Publications by authors named "Madeleine Strohl"

30 Publications

  • Page 1 of 1

Access Challenge Index: A Novel Disparity Measure Predictive of Language Outcomes in Children Who Are Deaf/Hard of Hearing.

Otolaryngol Head Neck Surg 2021 Sep 7:1945998211040017. Epub 2021 Sep 7.

Division of Pediatric Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, USA.

Objective: To evaluate the effect of demographic disparities on language outcomes in a diverse group of children who are deaf or hard of hearing.

Study Design: Retrospective cohort study.

Setting: UCSF Benioff Children's Hospital (a tertiary care center).

Methods: Forty-four patients aged <18 years were identified with sensorineural hearing loss managed with a behind-the-ear hearing aid or cochlear implant. Demographic and clinical data were extracted from the medical record. The primary outcome measure was the Preschool Language Scales-5 at least 6 months after intervention. Predictors of language outcome were assessed: hearing level at the time of hearing intervention, cochlear implant status, age of identification and intervention, travel time to site of hearing care, home language, race/ethnicity, insurance type, and Access Challenge Index-a novel measure of educational environment and family support based on the Child Cochlear Implant Profile. Multivariate and univariate analysis assessed predictors for association with intervention and receptive, expressive, and total language scores.

Results: Overall 82% of patients had cochlear implants. The median age at hearing intervention was 12 months. The sample was 59% female, 52% non-White, and 61% publicly insured, and 20% had a non-English primary home language. Accounting for multiple demographic and clinical predictors, a high Access Challenge Index score was independently associated with longer time to intervention ( = .01) and poorer language outcomes ( < .001).

Conclusion: Access Challenge Index-a novel comprehensive measure of educational and family environment-is a strong independent predictor of language outcomes in children who are deaf or hard of hearing.
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http://dx.doi.org/10.1177/01945998211040017DOI Listing
September 2021

Hepatitis C as a Potential Risk Factor for Adverse Surgical Outcomes in Head and Neck Free Tissue Transfer Reconstruction.

Facial Plast Surg Aesthet Med 2021 Aug 27. Epub 2021 Aug 27.

Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA.

Infection with hepatitis C virus (HCV) is associated with an increased risk of developing head and neck cancer (HNC), and negatively impacts cancer-specific survival. To measure the impact of HCV status on free tissue transfer failure, flap takeback, and length of stay in HNC patients undergoing reconstruction. We retrospectively reviewed patients who underwent head and neck free tissue transfer reconstruction at a single academic institution between August 2011 and June 2020. In the HCV-infected group, total flap failure rate was 2.9% versus 1.3% in the control group and the takeback rate was 11.1% versus 9.6%. On multivariate analysis, HCV status was not associated with flap failure, flap takeback, or total length of hospital stay >7 days. In this study, HCV status was not associated with differences in postoperative complications or length of stay. Future research with greater numbers of HCV-positive study subjects is required to elucidate the effect of HCV infection in this patient population.
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http://dx.doi.org/10.1089/fpsam.2021.0082DOI Listing
August 2021

Aesthesiometer-Based Testing for Laryngopharyngeal Hyposensitivity.

Laryngoscope 2021 Jul 20. Epub 2021 Jul 20.

Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, U.S.A.

Objectives/hypothesis: To develop a method for threshold estimation of the laryngeal adductor reflex (LAR) response using Cheung-Bearelly monofilaments.

Study Design: Cross-sectional.

Methods: Twenty-two healthy adults (12 men, 10 women) were tested for LAR response outcome using 30 mm 5-0 and 4-0 nylon monofilaments. Tactile stimuli were delivered to the aryepiglottic (AE) fold and medial pyriform sinus (MPS). Dichotomous classifier features and performance (area under the curve (AUC)), the LAR response outcome agreement and disagreement matrix, and test-retest reliability were examined. From those data, a test protocol that would minimize patient burden to estimate the LAR triggering threshold was formulated.

Results: Classifier performance of 5-0 monofilament stimulation of the AE fold (sensitivity = 0.63, specificity = 0.63, PPV = 0.74, NPV = 0.25) and MPS (sensitivity = 0.45, specificity = 0.77, PPV = 0.74, NPV = 0.23,) was slightly below that of 4-0 monofilament stimulation of the AE fold (sensitivity = 0.82, specificity = 0.50, PPV = 0.82, NPV = 0.50) and MPS (sensitivity = 0.84, specificity = 0.64, PPV = 0.90, NPV = 0.56), based on AUC. LAR response outcome agreement for 5-0 and 4-0 stimulations was high (93%) for 5-0 positive response, but low (29%) for 5-0 negative response. Aesthesiometer test-retest reliability for LAR response outcome was excellent (Cronbach's alpha = 0.97).

Conclusions: Threshold estimation of the LAR response may be operationalized by adopting a decision tree protocol. For negative LAR response to initial 5-0 monofilament stimulation and positive response to subsequent 4-0 monofilament stimulation, the higher threshold is confirmed. Positive LAR response to 5-0 or 4-0 monofilament stimulation is expected in over 90% of asymptomatic adults. Negative LAR response to 4-0 monofilament stimulation identifies patients at risk for laryngopharyngeal hyposensitivity.

Level Of Evidence: 3b Laryngoscope, 2021.
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http://dx.doi.org/10.1002/lary.29761DOI Listing
July 2021

Laryngeal Adductor Reflex Movement Latency Following Tactile Stimulation.

Otolaryngol Head Neck Surg 2021 Jul 13:1945998211025517. Epub 2021 Jul 13.

Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA.

Objective: To measure the latency of laryngeal adductor reflex (LAR) motion onset at 2 laryngopharyngeal subsites using calibrated aesthesiometers.

Study Design: Cross-sectional.

Setting: Academic institution.

