Airway decision making in major head and neck surgery: Irish multicenter, multidisciplinary recommendations.

Major head and neck surgery poses a threat to perioperative airway patency. Adverse airway events are associated with significant morbidity, potentially leading to hypoxic brain injury and even death. Following a review of the literature, recommendations regarding airway management in head and neck surgery were developed with multicenter, multidisciplinary agreement among all Irish head and neck units. Immediate extubation is appropriate in many cases where there is a low risk of adverse airway events. Where a prolonged definitive airway is required, elective tracheostomy provides increased airway security postoperatively while delayed extubation may be appropriate in select cases to reduce postoperative morbidity. Local institutional protocols should be developed to care for a tracheostomy once inserted. We provide guidance on decision making surrounding airway management at time of head and neck surgery. All decisions should be agreed between the operating, anesthetic, and critical care teams.

Retrospective analysis of radiological investigation of surgically excised head and neck lipomas.

PURPOSE: Differentiating benign lipomas from malignant causes is challenging and preoperative investigative guidelines are not well-defined. The purpose of this study was to retrospectively identify cases of head and neck lipomas that were surgically resected over a 5-year period and to identify the radiological modality chosen and features discussed in the final report. Multidisciplinary outcomes and pathology reports were examined with a view to identifying high risk features of a lipoma to aid in future risk stratification. METHODS: Retrospective chart review of pathology characteristics, radiological features (modality, size, calcifications, septations, globular/nodular foci), multidisciplinary discussion and history of presenting complaint was performed. RESULTS: Two liposarcomas and 138 lipomas were identified. Twenty-two percent of all lipomas received radiological investigation. Twenty-two percent of imaging referrals were possibly inappropriate. Furthermore, radiological features suggestive of malignancy were not present in the final radiology report, X2 = 28.8, p < 0.0001. CONCLUSION: As expected, the incidence of liposarcoma is low. There is limited awareness of radiology referral guidelines superimposed with a tendency to over-investigate lipomas. Furthermore, radiological features suggestive of malignancy were inconsistently reported on and not documented in multidisciplinary discussions. Therefore, we propose a multidisciplinary checklist for referring physicians and radiologists to aid in diagnostic work-up.

Staphylococcus Scalded Skin Syndrome-Induced Thrombosis Leading to Free Flap Complications: A Case Report and Review.

Staphylococcal scalded skin syndrome (SSSS) is a clinical term used for a spectrum of blistering skin conditions induced by the epidermolytic toxins of the Staphylococcus aureus bacteria. The complications of SSSS include thrombosis; however, the pathophysiology of this is still poorly understood. We present a case of free anterolateral thigh (ALT) flap failure in a patient as a result of widespread flap thrombosis associated with staphylococcal scalded skin syndrome (SSSS). This is the first reported case of free flap failure associated with SSSS. Free flap failure due to acquired prothrombotic conditions, such as infection, is a rare and potentially under-reported phenomenon. This article aims to further explore the role of both thrombophilias and provoked thrombotic events in free flap failure. A review of the literature will also be presented, and cases of free flap failure in patients with infection-induced vascular complications will be summarised.

Ocular lymphoma: overcoming a diagnostic challenge with an endoscopic sinus approach.

BACKGROUND: Ocular lymphomas are rare, indolent tumours that pose a diagnostic challenge. Patients may be asymptomatic or present with symptoms of increased orbital mass. An index of suspicion is required alongside an understanding of the diagnostics and staging required to facilitate expedited multi-disciplinary work-up and management. METHODS: A comprehensive literature review was performed. We present a series of three cases, each presenting their own diagnostic challenge. RESULTS: Although ocular lymphomas are notoriously difficult to diagnose histologically, our case series show procurement of a diagnostic histological sample using an image-guided endoscopic sinus approach. CONCLUSIONS: Although not typically involved in the diagnosis or management, the otolaryngologist may encounter ocular lymphoma masquerading as sinus disease or with disseminated disease at other sites in the head and neck. Endoscopic sinus surgery is considered a safe, effective approach for achieving a histological diagnosis in these cases.

Parathyroid carcinoma: Current management and outcomes - A systematic review.

