Publications by authors named "Neerav Goyal"

108 Publications

An invasive tracheal paraganglioma: A rare cause of a thyroid mass.

Ear Nose Throat J 2022 Jul 10:1455613221112347. Epub 2022 Jul 10.

Department of Otolaryngology-Head and Neck Surgery, 12310Pennsylvania State College of Medicine, Hershey, PA, USA.

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http://dx.doi.org/10.1177/01455613221112347DOI Listing
July 2022

Can a flexible surgical robot be used in the pediatric population: A feasibility study.

Int J Pediatr Otorhinolaryngol 2022 Aug 13;159:111206. Epub 2022 Jun 13.

Department of Otolaryngology, Penn State Milton S Hershey Medical Center, 500 University Drive, Hershey, PA, United States.

Objectives: Transoral robotic surgery in adults confers excellent results and decreased morbidity. Application of these techniques has not yet been rigorously investigated in children. The goal of this study is to evaluate the feasibility of a flexible robotic surgical system in a pediatric population.

Methods: This was a non-randomized, non-blinded, prospective clinical trial. An Investigational Device Exemption was obtained from the FDA. Patients 8-12 years old scheduled for tonsillectomy and adenoidectomy between February and December 2019 at an academic tertiary care children's hospital were included. Exclusion criteria included pulmonary or vascular conditions posing risks for extended anesthesia, or a smaller mouth opening than the instrumentation (28 mm × 15 mm). Tonsillectomy was completed with standard monopolar cautery. After the surgery was complete, the robot was utilized for evaluation and assessment of exposure. A pediatric anesthesiologist screened patients for tolerance of additional anesthesia (up to 15 min). A flexible robotic surgical system, the MedRobotics Flex® Robotic System, was used to visualize and access the tonsillar fossa, posterior pharynx, base of tongue, epiglottis and false vocal folds. Visualization and access were graded on a five-point Likert scale.

Results: A total of ten patients, eight males and two females, with obstructive sleep apnea (OSA) or sleep disordered breathing (SDB) were recruited in 2019. One patient did not complete the study due to equipment malfunction. The average patient demographics were: age 10.1 years (8.6-11.8 years), height 142.4 cm (127-164.9 cm), weight 47.5 kg (24.4-84.5 kg), and BMI 22.6 (13.9-31.0). Study time averaged 10.3 min (5-13 min). The tonsillar fossa, base of tongue, and posterior pharynx were visualized completely and easily accessed with the robotic instruments. The epiglottis and false vocal folds were visualized and accessed in 66% and 55% of patients, respectively. There were no adverse effects.

Conclusions: This study demonstrated that a flexible robotic surgical system is feasible for use in children 8-12 years of age when performing otolaryngology - head and neck surgery procedures of the oropharynx and larynx.
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http://dx.doi.org/10.1016/j.ijporl.2022.111206DOI Listing
August 2022

Descriptive Analysis of Otolaryngology Program Directors with a Focus on Gender Disparity.

Ear Nose Throat J 2022 Jun 5:1455613221107149. Epub 2022 Jun 5.

College of Medicine, 12310The Pennsylvania State University, Hershey, PA, USA.

Objective: To describe and analyze the demographics and academic backgrounds of United States otolaryngology program directors (PD) and assess gender disparity in the field.

Methods: This was a cross-sectional study in which an online search using publicly available sources was performed to gather information on PDs for 125 United States otolaryngology programs from May 14, 2021, to May 30, 2021. Data collected included PD appointment year, age, gender, resident gender breakdown, degree, as well as training location and graduation year.

Results: There were 69.6% programs with a male PD and 30.4% with a female PD. Ninety percent of PDs have an MD degree and 9.6% have a DO degree. The current average age of PDs was 49.9 years old (range 35-79). Males were older than females PD (51.0 vs 47.1 years, = 0.045) and have served a longer time as PD (7.1 vs 4.8 years, = 0.019). There was no significant difference in other variables collected. There were 27.3% of program directors that held the position of professor, 44.5% associate professor, and 28.2% assistant professor. The most common subspecialty practiced by otolaryngology PDs was head and neck oncology.

Conclusion: Disparity in women's representation in otolaryngology still exists, but the program director leadership position demonstrates better parity. There is an equal percent representation when examining female PDs and female otolaryngologists in academic medicine. Continued efforts to encourage women to enter and become leaders in otolaryngology are necessary moving forward.
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http://dx.doi.org/10.1177/01455613221107149DOI Listing
June 2022

In Vivo Transfection of Rat Salivary Glands With Fluorescently Tagged Aquaporin-5 Channel DNA.

Cureus 2022 Apr 28;14(4):e24555. Epub 2022 Apr 28.

Otolaryngology - Head and Neck Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA.