Methods: Twenty-one asymptomatic, healthy subjects (11 male, 10 female) underwent laryngopharyngeal sensory testing with tactile stimuli delivered to the aryepiglottic fold and medial pyriform sinus using 30-mm Cheung-Bearelly monofilaments (4-0 and 5-0 nylon sutures) via channeled flexible laryngoscope. The LAR onset latency, defined as the first visual detection of ipsilateral vocal fold adduction following tactile stimulation, was measured with frame-by-frame analysis of video recordings.

Results: The overall mean LAR latency across both subsites and stimulation forces was 176.6 (95% CI, 170.3-183.0) ms, without significant difference between subsites or forces. The critical value for LAR response latency prolongation at the .01 significance level was 244 ms. At 30 frames/s video capture resolution, LAR response latency ≥8 frame intervals would indicate abnormal prolongation.

Conclusion: Aesthesiometer-triggered LAR latency appears to be invariant over an 8.7-dB force range and between the aryepiglottic fold and medial pyriform sinus subsites in controls. Laryngeal adductor reflex latency incongruences between stimulation forces or laryngopharyngeal subsites may serve as pathophysiological features to dissect mechanisms of upper aerodigestive tract disorders.

Level Of Evidence: Level 3B.
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http://dx.doi.org/10.1177/01945998211025517DOI Listing
July 2021

Botulinum toxin for chronic parotid sialadenitis: A case series and systematic review.

Laryngoscope Investig Otolaryngol 2021 Jun 2;6(3):404-413. Epub 2021 May 2.

Department of Otolaryngology-Head and Neck Surgery University of California San Francisco San Francisco California USA.

Objective: To evaluate salivary gland chemodenervation with botulinum toxin in chronic parotid sialadenitis.

Methods: Patients who underwent parotid gland chemodenervation for chronic sialadenitis due to duct stenosis refractory to siaendoscopy were reviewed (case series). Additionally, a systematic review of the literature on botulinum toxin injection for chronic parotid sialadenitis was performed. Inclusion criteria included studies containing original data on botulinum toxin injections in patients with chronic sialadenitis symptoms.

Results: Sialadenitis symptoms from 10 patients with 13 affected parotid glands were examined. All had duct stenosis diagnosed on sialendoscopy, refractory sialadenitis symptoms, and received parotid onabotulinum toxin injection(s) (median dose 65U). Of patients with 3-month follow-up, 78% reported significant improvement in symptoms. Mean Chronic Obstructive Sialadenitis Symptoms (COSS) Score improved at 3 months post-injection (47-25.9, = .039) with significant reduction in gland pain frequency and gland swelling severity. No patients had a facial nerve paralysis or increased xerostomia. With the systematic review, 518 abstracts were reviewed and 11 studies met inclusion criteria and included case series or case reports with a total of 40 patients treated with botulinum toxin for chronic parotitis. Thirty-four out of a total of 35 patients in the studies (97%) reported complete (9, 26%) or partial (25, 71%) improvement in sialadenitis symptoms with minimal complications.

Conclusion: Parotid gland chemodenervation with botulinum toxin is a minimally invasive treatment option for symptomatic chronic sialadenitis refractory to medical treatment or sialendoscopy. Botulinum toxin injections alleviate gland pain and swelling associated with salivary obstruction and provide an alternative to parotidectomy for recurrent sialadenitis.Level of evidence: 4.
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http://dx.doi.org/10.1002/lio2.558DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8223475PMC
June 2021

Stabilization of Recurrent Respiratory Papillomatosis with Pembrolizumab Therapy: A Case Report.

J Voice 2021 May 12. Epub 2021 May 12.

Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, CA.

Recurrent respiratory papillomatosis (RRP) is a benign neoplastic disease of the respiratory tract that is caused by human papilloma virus (HPV). The current standard of care is surgical excision with adjuvant treatment as needed. Multiple adjuvant treatments have been used with some success, but long-term control of disease remains difficult. We report on a case of a patient with a long history of RRP who had stabilized true vocal fold disease while on pembrolizumab for concurrent early stage lung squamous cell carcinoma.
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http://dx.doi.org/10.1016/j.jvoice.2021.03.017DOI Listing
May 2021

Impact of surgical margins on local control in patients undergoing single-modality transoral robotic surgery for HPV-related oropharyngeal squamous cell carcinoma.

Head Neck 2021 08 15;43(8):2434-2444. Epub 2021 Apr 15.

Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA.

Background: The impact of close surgical margins on oncologic outcomes in HPV-related oropharyngeal squamous cell carcinoma (HPV + OPSCC) is unclear.

Methods: Retrospective case series including patients undergoing single modality transoral robotic surgery (TORS) for HPV + OPSCC at three academic medical centers from 2010 to 2019. Outcomes were compared between patients with close surgical margins (<1 mm or requiring re-resection) and clear margins using the Kaplan-Meier method.

Results: Ninety-nine patients were included (median follow-up 21 months, range 6-121). Final margins were close in 22 (22.2%) patients, clear in 75 (75.8%), and positive in two (2.0%). Eight patients (8.1%) recurred, including two local recurrences (2.0%). Four patients died during the study period (4.0%). Local control (p = 0.470), disease-free survival (p = 0.513), and overall survival (p = 0.064) did not differ between patients with close and clear margins.

Conclusions: Patients with close surgical margins after TORS for HPV + OPSCC without concurrent indications for adjuvant therapy may be considered for observation alone.
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http://dx.doi.org/10.1002/hed.26708DOI Listing
August 2021

De-intensification strategies in HPV-related oropharyngeal squamous cell carcinoma-a narrative review.

Ann Transl Med 2020 Dec;8(23):1601

Division of Head and Neck Surgical Oncology, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, CA, USA.