OBJECTIVE: Parathyroid carcinoma is rarely encountered in clinical practice. When faced with this clinical challenge, there is currently a paucity of evidence available for the optimal management of patients with parathyroid carcinoma. This systematic review synthesizes the available literature to evaluate the optimal management approach, thus providing guidance for future management. METHODS: A systematic review was conducted according to PRISMA guidelines using Ovid MEDLINE, EMBASE, and PubMed databases for studies, published in English, reporting on parathyroid carcinoma. Full text of potentially eligible articles were reviewed by two authors independently and eligible studies selected. Treatment options and associated outcomes were evaluated. Descriptive statistics were used to describe pooled patient cohorts. RESULTS: 3203 articles were initially identified using the search criteria with 59 full-text articles then screened for eligibility. Seven articles, all retrospective studies, concerning 2307 patients (median 224/study). Parathyroidectomy alone was the most frequently utilised surgical approach across all studies, followed by en-bloc resection (with adjacent thyroid and/or nodal tissue). There was no difference in post-operative morbidity, mortality or survival between surgical approaches (p < 0.005). Patients who underwent either form of surgery had longer overall survival than those managed non-operatively (p < 0.005). CONCLUSION: Surgical resection is the optimal treatment of parathyroid carcinoma. However there remains no consensus on the optimal extent of surgery, and as such future randomised prospective studies are necessary to evaluate the effects of different surgical approaches on morbidity, mortality and oncologic outcomes. Following resection, long-term surveillance with PTH is advised.

A curious case of metastatic parotid adenoid cystic carcinoma to kidney.

A woman in her 60s presented with a 2-week history of non-specific left-sided abdominal pain. She previously underwent a total parotidectomy and adjuvant radiotherapy for left parotid adenoid cystic carcinoma 13 years prior, with a local recurrence 4 years after. Investigations revealed a large left-sided renal mass with appearances of renal carcinoma and no signs of metastatic disease. Pathology following nephrectomy revealed a metastatic adenoid cystic carcinoma.Metastatic disease recurred 11 months postradical nephrectomy to the contralateral kidney and lung, and she was referred to medical oncology for further management.This case history demonstrates the highly aggressive nature of an adenoid cystic carcinoma primary of salivary gland origin with rare metastasis to the kidney.

Multispecialty surgical management of large clavicular tumor: A case report.

INTRODUCTION: Primary and metastatic malignancies of the clavicle are extremely uncommon and difficult to treat. It carries a high morbidity rate. Total or partial claviculectomy is the recommended treatment option. PRESENTATION OF CASE: A 59-year-old male was admitted with a large left clavicular huge mass; biopsy showed poorly differentiated adenocarcinoma. Treatment started with chemoradiotherapy followed by complete excision of the tumor surgically. DISCUSSION: For treating this rare, difficult case, partial claviculectomy performed by a multispecialty team integrating three surgical skill sets: thoracic, ENT, and orthopedic surgeons, yields the best results. Clavicular carcinoma of known primary (CUP) is rare, and chemoradiotherapy showed preferable results in management. CONCLUSION: MDT reviews with surgeons, radiologists, pathologists, oncologists, and radiation oncologists are required in rare and complex cases of clavicular malignancy. Multispecialty surgical involvement is required for the safe excision of clavicular tumors with appropriate oncologic margins and fewer complications.

Transoral robotic surgery in Ireland: the beginning.

BACKGROUND: Transoral robotic surgery (TORS) has shown promising results in the treatment of myriad head and neck pathologies but is now most commonly used in the investigation and management of oropharyngeal squamous cell carcinoma. AIMS: The aim of this study was to report our cases of the newly introduced TORS, particularly its role in identifying primary of unknown origin and the potential implications for patients. A literature review and our early experience should begin to debunk some of the criticisms of TORS including setup times and cost. METHODS: Prospective data was collected from all patients undergoing transoral robotic surgery including demographics, indication, histology results in primary of unknown origin and complications. RESULTS: We have performed 36 TORS procedures in total ranging from intermediate to major complex. Our complication rate is low, and this has improved with the passage of time. Haemorrhage rates remain at 5.6% (n = 2), and the average length of stay is 1 day. Successful identification of a primary tumour in cancer of unknown primary was 80% (n = 8). CONCLUSIONS: We anticipate the integration of TORS into routine practice in the investigation and management of a number of ENT pathologies following robust clinical trials.

