Prediction of severe adverse neonatal outcomes at the second stage of labour using machine learning: a retrospective cohort study.

OBJECTIVE: To create a personalised machine learning model for prediction of severe adverse neonatal outcomes (SANO) during the second stage of labour. DESIGN: Retrospective Electronic-Medical-Record (EMR) -based study. POPULATION: A cohort of 73 868 singleton, term deliveries that reached the second stage of labour, including 1346 (1.8%) deliveries with SANO. METHODS: A gradient boosting model was created, analysing 21 million data points from antepartum features (e.g. gravidity and parity) gathered at admission to the delivery unit, and intrapartum data (e.g. cervical dilatation and effacement) gathered during the first stage of labour. Deliveries were allocated to high-risk and low-risk groups based on the Youden index to maximise sensitivity and specificity. MAIN OUTCOME MEASURES: SANO was defined as either umbilical cord pH levels ≤7.1 or 1-minute or 5-minute Apgar score ≤7. RESULTS: The model for prediction of SANO yielded an area under the receiver operating curve (AUC) of 0.761 (95% CI 0.748-0.774). A third of the cohort (33.5%, n = 24 721) were allocated to a high-risk group for SANO, which captured up to 72.1% of these cases (odds ratio 5.3, 95% CI 4.7-6.0; high-risk versus low-risk groups). CONCLUSIONS: Data acquired throughout the first stage of labour can be used to predict SANO during the second stage of labour using a machine learning model. Stratifying parturients at the beginning of the second stage of labour in a 'time out' session, can direct a personalised approach to management of this challenging aspect of labour, as well as improve allocation of staff and resources. TWEETABLE ABSTRACT: Personalised prediction score for severe adverse neonatal outcomes in labour using machine learning model.

Osteoradionecrosis of the subaxial cervical spine following treatment for head and neck carcinomas.

OBJECTIVE: To study MRI and positron emission tomography (PET)/CT imaging of osteoradionecrosis (ORN) of the subaxial cervical spine, a serious long-term complication of radiation therapy (RT) for head and neck cancers that can lead to pain, vertebral instability, myelopathy and cord compression. METHODS: This is a single-institution retrospective review of patients diagnosed and treated for ORN of the subaxial cervical spine following surgery and radiation for head and neck cancer. RESULTS: We report PET/CT imaging and MRI for four patients, each with extensive treatment for recurrent head and neck cancer. Osteomyelitis (OM) and discitis are the end-stage manifestations of ORN of the subaxial spine. CONCLUSION: ORN of the subaxial spine has variable imaging appearance and needs to be differentiated from recurrent or metastatic disease. Surgical violation of the posterior pharyngeal wall on top of the compromised vasculature in patients treated heavily with RT may pre-dispose the subaxial cervical vertebrae to ORN, with possible resultant OM and discitis. MRI and PET/CT imaging are complimentary in this setting. PET/CT images may be misinterpreted in view of the history of head and neck cancer. MRI should be utilized for definitive diagnosis of OM and discitis in view of its imaging specificity. ADVANCES IN KNOWLEDGE: We identify the end-stage manifestation of ORN in the sub-axial spine on PET/CT and MRI to facilitate its correct diagnosis.

Functional outcomes and quality of life after chemoradiotherapy: baseline and 3 and 6 months post-treatment.

