58.8%) T2 (stage II). Treatment varied among radiotherapy, surgery, or combined radiotherapy and surgery. Twelve patients underwent elective neck dissection, one of whom (8.3%) was found to have occult metastases. Local failures were noted in 22 patients (11 T1: 11 T2), three of whom also had neck metastases. All except one T2 patient received radiotherapy. Radiotherapy yielded the best survival rates for T1 disease as combined therapy did for T2. Five-year recurrence rates for T1 patients were 35% for those treated by radiotherapy and 42% for those treated with combined therapy; corresponding figures for T2 patients were 39% and 28%. We suggest that patients with T1 supraglottic carcinoma be managed with radiotherapy and patients with T2 with combined therapy. We believe there is no need for elective neck dissection, especially in T1.

Carcinoma of the thyroid in children--a review.

Thyroid cancer is the third most common solid tumor in children and adolescents. A review was made of the data on 540 such patients reported from nine large centers renowned for their experience with thyroid cancer. In respect to the pathogenesis the only factor conclusively known to promote development of thyroid cancer in the pediatric age group is irradiation, as documented by the Chernobyl experience. The evidence indicates that thyroid carcinoma in the pediatric age group is a biologically independent and more aggressive entity than in adults; paradoxically the prognosis is good. In the great majority of cases the only presenting sign was a neck mass. In a high percentage (60-80%) there were also palpable lymph nodes. The findings regarding lung metastases were not clear-cut: in most series they were present in about 10%, with a high of 28% in one group and a low of 5% in another group. Papillary carcinoma or the follicular variant of papillary carcinoma were the dominant histologic types, pure follicular carcinoma being found much less frequently than among adults with thyroid cancer. Despite the relatively advanced stage of the disease upon diagnosis, only 13 patients died of the disease, 12 to 33 years postoperatively. Recurrence rates ranged between 10% to 35%, with involvement of the lateral neck, thyroidal bed or distant sites 3 to 33 years after treatment; most failures responded to further surgery or radioactive iodine. There is almost general agreement that surgical intervention should consist of total or near total thyroidectomy despite the high rates of recurrent laryngeal nerve paralysis and hypocalcemia. In regard to neck metastases less than radical surgery has proved during the years to be sufficiently effective. Radioactive iodine, used by all at some stage of management for treatment purposes, should be used prophylactically only after due consideration in view of possible teratogenicity.

Cancer of the thyroid in children and adolescents.

Thyroid cancer is a rare but intriguing malignancy when it occurs in childhood and adolescence. In this retrospective study 58 young patients with thyroid cancer treated at the Rabin Medical Centre are presented. We found that thyroid carcinoma in children presented in a more advanced stage than in adults, and the incidence of regional metastases at the time of presentation is higher. Nevertheless, the biological behaviour of the tumour is more benign. We believe that near-total thyroidectomy is the treatment of choice in this age group for disease limited to the gland, and total thyroidectomy with perithyroidal neck dissection should be performed in patients with nodal disease. For follow-up, we recommend physical examination with measurement of thyroglobulin and TSH levels, ultrasound examination of the neck and chest radiography.