Persistent Tobacco Use After Treatment for Head and Neck Cancer.

Importance: Smoking during and after treatment has been linked to increased morbidity and mortality in patients with head and neck squamous cell carcinoma (HNSCC). Posttreatment tobacco use patterns and the appropriate timing for cessation interventions are understudied. Objective: To determine the frequency and patterns of posttreatment smoking cessation in smokers with HNSCC. Design, Setting, and Participants: This prospective cohort study assessed smoking status after a new diagnosis of HNSCC among daily smokers who were treated at a tertiary care center at an academic institution between January 1, 2009, and December 31, 2017. Exposures: Being current daily cigarette smoker at the time of diagnosis of HNSCC and having smoked at least 5 cigarettes per day for at least 5 years. Main Outcomes and Measures: Patients provided data indicating smoking intensity, duration of tobacco use, number of cessation attempts, number of successful cessation days, and symptoms during cessation attempts, as well as demographic and clinical information at the time of diagnosis, as well as smoking and disease status at 6 months, 12 months, 18 months, and 24 months after treatment. Results: Eighty-nine smokers with HNSCC (mean [SD] age at enrollment, 60.1 [9.2] years; 74 [83.1%] male and 15 [16.9%] female; 2 [2.2%] American Indian or Alaska Native, 1 [1.1%] Asian, 3 [3.4%] Black, 71 [79.8%] White, and 12 [13.5%] of unknown race and ethnicity or whose race and ethnicity were not reported) completed 24 months of posttreatment follow-up and were included in the study. Fifty-two patients (58.4%) continued to smoke at 6 months after treatment, 47 patients (52.8%) smoked at 12 months after treatment, 41 patients (46.1%) smoked at 18 months after treatment, and 40 patients (44.9%) smoked at 24 months after treatment. The probability of smoking cessation was highest during the first 6 months after treatment, at 0.36. Mean (SD) number of cigarettes per day (17.8 [9.6] vs 12.4 [10.0], mean difference, 5.1 [95% CI, 0.2 to 10.6]), duration of tobacco use (28.2 [18.1] vs 16.4 [17.4] years, mean difference, 11.8 [1.9 to 21.7] years), and lower number of prior quit attempts (5.3 [5.9] vs 10.4 [22.9], mean difference, -5.2 [95% CI, -15.7 to 5.4]) were all associated with persistent tobacco use at 24 months after treatment vs those who successfully quit. Conclusions and Relevance: The results of this cohort study suggest that a significant proportion of patients with HNSCC who are daily smokers at the time of diagnosis continue to smoke after treatment. Smokers with HNSCC who successfully quit smoking were most likely to do so in the first 6 months after treatment, which could potentially serve as a preferred window for smoking cessation interventions. These data highlight the need for inclusion of aggressive smoking cessation intervention in head and neck cancer care pathways.

Upper airway obstruction in neonates: Does sleep exacerbate symptoms?

OBJECTIVE: Describe the factors that exacerbate upper airway obstructions (UAOs) in neonates. STUDY DESIGN: Retrospective chart review. SETTING: Pediatric tertiary care hospital. SUBJECTS AND METHODS: All neonates hospitalized between 1/1/2010 and 12/31/2014 diagnosed with either: 1) laryngomalacia, 2) Pierre Robin sequence, or 3) vocal cord paralysis were included in this study. Patient charts were reviewed to determine factors that exacerbated symptoms of airway obstruction. The independent variable was patient diagnosis, and the outcome measure was exacerbating factors. RESULTS: In patients with laryngomalacia (n = 31), 41.9% worsened with agitation, 38.7% worsened with feeding, 16.1% worsened with positioning, 0.0% worsened during sleep, and 25.8% had no aggravating factors. In Pierre-Robin patients (n = 31), 48.4% worsened with agitation, 16.1% worsened with feeding, 61.3% worsened with positional changes, 0.0% worsened during sleep, and 12.9% had no aggravating factors. In vocal cord paralysis patients (n = 25), 72.0% worsened with agitation, 8.0% worsened with feeding, 20.0% worsened with positional changes, 4.0% worsened during sleep, and 24.0% had no aggravating factors. CONCLUSION: Airway obstruction was not reliably exacerbated during sleep for any of the diagnoses studied in this review. Our findings show that agitation exacerbates airway obstruction in most patients with vocal cord paralysis, and positioning exacerbates airway obstruction in the majority of patients with PRS. Aggravating factors in laryngomalacia are variable. These findings question the utility of polysomnography as a diagnostic tool for hospitalized neonates with these conditions. LEVEL OF EVIDENCE: 4.

Assessment of moral reasoning skills in the orthopaedic surgery resident applicant.

BACKGROUND: Assessing orthopaedic surgery residency applicants is a complex process. One important applicant characteristic not commonly measured during the interview process is moral behavior, a key component of the guidelines of the Accreditation Council for Graduate Medical Education for professionalism competency. We sought to determine whether a relationship exists between the results of residency selection interviews, as measured by match rank order, and moral reasoning skills, as measured by the revised version of the Defining Issues Test (DIT-2). METHODS: The DIT-2, a psychological tool that has been validated in assessing moral reasoning in >30,000 subjects, was administered to orthopaedic surgery residency candidates on a voluntary basis during their interview day. Data were collected annually from four applicant classes (2009 to 2012) at one institution. Each candidate was interviewed by an orthopaedic faculty team and was ranked comparatively with the other interviewing applicants. The five-part aggregate interview method for ranking applicants for the match list included a focused interview station presenting ethical dilemmas as one part of determining rank order. RESULTS: One hundred and twenty-four fourth-year medical students interviewing for orthopaedic surgery residency were assessed with the DIT-2. The results from the DIT-2 produced a postconventional score, which correlates with various levels of moral development. Each applicant's postconventional score was then compared with the patient's overall rank order. Applicants had highly variable moral reasoning skills, with no relationship to the final rank list. CONCLUSIONS: Despite a wide range of DIT-2 scores, the interview process did not differentiate applicants based on moral reasoning skills. It remains unclear whether the DIT-2 could (or should) be used as an additional data point to help stratify orthopaedic residency applicants and to predict their performance.

Injuries to the ankle syndesmosis.

➤ Despite being common, syndesmotic injuries are challenging to diagnose and treat.➤ Anatomic reduction of the ankle syndesmosis is critical for good clinical outcomes.➤ Intraoperative three-dimensional radiography and direct syndesmotic visualization can improve rates of anatomic reduction.➤ The so-called gold-standard syndesmotic screw fixation is being brought increasingly into question as new fixation techniques emerge.➤ Syndesmotic screw removal remains controversial, but may allow spontaneous correction of malreductions.