Concomitant chemoradiotherapy provides organ preservation for those patients with head and neck cancer. We report the results of a prospective study that examined functional outcomes and quality of life (QOL) after chemoradiotherapy over the first 6 months post-treatment (tx). Twenty-nine patients with head and neck cancer were treated with chemoradiotherapy. All were seen baseline and 3 and 6 months post-tx. Assessments included the performance status scale (PSS), Karnofsky performance status scale, tongue strength, jaw opening, and saliva weight. QOL was patient-rated using the eating assessment tool (EAT-10), MD Anderson dysphagia inventory, speech handicap index (SHI), and the EORTC H&N35 scale. Repeated-measures ANOVAs were used, with significance at p < 0.05. PSS scores were significantly different across time points. Tongue strength, jaw range of motion (ROM), and saliva weight were significantly lower at 3 and 6 months than at baseline. QOL was significantly worse after tx, although it improved by 6 months as rated with the EAT-10 and the SHI scores were significantly worse at 3 and 6 months. EORTC domains of swallowing, senses, speech, dry mouth, and sticky saliva were significantly worse at 3 and 6 months. Concomitant chemoradiotherapy for treatment of head and neck tumors can result in impaired performance outcomes and QOL over the first 6 months post-tx. However, performance status, tongue strength, jaw ROM, and eating QOL were only mildly impaired by 6 months post-tx. Saliva production and speech QOL remained significantly impaired at 6 months post-treatment. Current studies are examining outcomes at 12 and 24 months post-treatment to better predict outcomes over time in this population.

Quality of life after management of advanced osteoradionecrosis of the mandible.

Osteoradionecrosis (ORN) of the mandible is a severe complication of radiation therapy for head and neck cancer. In this case series, the authors analyzed their treatment and quality of life outcomes over the past 6 years. A retrospective chart review of 42 patients treated surgically for advanced ORN was conducted. A telephone survey was conducted and quality of life (QOL) questionnaires were completed in a subset of patients. 30 patients responded to the telephone survey assessing QOL for speech, swallowing and overall functioning correlated with oral nutrition and performance status. Surgery for ORN can result in an improved QOL. Functional outcomes of oral intake, speech intelligibility, and eating in public correlated with patient rated QOL measures. A lack of improvement in QOL, despite the restoration of an intact mandible, relates to the persistent effects of chemoradiotherapy.

A phase I safety, pharmacological and biological study of the farnesyl protein transferase inhibitor, tipifarnib and capecitabine in advanced solid tumors.

BACKGROUND: To evaluate the toxicity and pharmacological and biological properties of the farnesyl protein transferase (FPTase) inhibitor, tipifarnib (R115777, ZARNESTRAtrade mark) and capecitabine administered for 14 days every 3 weeks. PATIENTS AND METHODS: Patients with advanced cancers received twice daily tipifarnib (100-500 mg) and capecitabine (1000-1125 mg/m(2)) for 14 days every 3 weeks. Pharmacokinetics of tipifarnib, capecitabine and 5-fluorouracil (5-FU) were determined. Peripheral blood mononuclear cells were analyzed for farnesylation of the HDJ2 chaperone protein and FPTase activity. RESULTS: Forty-one patients received 185 courses of treatment. Diarrhea and palmar-plantar erythrodysesthesia were dose limiting at 300 mg tipifarnib/1125 mg/m(2) capecitabine b.i.d. When the capecitabine dose was fixed at 1000 mg/m(2) b.i.d., neutropenia was dose limiting at 400 and 500 mg b.i.d. of tipifarnib. Capecitabine did not affect the pharmacology of tipifarnib at 100-300 mg b.i.d., although tipifarnib significantly increased the C(max) of 5-FU at 400 mg b.i.d. HDJ2 farnesylation and FPTase activity decreased between 200 and 400 mg b.i.d. doses of tipifarnib, without a dose-response relationship. Five patients demonstrated partial remissions and 11 patients maintained prolonged stable disease. CONCLUSIONS: Tipifarnib and capecitabine are well tolerated at 300 mg/1000 mg/m(2) b.i.d., respectively, resulting in biologically relevant plasma concentrations and antitumor activity. The recommended dose for further disease-focused studies is 300 mg b.i.d. tipifarnib and 1000 mg/m(2) b.i.d. capecitabine, given for 14 days every 3 weeks.

Infrasellar craniopharyngiomas: case report and review of the literature.

