ACR Appropriateness Criteria® Penetrating Neck Injury.

In patients with penetrating neck injuries with clinical soft injury signs, and patients with hard signs of injury who do not require immediate surgery, CT angiography of the neck is the preferred imaging procedure to evaluate extent of injury. Other modalities, such as radiography and fluoroscopy, catheter-based angiography, ultrasound, and MR angiography have their place in the evaluation of the patient, depending on the specific clinical situation and question at hand. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Aberrant position of nonrecurrent inferior laryngeal nerve: Report of 3 cases and a review of the literature.

The presence of a nonrecurrent inferior laryngeal nerve (NRILN) is a significant risk factor for nerve injury during thyroid, parathyroid, and vascular surgeries involving the paratracheal area of the head and neck. The objective of this report is to review the association between an aberrant right subclavian artery (SCA) identified on preoperative imaging and an NRILN identified intraoperatively during thyroid and parathyroid surgery. We reviewed 3 selected cases in which we preoperatively identified an aberrant right SCA and determined the intraoperative position of the inferior laryngeal nerve on the right. It is important to note that 1 of these cases demonstrated that the inferior laryngeal nerve may be found in its normal anatomic position, coursing inferiorly through the tracheoesophageal groove. This anatomic finding is unexpected in a patient with a preoperatively identified aberrant right SCA. We also performed a literature review of more than 250 cases to investigate the association between an intraoperative finding of NRILN and vascular anomalies on imaging. We found 5 reported cases that involved an aberrant right SCA, predictive of NRILN, with the nerve identified in the tracheoesophageal groove.

Implementation of TeamSTEPPS at a Level-1 Military Trauma Center: The San Antonio Military Medical Center Experience.

CONTEXT: When a health care system deals with complex trauma patients while simultaneously serving as an educational platform, teamwork and clear communication are imperative. While there are numerous tools and resources available to address the concerns surrounding patient safety, Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) emphasizes a team approach to improve communication among all caregivers and is specifically designed to improve patient safety through improved communication. This article reports the interim results of implementation of TeamSTEPPS in the operating room environment at the most complex and busiest tertiary military trauma center in the Department of Defense in the midst of the longest period of continuous combat operations in US history. METHODS: Data were collected from December 2013 through March 2014 on the number of total cases performed by month, number of debrief surveys submitted for those months, and associated percentage of surveys completed based on case category. RESULTS: The overall compliance rate for the TeamSTEPPS process (from the pre-op brief to the debrief survey completion) was 75.1%. Responses showed a decrease in concerns in all areas during the period of observation. Equipment-related complaints decreased by 48%; instrument-related issues decreased by 29.9%; supply issues decreased by 53.3%; personnel issues decreased by 90.5%; case scheduling issues decreased by 35.7%; and preference card issues decreased by 72.1%. CONCLUSIONS: Our results demonstrate that TeamSTEPPS can be successfully implemented in an integrated level-1 trauma center in the midst of combat casualty care with a greater than 75% overall compliance with TeamSTEPPS briefs. Further study on the sustainability of these results and the effect on operating room safety, productivity, and efficiency is necessary.

Alteration of cellular and humoral immunity by mutant p53 protein and processed mutant peptide in head and neck cancer.