Human papillomavirus-related (HPV+) oropharyngeal squamous cell carcinoma (OPSCC) is a relatively new clinical entity that is dramatically on the rise globally. HPV+ OPSCC is thought to be a separate clinical entity compared to HPV- OPSCC with a distinct tumor biology. Patients with HPV associated disease have been shown to have a substantially better prognosis and overall survival than those patients with the HPV negative (HPV-) counterpart. The standard of care for OPSCC is definitive radiation therapy (RT) and concurrent chemoradiation therapy (CRT), for lower and higher stage disease, respectively. However, traditional CRT is also associated with severe acute and late toxicities affecting patient quality of life, such as severe mucositis, dry mouth and dysphagia. Considering that HPV+ OPSCC is on the rise in a younger, healthier patient population and the good prognosis of HPV-related disease, there has been a focus on reducing treatment toxicities and optimizing quality of life while maintaining favorable oncologic outcomes. A variety of such de-escalation regimens are currently being explored in recently completed and ongoing clinical trials. Alterations to the standard chemotherapy, radiation and surgical regimens are being explored. This review will provide an overview of the rationale for and available results of the major de-intensification strategies in the treatment of locally advanced HPV+ OPSCC.
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http://dx.doi.org/10.21037/atm-20-2984DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7791209PMC
December 2020

PET/CT in Surgical Planning for Head and Neck Cancer.

Semin Nucl Med 2021 Jan 7;51(1):50-58. Epub 2020 Aug 7.

Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA. Electronic address:

Fluorine-18 (F)-fluorodeoxyglucose (FDG) positron emission tomography fused with computed tomography (PET/CT) is a valuable tool in surgical planning for head and neck squamous cell carcinoma (HNSCC). If performed prior to biopsy or other surgical intervention, FDG-PET/CT has high sensitivity for the detection of the primary site in patients with cervical lymph node metastases from unknown primary origin and can be used to direct the surgical workup. FDG-PET/CT is superior to CT alone for detection of nodal metastases outside the expected pattern or distant metastases or second primary cancers and can greatly affect determination of appropriate management including surgical eligibility. Prior to the advent of PET/CT, many patients undergoing (chemo)radiation-based therapy had planned post-treatment neck dissection; FDG-PET/CT now has a proven role in the evaluation of recurrent or persistent disease amenable to salvage surgery and enables safe avoidance of planned postradiation neck dissection with a high negative predictive value. Specifically for this important application, two standardized reporting metrics may be used in the head and neck anatomic region: the "Hopkins criteria" and the "Neck Imaging Reporting and Data System"; both systems produce a formalized evaluation and recommendation based on PET/CT findings. The role of PET/CT as a replacement for elective neck dissection or examination under anesthesia remains controversial but deserves further study. FDG-PET/CT has a wide-ranging impact on the surgical management of patients with HNSCC and should be used routinely in patients with unknown primary nodal disease and those presenting with advanced-stage cancers at initial staging and to assess treatment response.
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http://dx.doi.org/10.1053/j.semnuclmed.2020.07.009DOI Listing
January 2021

Communication Chaos from Discrepancies in Personal Protective Equipment and Preoperative Guidelines.

Laryngoscope 2021 03 11;131(3):E746-E754. Epub 2020 Nov 11.

Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA.

Objectives/hypothesis: To compare personal protective equipment (PPE) guidelines, specifically respirator use, among international public health agencies, academic hospitals, and otolaryngology-head and neck surgery (OHNS) departments in the United States for the care of coronavirus-19 (COVID-19) patients.

Study Design: Cross sectional survey.

Methods: Review of publicly available public health and academic hospitals guidelines along with review of communication among otolaryngology departments.

Results: Among 114 academic institutions affiliated with OHNS residencies, 20 (17.5%) institutions provided public access to some form of guidance on PPE and 73 (64%) provided information on screening or diagnostic testing. PPE guidelines were uniquely described based on several variables: location of care, COVID-19 status, involvement of aerosol generating or high-risk procedures, and physical distance from the patient. Six hospital guidelines were highlighted. Across these six institutions, there was agreement that N95 respirators were needed for high-risk patients undergoing high-risk procedures. Variations existed among institutions for scenarios with low-risk patients. Definitions of the low-risk patient and high-risk procedures were inconsistent among institutions. Three of the highlighted institutions had OHNS departments recommending higher level of airway protection than the institution.

Conclusions: OHNS departments typically had more stringent PPE guidance than their institution. Discrepancies in communicating PPE use were frequent and provide inconsistent information on how healthcare workers should protect themselves in the COVID-19 pandemic. Identification of these inconsistencies serves as an opportunity to standardize communication and develop evidence-based guidelines.

Level Of Evidence: V Laryngoscope, 131:E746-E754, 2021.
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http://dx.doi.org/10.1002/lary.29257DOI Listing
March 2021

Implementation of Telemedicine in a Laryngology Practice During the COVID-19 Pandemic: Lessons Learned, Experiences Shared.

J Voice 2020 Jun 23. Epub 2020 Jun 23.

Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California. Electronic address:

Objectives: The novel coronavirus disease 2019 has posed significant limitations and barriers to providing in-person healthcare. We aim to provide a summary of learned experiences and important considerations for implementing and offering telehealth to provide laryngology subspecialty care during the COVID-19 pandemic and thereafter.

Materials And Methods: Four laryngologists and a voice-specialized speech-language pathologist from a tertiary-care academic Voice and Swallowing Center were engaged in a structured group consensus conference. Participants shared input, experiences, and practice patterns employed via telemedicine (via telephone or video-communication) during the early COVID-19 era.

Results: Key identified areas of consideration when offering telemedicine included (1) how to set up and structure a telemedicine visit and maintain patient confidentiality, (2) patient examination and treatment initiation, (3) optimization of the tele-visit, (4) limitations and recognition of when a tele-visit is insufficient for patient care needs, (5) billing/reimbursement considerations. Group consensus for the aforementioned topics is summarized and discussed.

Conclusion: During the COVID-19 pandemic, a telemedicine model can be effectively employed to improve patient access to subspecialty laryngology care, including a multidisciplinary care approach, with initiation of various therapeutic interventions. A major limitation given the preclusion of in-person assessment is the lack of access to laryngoscopy, which can likely be delayed safely in the majority of individuals.
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http://dx.doi.org/10.1016/j.jvoice.2020.06.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7309798PMC
June 2020

Novel Adaptation of a Validated Tactile Aesthesiometer to Evaluate Laryngopharyngeal Sensation.