Metastatic medullary thyroid carcinoma presenting as ectopic Cushing's syndrome.

SUMMARY: A 41-year-old male presented to the Emergency Department with a 6-month history of back and hip pain. Skeletal survey revealed bilateral pubic rami fractures and MRI of the spine demonstrated multiple thoracic and lumbar fractures. Secondary work up for osteoporosis was undertaken. There was no evidence of hyperparathyroidism and the patient was vitamin D replete. Testosterone (T) was low at 1.7 nmol/L (8.6-29.0) and gonadotrophins were undetectable. The patient failed a 1 mg dexamethasone suppression test (DST) with a morning cortisol of 570 nmol/L (<50) and subsequently a low dose DST with a cortisol post 48 h of dexamethasone of 773 nmol/L (<50) and an elevated ACTH 98 ng/L. A corticotropin-releasing factor (CRF) test suggested ectopic ACTH secretion. The patient was commenced on teriparatide for osteoporosis and metyrapone to control the hypercortisolaemia. A positron emission tomography (PET) scan to look for the source of ACTH secretion demonstrated right neck adenopathy. Biopsy and subsequent lymph node dissection were performed and histology revealed a metastatic neuroendocrine tumour. Immunostaining was positive for calcitonin and thyroid transcription factor 1 (TTF1). Serum calcitonin was also significantly elevated at 45 264 ng/L (<10). The patient proceeded to a total thyroidectomy and left neck dissection. Histology confirmed a 7 mm medullary thyroid carcinoma (MTC). Post-operatively, the patient commenced vandetanib therapy and achieved a clinical and biochemical response. After approximately 18 months of vandetanib therapy, the patient developed recurrent disease in his neck. He is currently on LOXO-292 and is doing well 36 months post-diagnosis. LEARNING POINTS: Unexplained osteoporosis requires thorough investigation and the workup for secondary causes is not complete without excluding glucocorticoid excess. MTC should be considered when searching for sources of ectopic ACTH secretion. Resistance to tyrosine kinase inhibitors is well described with MTC and clinicians should have a low threshold for screening for recurrent disease.

Twin pathologies: synchronous leiomyosarcoma and squamous cell carcinoma of the larynx.

The synchronous discovery of leiomyosarcoma (LMS) and squamous cell carcinoma (SCC) of the larynx is extremely rare. We describe our experience of managing a patient with this unusual presentation. A 35-year-old man was initially diagnosed with advanced stage (T4bN1M0) laryngeal LMS. Neoadjuvant sarcoma-directed chemotherapy and radiation therapy allowed a successful pharyngolaryngo-oesophagectomy to be performed in an otherwise inoperable cancer. Histological examination of the resection specimen revealed poorly differentiated SCC, indicating the underlying diagnosis was a sarcomatoid carcinoma of the larynx. Considering our limited experience of managing synchronous LMS and SCC of the larynx, it is important to carefully evaluate the natural history, route of spread and pathological characteristics of both tumours, when determining treatment.

Sexual Behaviour and Human Papillomavirus-Positive Oral Cavity and Oropharyngeal Cancer: An Irish Perspective.

Background Characterization of the sexual behaviours and lifestyle factors associated with human papillomavirus (HPV)-positive oral cavity and oropharyngeal squamous cell carcinoma (OPSCC) is crucial to optimal counselling. Our study aims to investigate the relationship between sexual behaviours, lifestyle factors and HPV-positive OPSCC in an Irish population. Methods We performed a case-control study of 60 patients with newly diagnosed HPV-positive and HPV-negative oral cavity and OPSCC. Results Oral sexual activity was more common in the HPV-positive tumour subgroup; however, this association was insignificant on multivariate analysis. No association between age of onset of sexual activity, number of sexual partners or practicing anal sex and HPV-positivity was found. The HPV-positive tumour subgroup had significantly less tobacco use than their HPV-negative counterparts (OR 0.93, 95% CI 0.90-0.97). Conclusion The emergence of HPV-positive OPSCC means head and neck surgeons must adopt new roles as counsellors of sexually transmitted disease, in addition to their previous role of delivering a cancer diagnosis.