Although craniopharyngiomas account for a large percentage of pediatric intracranial tumors, there is a bimodal age distribution. Most of these neoplasms are suprasellar or sellar in location. In this report we describe an unusual case of an infrasellar craniopharyngioma in a child. Only four previous cases of infrasellar craniopharyngiomas with no sellar involvement have been described. Infrasellar craniopharyngiomas are part of the continuum representing intracranial craniopharyngiomas and ameloblastomas of the jaw. A transnasal endoscopic biopsy was performed with a preliminary diagnosis of craniopharyngioma. The patient then underwent a radical resection of the infrasellar tumor via a subfrontal transbasal approach. This case illustrates a rare and unusual location for a craniopharyngioma. Craniopharyngiomas should be considered in the differential diagnosis of infrasellar neoplasms. Infrasellar craniopharyngiomas compromise part of the spectrum of tumors originating from enamel-forming neural crest cells.

Curative radiotherapy for anterior commissure laryngeal carcinoma.

There is continuing controversy surrounding the most effective treatment of glottic carcinoma involving the anterior commissure (AC). Surgery has been the preferred method of treatment, since studies previously indicated early tumor invasion of the thyroid cartilage at the AC, thereby assuming less curability by radiotherapy (RT). Subsequent laryngeal anatomic studies and refinement of RT techniques have brought into question the ineffectiveness of curative irradiation. A retrospective review of 174 patients with early-stage glottic carcinoma treated with standard fractionation curative RT revealed 34 patients with T1 and T2 lesions involving the AC. Allowing for a follow-up of at least 3 years, we observed only a 12% (4 of 34 patients) local recurrence rate after RT alone, with excellent voice quality and no major complications related to the irradiation. The 4 local recurrences were controlled by total laryngectomy, although 2 patients developed distant metastatic disease. Radiotherapy represents an effective method of treating T1 squamous cell carcinoma of the glottis with AC involvement. The small number of T2 glottic carcinomas in this study prevents a meaningful conclusion concerning treatment of these lesions.

Treatment of the clinically negative neck in oral squamous cell carcinoma.

OBJECTIVE: To define the most effect treatment plan of patients with oral cavity squamous cell carcinoma with clinically negative (NO) neck staging. STUDY DESIGN: Retrospective review of 54 patients with NO neck staging who underwent resection of an oral cavity primary tumor with or without elective neck dissection between January 1982 and December 1992 and with a minimum follow-up of 3 years. METHODS: The records of 54 patients with previously untreated oral cavity squamous cell carcinoma and NO neck staging were retrospectively reviewed to determine the impact of elective neck dissection on patient outcomes including regional recurrence and overall survival. RESULTS: All patients underwent surgical resection of their oral cavity tumors, with 33 patients undergoing "watchful waiting" observation for the development of neck disease while 21 patients had elective neck dissections. The most controversial group of patients were those with intermediate-sized (T2 and T3) primary tumors. Eighteen of these patients underwent elective neck dissection, with two patients developing recurrent neck disease and an ultimate prognosis of 72%. Twelve patients had observation of their necks, with five of these patients subsequently requiring neck dissection. An additional seven patients did not undergo neck dissection, and this group had four survivors free of disease. The prognosis was 42% in patients not having elective neck dissections. CONCLUSIONS: T1 tumors do well with neck treatment other than careful observation. The data suggest that patients with T2 and T3 oral squamous cell carcinoma should undergo surgical resection of their primary tumor site and elective neck dissection. Patients with T4 oral cavity lesions should routinely undergo neck dissection.

Evaluation and treatment of head and neck venous vascular malformations.

Congenital venous vascular malformations of the head and neck are low-flow, nonproliferative lesions that should be distinguished from hemangiomas. The characteristic history and clinical findings can establish the diagnosis. Direct percutaneous puncture and contrast injection at the time of treatment delineate the lesion and its drainage pattern. Treatment must be individualized according to lesion extent, patient tolerance and physician experience. Sclerotherapy with ethanol has proved to be a successful treatment modality for these lesions, as demonstrated in this study of 57 patients. Surgery is used for treatment of clinically significant residual disease. A multidisciplinary approach to evaluation and treatment is key to successful management.

Corniculate-cuneiform flap for reconstruction in the extended vertical partial laryngectomy.