Laryngoscope 2021 06 31;131(6):1324-1331. Epub 2020 Jul 31.

Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, U.S.A.

Objectives: To evaluate laryngopharyngeal sensation at specific subsites using a novel adaptation of a buckling force aesthesiometer for delivery of calibrated tactile stimuli.

Study Design: Cross-sectional.

Methods: Twenty-two healthy adults (12 men, 10 women) were tested for responses to tactile forces, using 30-mm 6-0, 5-0, and 4-0 nylon monofilaments to map sensation of the aryepiglottic (AE) fold, lateral pyriform sinus (PS), and medial PS bilaterally. The outcome measures were the laryngeal adductor reflex (LAR) and patient reported rating of perceptual strength.

Results: Rates of triggered LAR response grew monotonically with increasing tactile force at a mean (SD) stimulus duration of 663 (164) msec across all three subsites. The AE fold and medial PS had similar profiles and were the most responsive, while the lateral PS was the least responsive. Low force (6-0) response rate was ≤14% for all subsites. High force (4-0) response rate was 91% for AE fold and medial PS, and 23% for lateral PS. The perceptual strength gradient was in the lateral to medial trajectory.

Conclusion: Normative data for LAR response rates to low, medium, and high stimulation forces will be useful to assess sensory dysfunction in a variety of laryngopharyngeal disorders, including aspiration, dysphagia, chronic cough, and spasmodic dysphonia. In turn, that information will guide the creation of innovative treatments. LAR response profiles to low and high force stimuli will inform the development of screening tools to diagnose laryngopharyngeal hypersensitivity and hyposensitivity conditions.

Level Of Evidence: 3b Laryngoscope, 131:1324-1331, 2021.
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http://dx.doi.org/10.1002/lary.28947DOI Listing
June 2021

Temporalis Tendon Transfer/Lengthening Temporalis Myoplasty for Midfacial Static and Dynamic Reanimation After Head and Neck Oncologic Surgery.

Facial Plast Surg Aesthet Med 2021 Jan-Feb;23(1):31-35. Epub 2020 Jun 2.

Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA.

Facial nerve paralysis is an unfortunate, yet relatively common sequela in the treatment of head and neck cancer. Static options for reanimation of the paralyzed midface and oral commissure offer limited quality-of-life improvement and may stretch over time. Reinnervation offers a prolonged recovery and may not be possible among patients with advanced cancer or in salvage situations. To determine the improvement in resting tone and dynamic excursion gained by use of temporalis tendon transfer (TTT) and lengthening temporalis myoplasty (LTM) for facial nerve reanimation among patients undergoing oncologic head and neck cancer surgery. We present the largest series of primary and secondary TTT operations with prolonged photographic and video-based data with analysis enabled by FaceGram open-source quantitative methodology. This was achieved using preoperative and postoperative digital photographs of each patient at rest and full smile excursion. Using the JAVA-based program Facegram v1.0, measurements were taken of the oral commissure in relation to a line tangent to the inferior border of the lower lip. All operations were performed at the University of California, San Francisco, following oncologic resections between April 2011 and June 2018. Quantitative analysis of facial measurement with Facegram. Of the 32 patients in our series, 19 (59.4%) were male and 13 (40.6%) were female. The average age was 71.3 ± 10 years. There was a mean 4.89 mm ( < 0.01, 95% confidence interval [CI]: 2.78-6.99) increase in height of affected side oral commissure compared with preoperative measurements during full smile excursion, and a 3.05 mm ( < 0.04, 95% CI: 0.22-5.87) increase in horizontal excursion of smile vector. There was also a significant increase in static support at rest, measuring an average of 5.45 mm ( < 0.01, 95% CI: 2.56-8.33) and 2.71 mm ( < 0.04, 95% CI: 0.18-5.25) increase in affected oral commissure vertical and horizontal positions at rest, respectively. The average postoperative follow-up was 11.4 months (95% CI: 5.6-14.11). In addition, when compared with patients treated with postoperative radiation therapy (9 patients), those who received preoperative radiation (15 patients) had a significant improvement in the resting vertical height of the affected side (mean 5.32 mm ( < 0.05, 95% CI: 0.06-10.57)). These findings encourage the use of TTT/LTM for facial nerve paralysis in appropriately selected head and neck oncologic patients.
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http://dx.doi.org/10.1089/fpsam.2020.0069DOI Listing
August 2021

Immediate Voice and Swallowing Complaints Following Revision Anterior Cervical Spine Surgery.

Otolaryngol Head Neck Surg 2020 Oct 2;163(4):778-784. Epub 2020 Jun 2.

Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, USA.

Objective: To report on the incidence of dysphagia, dysphonia, and acute vocal fold motion impairment (VFMI) following revision anterior cervical spine surgery, as well as to identify risk factors associated with acute VFMI in the immediate postoperative period.

Study Design: Retrospective cohort study.

Setting: Tertiary care center.

Subjects And Methods: All patients who underwent 2-team reoperative anterior cervical discectomy and fusion (ACDF) were retrospectively reviewed. Incidence of dysphonia, dysphagia, and acute VFMI was noted. Patient and operative factors were evaluated for association with risk of acute VFMI.

Results: The incidence of postoperative dysphonia and dysphagia was 25% (18/72) and 52% (37/72), respectively. The incidence of immediate VFMI was 21% (15/72). Subjective postoperative dysphonia (odds ratio, [OR] 8; 95% CI, 2.2-28; = .001) and dysphagia (OR, 22; 95% CI, 2.5-168; = .005) were significantly associated with increased risk of VFMI. Three patients with VFMI required temporary injection medialization for voice complaints and/or aspiration. Infection (OR, 14; 95% CI, 1.4-147, = .025) and level C7/T1 (OR, 5.5; 95% CI, 1.3-23, = .02) were significantly associated with an increased risk of acute VFMI on multivariate logistic regression analysis. Number of prior surgeries, laterality of approach, side of approach relative to prior operations, and number of levels exposed were not significant.