Is Bismuth Really the "Green" Metal? Exploring the Antimicrobial Activity and Cytotoxicity of Organobismuth Thiolate Complexes.

Antimicrobial resistance is becoming an ever-increasing threat for human health. Metal complexes and, in particular, those that incorporate bismuth offer an attractive alternative to the typically used organic compounds to which bacteria are often able to develop resistance determinants. Herein we report the synthesis, characterization, and biological evaluation of a series of homo- and heteroleptic bismuth(III) thiolates incorporating either one (BiPh2L), two (BiPhL2), or three (BiL3) sulfur-containing azole ligands where LH = tetrazolethiols or triazolethiols (thiones). Despite bismuth typically being considered a nontoxic heavy metal, we demonstrate that the environment surrounding the metal center has a clear influence on the safety of bismuth-containing complexes. In particular, heteroleptic thiolate complexes (BiPh2L and BiPhL2) display strong antibacterial activity yet are also nonselectively cytotoxic to mammalian cells. Interestingly, the homoleptic thiolate complexes (BiL3) were shown to be completely inactive toward both bacterial and mammalian cells. Further biological analysis of the complexes revealed the first insights into the biological mode of action of these particular bismuth thiolates. Scanning electron microscopy images of methicillin-resistant Staphylococcus aureus (MRSA) cells have revealed that the cell membrane is the likely target site of action for bismuth thiolates against bacterial cells. This points toward a nonspecific mode of action that is likely to contribute to the poor selectivity's demonstrated by the bismuth thiolate complexes in vitro. Uptake studies suggest that reduced cellular uptake could explain the marked difference in activity between the homo- and heteroleptic complexes.

N-Acetyl-2-Aminofluorene (AAF) Processing in Adult Rat Hepatocytes in Primary Culture Occurs by High-Affinity Low-Velocity and Low-Affinity High-Velocity AAF Metabolite-Forming Systems.

N-acetyl-2-aminofluorene (AAF) is a procarcinogen used widely in physiological investigations of chemical hepatocarcinogenesis. Its metabolic pathways have been described extensively, yet little is known about its biochemical processing, growth cycle expression, and pharmacological properties inside living hepatocytes-the principal cellular targets of this hepatocarcinogen. In this report, primary monolayer adult rat hepatocyte cultures and high specific-activity [ring G-3 H]-N-acetyl-2-aminofluorene were used to extend previous observations of metabolic activation of AAF by highly differentiated, proliferation-competent hepatocytes in long-term cultures. AAF metabolism proceeded by zero-order kinetics. Hepatocytes processed significant amounts of procarcinogen (≈12 µg AAF/106 cells/day). Five ring-hydroxylated and one deacetylated species of AAF were secreted into the culture media. Extracellular metabolite levels varied during the growth cycle (days 0-13), but their rank quantitative order was time invariant: 5-OH-AAF > 7-OH-AAF > 3-OH-AAF > N-OH-AAF > aminofluorene (AF) > 1-OH-AAF. Lineweaver-Burk analyses revealed two principal classes of metabolism: System I (high-affinity and low-velocity), Km[APPARENT] = 1.64 × 10-7 M and VMAX[APPARENT] = 0.1 nmol/106 cells/day and System II (low-affinity and high-velocity), Km[APPARENT] = 3.25 × 10-5 M and VMAX[APPARENT] = 1000 nmol/106 cells/day. A third system of metabolism of AAF to AF, with Km[APPARENT] and VMAX[APPARENT] constants of 9.6 × 10-5 M and 4.7 nmol/106 cells/day, was also observed. Evidence provided in this report and its companion paper suggests selective roles and intracellular locations for System I- and System II-mediated AAF metabolite formation during hepatocarcinogenesis, although some of the molecules and mechanisms responsible for multi-system processing remain to be fully defined.

High-Affinity Low-Capacity and Low-Affinity High-Capacity N-Acetyl-2-Aminofluorene (AAF) Macromolecular Binding Sites Are Revealed During the Growth Cycle of Adult Rat Hepatocytes in Primary Culture.