PURPOSE: To determine if serologic recognition of p53 mutations at the protein level depends upon the ability of mutant p53 to express new peptide epitopes that bind to human leukocyte antigen (HLA) class II molecules, we used anti-p53 antibody production as a marker for HLA class II-restricted T-cell involvement in head and neck cancer. EXPERIMENTAL DESIGN: An anti-p53 antibody response was correlated with specific p53 mutations and the patients' HLA class II alleles and haplotypes. HLA binding studies and in vitro stimulation (IVS) of peripheral blood mononuclear cells were done using a mutant versus wild-type HLA-DQ7-binding p53 peptide. RESULTS: Certain HLA-DQ and HLA-DR alleles were frequently present in p53 seropositive patients who produced serum anti-p53 antibodies. Selected mutated p53 peptides fit published allele-specific HLA class II binding motifs for the HLA-DQ7 or HLA-DR1 molecules. Moreover, a mutant p53 peptide bound with a 10-fold greater affinity than the wild-type p53 peptide to HLA-DQ7 molecules. IVS of CD4(+) T cells from seven healthy HLA-DQ7(+) donors using this mutant p53 peptide (p53(220C)) was associated with a partial T helper type 2 phenotype compared with IVS using the wild-type p53(210-223) peptide. CONCLUSIONS: Our results support the hypothesis that mutated p53 neoantigens can bind to specific HLA class II molecules, leading to a break in tolerance. This may lead to skewing of the CD4(+) T lymphocyte response toward a tumor-permissive T helper type 2 profile in head and neck cancer patients, as manifested by seropositivity for p53.

Prevalence and patterns of intraoperative nerve monitoring for thyroidectomy.

OBJECTIVE: To estimate the patterns of use of intraoperative recurrent laryngeal nerve (RLN)-monitoring devices during thyroid surgery by otolaryngologists in the United States. METHODS: A questionnaire was mailed to 1685 randomly selected otolaryngologists, representing approximately half of all otolaryngologists currently practicing in the United States. Topics covered included training history and current practice setting, use and characteristics of use of RLN monitoring during thyroid surgery, as well as history of RLN injury and/or subsequent lawsuits. chi(2) test was used to examine associations between monitor usage and dependent variables, and odds ratios calculated by logistic regression were used to refine the magnitude of these associations. RESULTS: A total of 685 (40.7%) of questionnaires were returned, and 81 percent (555) of respondents reported performing thyroidectomy. Of those, only 28.6 percent (159) reported using intraoperative monitoring for all cases. Respondents were 3.14 times more likely to currently use intraoperative monitoring if they used it during their training. Surgeons currently using intraoperative RLN monitoring during thyroidectomy were 41 percent less likely to report a history of permanent RLN injury. Further information about surgeon background and rationale for decisions regarding RLN monitor usage are discussed. CONCLUSIONS: Presently, the majority of otolaryngologists in the United States do not report regular usage of RLN monitoring in their practices. Surgeon background and training, more so than surgical volume, significantly influenced the use of intraoperative RLN monitoring.

Patterns of use of facial nerve monitoring during parotid gland surgery.

OBJECTIVE: To determine current patterns of use of facial nerve monitoring during parotid gland surgery by otolaryngologists in the United States. STUDY DESIGN AND SETTING: A questionnaire encompassing surgeon training background, practice setting, patterns of facial nerve monitor usage during parotid gland surgery, and history of permanent facial nerve injury or legal action resulting from parotid surgery was mailed to 3139 otolaryngologists in the United States. Associations between facial nerve monitor usage and dependent variables were examined by using the chi(2) test. Magnitudes of the associations were determined from odds ratios calculated using logistic regression. RESULTS: A 49.3% questionnaire response rate was achieved. Sixty percent of respondents who perform parotidectomy employed facial nerve monitoring some or all of the time. Respondents were 5.6 times more likely to use the monitor in practice if they used it in training and 79% more likely to use it if they performed more than 10 parotidectomies per year. Respondents were 35% less likely to have a history of inadvertent nerve injury if they performed more than 10 parotidectomies per year. Surgeons who employed monitoring in their practice were 20.8% less likely to have a history of a parotid surgery-associated lawsuit. Additional information regarding surgeon demographics, types of nerve monitors used, and reasons for and against monitor usage are discussed. CONCLUSION: Permanent facial nerve paralysis after parotidectomy occurs in 0-7% of cases. Currently, a majority of otolaryngologists in the United States are employing facial nerve monitoring during parotid surgery some or all of the time, even though no studies to date have demonstrated improved outcomes with its use. Physician training background and surgery caseload were significant factors influencing usage of facial nerve monitoring in this study.