Conclusion: Early involvement of an otolaryngologist in the care of a patient undergoing revision ACDF can be helpful to the patient in anticipation of voice and swallowing changes in the postoperative period. This may be particularly important in those being treated at C7/T1 or those with spinal infections.
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http://dx.doi.org/10.1177/0194599820926133DOI Listing
October 2020

Long-Term Stability of Vascularized Adipofascial Flaps in Facial Reconstruction.

Facial Plast Surg Aesthet Med 2020 Jul/Aug;22(4):262-267. Epub 2020 Apr 6.

Section of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California.

To determine the quantitative volume change over time of vascularized adipofascial anterolateral thigh (AFALT) free flaps in facial reconstruction, and to evaluate patient factors that are associated with changes in volume. A retrospective review was performed on patients who underwent AFALT reconstruction for large volume parotid and midface defects after head and neck cancer surgery at a single tertiary care hospital from 2011 to 2018. Flap volume was measured at different time points using 3D Slicer, a free open source software for medical image computing. Trends in volume change over time were evaluated. A multiple linear regression model was used to analyze patient factors associated with mean final volume change. Twenty-one patients were included. The median follow-up period from surgery was 17 months (interquartile range [IQR] = 9-25 months). The first imaging study was obtained a median of 3 months after surgery (IQR = 1-4 months). The majority of patients underwent postoperative radiation (20/21, 95%). Mean final total volume percentage change over time was 96.6% (standard deviation = 21.7%). After controlling for age, smoking history, recurrence, and length of follow-up, a reduction in body mass index (BMI) ≥1.5 U from baseline had the greatest association with mean final volume percentage change ( -31, 95% confidence interval: -52 to -11,  = 0.005). Free tissue transfer using AFALT flaps in the head and neck provided relatively stable volume maintenance over time, even after postoperative radiation. The volume of transplanted fat can change depending on patient factors, such as BMI.
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http://dx.doi.org/10.1089/fpsam.2019.0015DOI Listing
November 2020

Outcomes of sinonasal mucosal melanomas with endoscopic and open resection: a retrospective cohort study.

J Neurooncol 2020 Dec 29;150(3):387-392. Epub 2020 Mar 29.

Department of Otolaryngology-Head and Neck Surgery, Center for Minimally Invasive Skull Base Surgery, University of California-San Francisco, 2233 Post St, 3rd Floor, San Francisco, CA, 94115, USA.

Purpose: To compare the outcomes of Sinonasal Mucosal Melanomas (SNMM) treated with endoscopic and open resection.

Methods: A retrospective case review of 20 patients with SNMM treated surgically at UCSF. Kaplan-Meier analyses were calculated to determine outcome differences in endoscopic vs. open resections.

Results: From 2005 to 2014, 20 cases of SNMM were confirmed and treated at UCSF. All cases underwent surgical resection, with 10 cases by open resection and 10 cases by endoscopic resection. Using Kaplan-Meier analyses, the open resection group had a 1-year survival of 30% whereas endoscopic resection group was 80% (p = 0.032). Endoscopic resection showed improved survival at all time points after surgery compared to open resection.

Conclusion: SNMM is a rare and aggressive tumor that is associated with low survival rates. In this small case series, endoscopic resection had improved survival outcomes compared to open resection.
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http://dx.doi.org/10.1007/s11060-020-03449-0DOI Listing
December 2020

Molecular Diagnostics in Human Papillomavirus-Related Head and Neck Squamous Cell Carcinoma.

Cells 2020 02 22;9(2). Epub 2020 Feb 22.

Department of Otolaryngology Head and Neck Surgery, University of California San Francisco, San Francisco, CA 94158, USA.

The incidence of human papillomavirus (HPV)-related head and neck squamous cell carcinoma continues to increase. Accurate diagnosis of the HPV status of a tumor is vital, as HPV+ versus HPV- tumors represent two unique biological and clinical entities with different treatment strategies. High-risk HPV subtypes encode oncoproteins E6 and E7 that disrupt cellular senescence and ultimately drive tumorigenesis. Current methods for detection of HPV take advantage of this established oncogenic pathway and detect HPV at various biological stages. This review article provides an overview of the existing technologies employed for the detection of HPV and their current or potential future role in management and prognostication.
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http://dx.doi.org/10.3390/cells9020500DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7072739PMC
February 2020

Contemporary Management of Parapharyngeal Tumors.

Curr Oncol Rep 2019 11 14;21(11):103. Epub 2019 Nov 14.

Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, 2233 Post St 3rd Floor, San Francisco, CA, 94115, USA.

Purpose Of Review: Management of parapharyngeal tumors is challenging due to the complex anatomic nature of the space and the wide range of pathologies encountered. This article will review the anatomy, common pathologies, and management of parapharyngeal masses. Surgical strategies are also reviewed.

Recent Findings: Masses of the parapharyngeal space are most commonly benign (80%). More recent longitudinal studies have shown that observation and non-surgical therapy are indicated in many cases. When surgery is indicated, innovative endoscopic and robotic-assisted techniques allow for improved visualization and complete tumor removal while avoiding significant blood loss, tumor spillage, and injury to surrounding nerves and vessels. Management of parapharyngeal masses should consider morbidity of surgical resection versus the natural course of the disease. Surgical strategy is determined by location, size, and pathology. Adequate access is needed surgically to ensure complete resection and avoid tumor rupture.
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http://dx.doi.org/10.1007/s11912-019-0853-8DOI Listing
November 2019

Can Early Dental Extractions Reduce Delays in Postoperative Radiation for Patients With Advanced Oral Cavity Carcinoma?

J Oral Maxillofac Surg 2019 Nov 25;77(11):2215-2220. Epub 2019 May 25.

Assistant professor, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, CA.