The extended vertical partial laryngectomy involves removal of the vocal cord and adjacent arytenoid cartilage. Arytenoid sacrifice predisposes the patient to postoperative aspiration, since adequate laryngeal closure during swallowing cannot be accomplished. Various techniques have been previously described for reconstruction of this defect. We present five patients who had reconstruction of this area with a local, mucosally based corniculate-cuneiform flap. All patients were decannulated, had no long-term aspiration, maintained socially acceptable voice quality, and had no tumor recurrence with a minimum of 3 years of follow-up. Our preliminary data suggest that this flap can be used in previously irradiated patients. The corniculate-cuneiform flap is an effective method of reconstruction in patients undergoing an extended vertical partial laryngectomy.

Sphenoid cranial base defects in siblings presenting with cerebrospinal fluid leak.

Two sisters presented to our medical center with nontraumatic cerebrospinal fluid (CSF) fistulas from left sphenoid sinocranial junction defects. One sister had recurrent meningitis over a 20-year period that prompted a skull base evaluation. Four years later, her younger sister presented with profuse CSF rhinorrhea. Transethmoid sphenoidotomy with sinus obliteration and lumbar-subarachnoid temporary CSF diversion successfully treated one sister, while the other required reoperation and permanent lumbar-peritoneal shunting. In both cases the skull base defect was identically located in the posterolateral left sphenoid sinus. Embryological considerations, evaluation and management are presented.

Metastatic cutaneous squamous cell carcinoma of the head and neck region.

Cutaneous squamous cell carcinoma has a relatively low metastatic rate (0.5% to 16%), but patients with the disease should always be evaluated for possible regional nodal involvement. We reviewed the records of 37 patients with metastatic disease among the 388 patients with head and neck cutaneous squamous cell carcinoma who were treated at New York University Medical Center between 1961 and 1992. In this group of patients the most common primary sit was the cheek or preauricular region and the most common metastatic site was the level I neck lymph nodes. Seven patients (18%) had metastases at initial presentation. Among the remaining patients the average time to the development of metastases was 19 months. Nineteen patients (51%) had recurrence at the primary site before metastasis; 11 (30%) developed metastases with control of the primary tumor. Analysis of the records of 31 patients treated for cure revealed that 13 were treated by surgery, 2 by radiation therapy, and 16 by a combination of surgery and radiation therapy. During the mean follow-up period of 49 months, 11 (35%) of these 31 patients died of their disease. Recurrence of the primary tumor appeared to increase the risk for nodal and distant metastases.

Perioperative complications of transseptosphenoidal excision for pituitary adenomas.

Although complications of transseptosphenoidal (TSS) pituitary surgery have been discussed in the literature, there has not been an analysis of complication rates related to clinical features and the nature of the tumor. A retrospective review of 366 TSS procedures (354 patients) for excision of pituitary adenomas evaluated the incidence and management of perioperative complications. The mortality rate was 0.82%. The most frequently encountered complications were transient diabetes insipidus (8.74%) and cerebrospinal fluid (CSF) rhinorrhea (4.10%). Other complications included exacerbation of visual acuity and visual field defects, hemorrhage, hydrocephalus, and meningitis. The factors evaluated were gender, age, tumor size, hormone secretory status, and any history of prior pituitary surgery.There was a significantly higher incidence of transient diabetes insipidus in patients with hormone-secreting tumors. Minor and total complication rates were significantly increased in microadenomas, hormone-secreting tumors, in female patients, and in patients less than 60 years of age reflecting the increased incidence of transient diabetes insipidus in young female patients with hormone-secreting tumors. Observed intraoperative CSF leaks predisposed to postoperative CSF rhinorrhea. There were no identifiable risk factors for major complications.

Metastatic basal cell carcinoma of the head and neck.