Long-term cultures of primary adult rat hepatocytes were used to study the effects of N-acetyl-2-aminofluorene (AAF) on hepatocyte proliferation during the growth cycle; on the initiation of hepatocyte DNA synthesis in quiescent cultures; and, on hepatocyte DNA replication following the initiation of DNA synthesis. Scatchard analyses were used to identify the pharmacologic properties of radiolabeled AAF metabolite binding to hepatocyte macromolecules. Two classes of growth cycle-dependent AAF metabolite binding sites-a high-affinity low-capacity site (designated Site I) and a low-affinity high-capacity site (designated Site II)-associated with two spatially distinct classes of macromolecular targets, were revealed. Based upon radiolabeled AAF metabolite binding to purified hepatocyte genomic DNA or to DNA, RNA, proteins, and lipids from isolated nuclei, Site IDAY 4 targets (KD[APPARENT] ≈ 2-4×10-6 M and BMAX[APPARENT] ≈ 6 pmol/106 cells/24 h) were consistent with genomic DNA; and with AAF metabolized by a nuclear cytochrome P450. Based upon radiolabeled AAF binding to total cellular lysates, Site IIDAY 4 targets (KD[APPARENT] ≈ 1.5×10-3 M and BMAX[APPARENT] ≈ 350 pmol/106 cells/24 h) were consistent with cytoplasmic proteins; and with AAF metabolized by cytoplasmic cytochrome P450s. DNA synthesis was not inhibited by concentrations of AAF that saturated DNA binding in the neighborhood of the Site I KD. Instead, hepatocyte DNA synthesis inhibition required higher concentrations of AAF approaching the Site II KD. These observations raise the possibility that carcinogenic DNA adducts derived from AAF metabolites form below concentrations of AAF that inhibit replicative and repair DNA synthesis.

Transient auditory hallucinations in an adolescent.

In adolescents, hallucinations can be a transient illness or can be associated with non-psychotic psychopathology, psychosocial adversity, or a physical illness. We present the case of a 15-year-old secondary-school student who presented with a 1-month history of first onset auditory hallucinations, which had been increasing in frequency and severity, and mild paranoid ideation. Over a 10-week period, there was a gradual diminution, followed by a complete resolution, of symptoms. We discuss issues regarding the diagnosis and prognosis of auditory hallucinations in adolescents.

Non-attendance at new appointments at St James's Child Guidance Clinic.

OBJECTIVE: This study aimed to examine non-attendance rates at new appointments at St James's Child Guidance Clinic. METHOD: The sample consisted of all new referrals to St. James's Child Guidance Clinic in one calendar year (2004). Data was collected retrospectively from an electronic patient information system (Pinpoint), the new patient-referral logbook, referral letters, the appointment diary, and from clinical records. RESULTS: There were 260 new referrals to St James's Child Guidance Clinic in 2004. Out of the 260 children and adolescents granted a new appointment, 34 (13.07%) who failed to keep their appointment were identified. All patients granted an urgent appointment did attend. CONCLUSIONS: Non-attendance rates at new assessment in St James's Child Guidance Clinic were slightly lower than those reported in other studies. The implemented evidence-based strategies to reduce non-attendance rates could explain the relatively low non-attendance rate at new assessment.

Routine investigations in paediatric psychopharmacology.

OBJECTIVES: This study examines (1) what are the minimum accepted baseline investigations recommended in the literature prior to prescribing in child psychiatry and (2) whether these investigations are routinely performed. METHOD: Medical literature on prescribing in child and adolescent psychiatry was reviewed, and a list of minimum baseline investigations recommended in the literature was established. A postal survey was performed to establish what current clinical practice is among child and adolescent psychiatrists. Current practice was compared with the recommendations in the literature. RESULTS: There are nine minimum accepted baseline investigations which are consistently recommended in the literature on child psychiatry. Six investigations are routinely performed by over 75% of respondents. However only 30% (n = 16) reported that they 'always' carried out eight or more of the nine recommended minimum investigations. CONCLUSIONS: A consensus statement is necessary, providing a list of recommended investigations prior to prescribing in child and adolescent psychiatry. Continuing medical education can then highlight the importance of these investigations.