Purpose: This study sought to evaluate the effect of early extractions on the timing of postoperative radiation (PORT) for patients with advanced oral cavity squamous cell carcinoma.

Materials And Methods: All patients with oral cavity squamous cell carcinoma who required resection, free flap reconstruction, and dental extractions in a 10-year period were retrospectively reviewed. The study included patients who preoperatively had advanced disease that indicated the need for adjuvant radiation as defined by an advanced clinical T category (T3 or T4a) or clinical N category (N2a or above). Multivariate logistic regression models were created to estimate the risk factors for initiation of PORT greater than 6 weeks after surgery.

Results: Thirty-four patients were included. Thirteen patients underwent early extractions (before or at the time of surgery). Twenty-one patients underwent extractions after surgery. Extractions included all teeth with periodontal disease within the expected field of radiation. Most patients underwent full-mouth extractions (91.1%). PORT was initiated at greater than 6 weeks in 30.8% of patients in the early cohort, whereas 72.4% of patients in the late group experienced a delay (P = .02). Early extractions were significantly associated with a decreased risk of PORT delay. No increase in operating room time occurred for patients who underwent same-day extractions.

Conclusions: Early involvement of the dental oncology department and oral-maxillofacial surgeons can aid in the timely delivery of care for patients with advanced oral cavity cancer.
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http://dx.doi.org/10.1016/j.joms.2019.05.007DOI Listing
November 2019

The prefabricated supraclavicular artery flap in high-risk tracheal stenosis patients.

Laryngoscope 2020 03 21;130(3):641-648. Epub 2019 May 21.

Department of Otolaryngology-Head and Neck Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, U.S.A.

Objectives/hypothesis: Primary tracheal resection in appropriately selected patients with tracheal stenosis achieves >90% success rate. Risk factors for complications have been identified, making some patients high risk for this procedure. Herein is a review and discussion of a novel treatment method for tracheal stenosis utilizing a prefabricated composite auricular cartilage graft embedded in a supraclavicular artery island flap (pSCAIF) for tracheal reconstruction in high-risk patients.

Study Design: Retrospective case series.

Methods: After institutional review board approval, cases were analyzed after data collection. Between 2014 and 2016, eight patients underwent airway reconstruction using an auricular cartilage graft prefabricated within a supraclavicular artery island flap reconstruction; all of these were included in the study. Each case was reviewed, and relevant details of patient and disease characteristics, operative course, postoperative course, decannulation, and status at last follow-up were isolated and reported.

Results: Seven of eight patients were female. The most common cause of stenosis was iatrogenically induced multilevel stenosis (7/8 patients). All patients had undergone prior airway procedures, were high risk based on comorbid conditions, and underwent grafting and reconstruction with a composite supraclavicular island flap. All patients continue to follow up in a multidisciplinary clinic, and at last follow-up, eight of eight patients were successfully decannulated.

Conclusions: The pSCAIF is a novel method for tracheal reconstruction. The analysis of the prefabricated locoregional approach cohort supports its utility for tracheal reconstruction in patients with complicated multilevel stenosis and adverse comorbidities and characteristics.

Level Of Evidence: 4 Laryngoscope, 130:641-648, 2020.
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http://dx.doi.org/10.1002/lary.28068DOI Listing
March 2020

Human Papillomavirus-Associated Oropharyngeal Cancer: Patterns of Nodal Disease.

Otolaryngol Head Neck Surg 2019 03 2;160(3):502-509. Epub 2018 Oct 2.

4 Division of Head and Neck Oncologic and Endocrine, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, USA.

Objective: To characterize patterns of neck lymph node (LN) metastases in human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma, represented by p16 positivity (p16+OPSCC).

Study Design: Case series with chart review.

Setting: Tertiary care center.

Subjects And Methods: Neck dissection (ND) specimens of nonirradiated p16+OPSCC patients were analyzed for frequencies of clinically evident and occult LNs by neck level. Local, regional, and distant recurrences were reviewed.

Results: Seventy p16+OPSCC patients underwent primary site transoral robotic surgery and 82 NDs of varying levels. Metastatic pathologic LNs were found at the following frequencies: 0% (0/28) in level I, 75.6% (62/82) in level II with 57.4% (35/61) in level IIA and 13.1% (8/61) in level IIB, 22.0% (18/82) in level III, 7.0% (5/71) in level IV, and 6.3% (1/16) in level V. The level V LN was clinically evident preoperatively. Five of 21 (23.8%) elective NDs contained occult LNs, all of which were in level II and without extranodal extension. Twenty-seven (38.6%) patients underwent adjuvant radiation; 19 (27.1%) patients underwent adjuvant chemoradiation. With a mean follow-up of 29 months, 3 patients had developed recurrences, with all but 1 patient still alive. All patients who recurred had refused at least a component of indicated adjuvant treatment.

Conclusions: For p16+OPSCC, therapeutic NDs should encompass any levels bearing suspicious LNs and levels IIA-B, III, and IV, while elective NDs should be performed and encompass at least levels IIA-B and III. These selective ND plans, followed by indicated adjuvant treatment, are associated with a low nodal recurrence rate.
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http://dx.doi.org/10.1177/0194599818801907DOI Listing
March 2019

Surgeon-performed ultrasound for the assessment of parotid masses.

Am J Otolaryngol 2018 Sep - Oct;39(5):467-471. Epub 2018 Apr 16.

Division of Head and Neck Oncologic and Endocrine Surgery, Salivary Gland Center, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, CA, United States. Electronic address:

Background: Studies on parotid gland ultrasound assessments performed specifically by surgeons are seldom reported.

Methods: Retrospective series of a single academic surgeon experience, analyzing 70 new parotid masses with evaluable preoperative SP-US characteristics, location measurements, and perioperative events.

Results: 31/70 masses were malignant. SP-US characteristics significantly associated with both malignancy and positive margins included extraparenchymal extension, irregular borders, hypervascularity, infiltration, and the lack of deep enhancement. The larger the skin-to-deep-aspect-of-tumor distance, the more likely the tumor was deep to FN. For the 39 cytologically benign tumors, neither CT nor MRI provided additional information to change management except for full delineation of parapharyngeal space extension in 2 cases.