Metastases are occasionally associated with cutaneous squamous cell carcinoma but only rarely with basal cell carcinoma. There are approximately 200 cases of metastases from basal cell carcinoma reported in the world literature. We describe 6 additional cases. All of our patients demonstrated recurrence at the primary site before they developed their metastases. Metastases presented in subcutaneous tissue, cervical lymph nodes, bone, and lung between 1.5 and 14 years after initial treatment of the primary lesion. The long interval seen in these patients between the initial treatment of the primary and the development of metastases underscores the need for long-term follow-up in what is often thought to be a nonaggressive, nonmetastasizing malignancy.

Reconstruction of the ligated external carotid artery for embolization of cervicofacial arteriovenous malformations.

PURPOSE: Until recently, the accepted management of life-threatening complications of unresectable cervicofacial arteriovenous malformations (AVMs) has been ligation of the major feeding vessels, usually the branches or the main trunk of the external carotid artery. Rapid enlargement of collateral vessels around the ligature is usually associated with an early return of symptoms. Percutaneous transcatheter embolization of the nidus of the arteriovenous malformation is now the preferred treatment for symptomatic AVMs that cannot be excised. Previous ligation of the main feeding vessels prevents catheter access and embolization therapy of the lesion. The purpose of this report is to describe our experience with the treatment of patients with symptomatic unresectable cervicofacial AVMs and previous external carotid artery ligation. METHODS: Six patients with symptoms from cervicofacial arteriovenous malformations required surgical reconstruction of their previously ligated external carotid artery with the anticipation of catheter embolization therapy to the branch vessels feeding the malformation. Saphenous vein was used in five reconstructions; a polytetrafluoroethylene graft was used in one. RESULTS: After successful arterial reconstruction, massive swelling of the tongue and perioral tissue developed in two patients, which necessitated tracheostomy in one patient; and embolization therapy before extubation could be safely performed in the other patient. In all, four patients underwent successful embolization therapy. One refused subsequent treatment. In one patient with severe epistaxis, external carotid artery revascularization led to the healing of the nasal ulcers without need for embolization therapy. CONCLUSIONS: For patients with previous ligations of the external carotid artery and symptomatic AVMs, revascularization of the external carotid artery is an important step in treatment. The surgery must be carefully coordinated with the interventional radiologist for possible emergency postoperative embolization therapy. External carotid artery ligation only complicates the treatment of patients with cervicofacial AVMs, and should no longer be used in the treatment of these individuals.

Refinement of the transpalatine exposure of the nasopharynx.

The intrasulcular incision provides excellent transpalatine exposure of the nasopharynx with a viable palatal flap. There is less chance for naso-oral fistula formation since the resulting suture line is always over underlying bone. This safely allows extensive removal of the hard palate. Additionally, the continuous sling suture allows excellent flap reapproximation using the teeth as anchors for the replaced palatal flap. Patients tolerate oral feedings within 24 hours of their operations and require minimal postoperative analgesics. The extended intrasulcular incision offers many advantages over other methods for transpalatine exposures to the nasopharynx.

Squamous cell carcinoma in older patients without risk factors.

Ten patients over sixty years of age with no history of tobacco or alcohol use were treated for squamous cell carcinoma of the upper aerodigestive tract between 1979 and 1991. Nine of these ten patients were women with lesions confined to the oral cavity and oropharynx. Modes of treatment included surgery, radiation, or a combination of surgery and radiation. Followup from 1 to 10 years revealed two deaths from local and distant spread, and eight patients with no evidence of disease. Recurrences after treatment were aggressive and occurred within the same region as the primary lesion. Although most patients with upper aerodigestive squamous cell carcinoma are men with alcohol and/or tobacco exposure, this study demonstrates findings consistent with field cancerization in a group of older women with no risk factors.

Mycotic aneurysms of the intracavernous carotid artery: a case report and review of the literature.

A case of mycotic aneurysm of the intracavernous carotid artery is reported and the literature is reviewed on this uncommon entity. Nineteen cases have been reported, most often occurring in the clinical setting of meningitis. Management recommendations include angiographic confirmation of aneurysm and follow-up with magnetic resonance imaging during antibiotic therapy. Evidence of aneurysm enlargement is an indication for endovascular trapping of the aneurysm or carotid occlusion.