Conclusion: SP-US can help predict parotid mass benignity/malignancy, positive margin risk, and tumor relation to FN. SP-US may be used as the sole imaging in cytologically benign tumors unless the deep tumor extent cannot be identified.
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http://dx.doi.org/10.1016/j.amjoto.2018.04.011DOI Listing
December 2018

Insights since FDA Approval of Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea.

Curr Sleep Med Rep 2017 Sep 5;3(3):133-141. Epub 2017 Aug 5.

Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Case School of Medicine, Cleveland OH.

Purpose: The literature on hypoglossal nerve stimulation (HNS) for the treatment of moderate-to-severe obstructive sleep apnea (OSA) was reviewed from 2014, the time of FDA approval for the Inspire Systems device, to 2017 for themes that might be useful conceptually and practically in the consideration of this new non-anatomic surgical therapy.

Recent Findings: there are now further follow-up articles since the 12-month results for Apnea Reduction (STAR) trial of the Inspire device, and post-approval publications which report similar and/0r improved AHI outcomes. Other emerging themes include drug-induced sedation endoscopy (DISE) as a tool in assessment of eligibility and a more detailed understanding of mechanisms for an HNS effects.

Summary: The post-STAR literature provides guidelines for an integrated coordination of medicine and surgery to appropriately screen and manage patients.
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http://dx.doi.org/10.1007/s40675-017-0088-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5739331PMC
September 2017

A Novel Approach to Oropharyngeal Foreign Body Removal.

Otolaryngol Head Neck Surg 2018 01 17;158(1):194-196. Epub 2017 Oct 17.

3 Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA.

Grill wire brush bristle foreign bodies most commonly embed in the oropharynx. Often these bristles can be removed in the clinic; however, on occasion, the patient requires general anesthesia for retrieval because of the gag reflex and difficulty with access and visualization. We report here on 2 cases of patients who underwent successful transoral robotic surgical retrieval of wire bristles from the base of tongue after unsuccessful direct laryngoscopy. Otolaryngologists should be aware of the use of robotic assistance for oropharyngeal foreign body retrieval.
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http://dx.doi.org/10.1177/0194599817737272DOI Listing
January 2018

Rare Neurosurgical Complications of Epidural Injections: An 8-Yr Single-Institution Experience.

Oper Neurosurg (Hagerstown) 2017 04;13(2):271-279

Department of Neurosurgery, University Hospitals Case Medical Center, Cleveland, Ohio.

Background: Neurosurgical complications from epidural injections have rarely been reported.

Objective: To define the spectrum of complications from these procedures in order to identify risk factors and strategies for prevention.

Methods: A prospectively maintained database of 14 247 neurosurgical admissions over 8 yr was screened to identify patients who had suffered procedural complications associated with 1182 cervical and 4617 lumbar interlaminar epidural injection procedures performed at a single institution. Patients who developed new neurological symptoms or deficits were included. A retrospective analysis of demographic and procedural features was performed.

Results: Thirteen patients experienced complications requiring neurosurgical treatment, accounting for an overall procedural complication rate of 0.22% (0.51% and 0.15% for cervical and lumbar injections, respectively), and representing 0.09% of all neurosurgical admissions over 8 yr. There were 3 categories: hemorrhage (n = 7), infection (n = 3), and inadvertent dural penetration (n = 3). There was significant association with anticoagulation use among patients with hemorrhagic vs nonhemorrhagic complications ( P < .01, Fisher's exact test). Six patients who developed epidural hematoma had been managed in accordance with current guidelines, either after prolonged cessation of anticoagulation (n = 3) or taking only aspirin (n = 3); all were decompressed promptly with good long-term outcome. All infections were associated with lumbar injection. Dural penetration resulted in diffuse pneumocephalus (n = 1), intramedullary air at the site of injection (n = 1), and acutely symptomatic colloid cyst (n = 1).

Conclusion: A majority of neurosurgical complications from epidural injections are hemorrhagic and associated with anticoagulation, although infection and inadvertent dural penetration also occur. Prompt treatment of compressive lesions is associated with good outcome.
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http://dx.doi.org/10.1093/ons/opw014DOI Listing
April 2017

Prevalence of atopic disease in patients with eosinophilic esophagitis.

Int Forum Allergy Rhinol 2017 08 14;7(8):757-762. Epub 2017 Jun 14.

The Cleveland Clinic, Cleveland, OH.

Background: The objective of this work was to evaluate prevalence of eosinophilic esophagitis (EoE) in the United States, and analyze prevalence of atopic disease in patients with EoE. The study design was a retrospective administrative database analysis in U.S.-based outpatient settings.

Methods: A retrospective claims analysis in the inpatient and outpatient setting (using MarketScan) was conducted to analyze prevalence of atopic disease diagnoses in patients with EoE in 2012, and timing of those diagnoses vs EoE.

Results: From published evidence, prevalence of EoE was estimated at 1 to 5 patients per 10,000 and prevalence of asthma, allergic rhinitis (AR), and atopic dermatitis (AD) concurrent to EoE ranged from 20% to 50%, 50% to 75%, and 2% to 19% cases, respectively. From 2009 and 2013, the estimated prevalence of EoE in MarketScan increased from 2.7 to 5.6 per 10,000 enrollees age 34.5 ± 18.43 years (mean ± standard deviation). Age followed a bimodal distribution with peaks at 12 and 41 years. Women accounted for 35.6% cases. Prevalence of asthma, AR, AD, and food allergies up to 12 months post-EoE diagnosis reached 44.7%, 27.1%, 25.2%, and 16.9%, respectively, with 63.5% of all patients suffering from at least 1 of these 4 diseases and 3.0% suffering from all 4.

Conclusion: The diagnosis of EoE is associated with the diagnoses of asthma, AR, AD, and food allergies. The high prevalence of these conditions in EoE patients further strengthens the hypothesis of a common pathogenesis.
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http://dx.doi.org/10.1002/alr.21968DOI Listing
August 2017

Hypoglossal nerve stimulation rescue surgery after multiple multilevel procedures for obstructive sleep apnea.

Am J Otolaryngol 2016 Jan-Feb;37(1):51-3. Epub 2015 Aug 18.

Department of Otolaryngology-Head and Neck Surgery, University Hospitals Case Medical Center, Cleveland, OH, USA.

Hypoglossal nerve stimulation (HNS) is a new procedure offered for the treatment of moderate-to-severe obstructive sleep apnea (OSA) that has been shown to decrease the severity and symptoms of OSA in select patients. We report on a case of a patient with persistent symptoms and findings of OSA despite a history of multiple multilevel procedures, including an uvulopalatopharyngoplasty (UPPP) with revision, a genioglossus advancement, and a maxillomandibular advancement. The patient then underwent HNS with significant improvement of his symptoms and severity. The success of this patient's HNS surgery demonstrates that we need to examine where HNS fits into the approach to surgery for OSA. There could be benefit to considering cranial nerve stimulation earlier than conventional approaches for select patients.
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http://dx.doi.org/10.1016/j.amjoto.2015.08.008DOI Listing
September 2016

Surgery for Localized Pancreatic Cancer: The Trend Is Not Improving.

Pancreas 2016 May-Jun;45(5):687-93

From the *School of Medicine, Case Western Reserve University; and †Division of Surgical Oncology, Department of Surgery, University Hospitals Seidman Cancer Center, Cleveland, OH.

Objectives: The aim of this study was to examine the trend in the use of surgery for localized pancreatic adenocarcinoma for the past 2 decades using the Surveillance, Epidemiology, and End Results database.

Methods: We identified a cohort of patients who received a diagnosis of localized pancreatic adenocarcinoma between 1988 and 2010 in the United States. Univariate and multivariate methods were used to determine factors associated with not receiving surgery. Cox proportional hazards regression modeling was used to determine factors associated with survival.

Results: Of 6742 patients with a diagnosis of localized pancreatic adenocarcinoma, 1715 patients (25.4%) underwent surgery. There was no significant change in use of surgery over time. Patients were less likely to undergo surgery if they were older than 50 years, black, unmarried, and located outside the East and had pancreatic head or body lesions, higher tumor grades, or tumor size greater than 2 cm (P < 0.0001). Receiving surgery had the most significant impact on the hazard of disease-specific death (hazards ratio, 1.41; 95% confidence interval, 1.29-1.53; P < 0.0001).

Conclusions: In contrast to recent studies that suggest an increasing use of surgery, the present study demonstrates that there has been no change in the rate of use of surgery in patients with localized pancreatic disease.
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http://dx.doi.org/10.1097/MPA.0000000000000511DOI Listing
January 2017

T Cells Derived From Human Melanoma Draining Lymph Nodes Mediate Melanoma-specific Antitumor Responses In Vitro and In Vivo in Human Melanoma Xenograft Model.

J Immunother 2015 Jul-Aug;38(6):229-38

*Department of Biomedical Engineering, Case Western Reserve University †Case Comprehensive Cancer Center ‡Seidman Cancer Center §Division of Surgical Oncology, University Hospitals Case Medical Center, Cleveland, OH.

It has been established in murine models that lymph nodes draining a progressively growing tumor contain antigen-specific T cells capable of mediating protective immune responses upon adoptive transfer. However, naturally occurring human tumor-draining lymph nodes (TDLNs) have yet to be fully investigated. In this study, we analyzed TDLNs from patients with stage III melanoma who were undergoing routine lymph node dissection. Following short-term (14 d) culture activation with anti-CD3/anti-CD28 microbeads and expansion in low concentrations of IL-2, the melanoma-draining lymph node (MDLN) cells were ∼ 60% CD4-activated and ∼ 40% CD8-activated T cells. The activated MDLN cells demonstrated reactivity in response to overlapping peptides spanning the sequence of 4 different known melanoma antigens MAGEA1, Melan-A/MART-1, NY-ESO-1, and Prame/OIP4, suggesting the presence of melanoma-specific T cells. Coculture of activated MDLN T cells with cancer cells in vitro resulted in preferential apoptosis of human cancer cell lines that were cocultured with T cells with high degree of MHC matching. Adoptive transfer of MDLN T cells with high degree of MHC matching to A375 to mice-bearing human A375 melanoma xenografts resulted in dose-dependent improvement in survival. Although prior human studies have demonstrated the immune responses within melanoma vaccine-draining lymph nodes, this study presents evidence for the first time that naturally occurring human MDLN samples contain melanoma-experienced CD4 and CD8 T cells that can be readily cultured and expanded to mediate protective immune responses both in vitro and in vivo in a human melanoma xenograft model.
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http://dx.doi.org/10.1097/CJI.0000000000000078DOI Listing
February 2016

Bradley's Benzedrine studies on children with behavioral disorders.

Yale J Biol Med 2011 Mar;84(1):27-33

History of Science/History of Medicine, Yale University, New Haven, Connecticut, USA.

In 1937, psychiatrist Charles Bradley administered Benzedrine sulfate, an amphetamine, to "problem" children at the Emma Pendleton Bradley Home in Providence, Rhode Island, in an attempt to alleviate headaches; however, Bradley noticed an unexpected effect upon the behavior of the children: improved school performance, social interactions, and emotional responses. Drawing on Bradley's published articles on his experiments, this paper explores the historical context of his experiments and the effect this background had on the emerging field of child psychiatry. Bradley's studies went largely ignored in the field of child psychiatry for nearly 25 years. However, they proved to be an important precursor to studies of amphetamines like Ritalin and their use in conditions such as attention deficit hyperactivity disorder. Bradley's Benzedrine trials were thus highly influential in shaping modern objective understandings of children with behavior disorders.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3064242PMC
March 2011
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