Background  The acinar cells of salivary glands are responsible for most saliva production and are, unfortunately, h--ighly radiosensitive. As such, dry mouth or xerostomia is an adverse effect experienced by half of head and neck cancer patients treated with radiation. We evaluate a novel method of gene transfection of aquaporin channels to rat salivary glands. Materials and methods A green fluorescent protein (GFP)-tagged human Aquaporin-5 cDNA sequence cloned into a pCMV6-AC-GFP vector was complexed with lipofectamine 2000. One submandibular gland of the anesthetized rats was injected with the complexed cDNA and lipid solution under ultrasound guidance, while the opposite gland was injected with the vehicle control. The animals were sacrificed between 24 to 48 hours post-injection. The salivary glands were removed and evaluated via fluorescence imaging. Western blot assays were also performed to determine cDNA expression. Results  In the experiments, the submandibular glands were identified and injected under ultrasound guidance. Four control glands and eight experimental glands were evaluated. The cDNA was expressed successfully and variably within the experimental glands, noting greater intensity along the cell surface consistent with appropriate trafficking of the channel. Western blot analysis demonstrated variable expression in the experimental sample with no expression in the control sample. Several glands across the groups showed mild to moderate interstitial edema or inflammation. Conclusion  In this study, we demonstrate an alternative in vivo transfection method via lipofection and demonstrate the successful expression of the AQP5 channel in rat salivary gland tissue.
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http://dx.doi.org/10.7759/cureus.24555DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9138633PMC
April 2022

Health and Well-Being Needs Among Head and Neck Cancer Caregivers - A Systematic Review.

Ann Otol Rhinol Laryngol 2022 May 12:34894221088180. Epub 2022 May 12.

Department of Otolaryngology - Head and Neck Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA.

Objective: This review provides a summary of the current understanding of the health and well-being of the head and neck cancer (HNC) caregiver. Our goal is to understand the healthcare needs required by the caregivers of our oncologic patients, which may ultimately influence quality of care and support that cancer patients require during treatment and recovery.

Methods: Independent database searches were conducted to identify articles describing HNC caregiver health and healthcare utilization. Search terms included key synonyms for head and neck cancer, caregiver, psychological stress, anxiety, depression, mental health service, and delivery of healthcare in the title/abstract.

Results: After following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Protocol, a total of 21 studies were included. Among the 21 studies in the review, a total of 1745 caregivers were included. The average age was 57 years, the majority were female (58%-100%), and spouses/partners of the patients (77%). The literature demonstrates significant anxiety, depression, post-traumatic stress disorder (PTSD), and physical health decline in addition to multifaceted unmet physical and mental health needs among HNC caregivers.

Conclusion: There is no standard for examining HNC caregiver healthcare needs, while there is evidence of increased healthcare utilization. The literature is limited regarding medical burdens faced by caregivers. Future research is needed to assess the physical health and comorbidities of HNC caregivers and their engagement with the healthcare system to guide further implementation of support models to address the needs of this population.
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http://dx.doi.org/10.1177/00034894221088180DOI Listing
May 2022

Progressive Familial Intrahepatic Cholestasis: A Study in Children From a Liver Transplant Center in India.

J Clin Exp Hepatol 2022 Mar-Apr;12(2):454-460. Epub 2021 Jun 13.

Department of Pediatric Gastroenterology and Hepatology, Indraprastha Apollo Hospital, New Delhi, India.

Background/aims: This study aimed to delineate the clinical profile of children diagnosed with progressive familial intrahepatic cholestasis (PFIC).

Methods: This study was a retrospective analysis of case records of children in the tertiary care hospital, with the diagnosis of PFIC from January 2017 to January 2020. The diagnosis was made using clinical and laboratory parameters and with genetic testing when available. Medical and surgical management was according to the departmental protocol. Liver transplant was offered to children with end-stage liver disease, intractable pruritus, or severe growth failure.

Result: There were 13 identified PFIC cases (familial intrahepatic cholestasis 1 [FIC1] deficiency-4, bile salt export pump (BSEP) deficiency-3, tight junction protein [TJP2] deficiency 3, multidrug-resistant protein 3 [MDR3] deficiency 2 and farnesoid X receptor deficiency-1). PFIC subtypes 1, 2, and 5 presented in infancy, whereas MDR3 presented in childhood. TJP2 deficiency had varied age of presentation from infancy to adolescence. Jaundice with or without pruritus was present in most cases. Genetic testing was carried out in 10 children, of which five had a homozygous mutation, three had a compound heterozygous mutation, and two had a heterozygous mutation. Three children (FIC1-2 and TJP2-1) underwent biliary diversion, of which clinical improvement was seen in two. Six children underwent liver transplantation, which was successful in four.

Conclusion: Byler's disease was the most common subtype. A clinicopathologic correlation with molecular diagnosis leads to early diagnosis and management. Liver transplantation provides good outcomes in children with end-stage liver disease.
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http://dx.doi.org/10.1016/j.jceh.2021.06.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9077189PMC
June 2021

Perioperative Topical Antisepsis and Surgical Site Infection in Patients Undergoing Upper Aerodigestive Tract Reconstruction.

JAMA Otolaryngol Head Neck Surg 2022 06;148(6):547-554

Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee.

Importance: Surgical site infections (SSIs) after vascularized reconstruction of the upper aerodigestive tract (UADT) are associated with considerable morbidity. The association between perioperative prophylaxis practices, particularly topical antisepsis, and SSIs remains uncertain.

Objective: To assess the association between perioperative topical antisepsis and SSIs in patients undergoing vascularized reconstruction of the UADT.

Design, Setting, And Participants: This cohort study included patients from 12 academic tertiary care centers over an 11-month period, from July 1, 2020, to June 1, 2021. Patients undergoing open surgical procedures requiring a communication between the UADT and cervical skin with a planned regional pedicled flap, free flap, or both were included. Patients with an active infection at the time of surgical procedure were excluded.

Main Outcomes And Measures: The primary outcome measure was an SSI within 30 days of surgery. The association of demographic characteristics, perioperative antibiotic prophylaxis, surgical technique, and postoperative care with SSIs was assessed using univariable and multivariable analyses. The relative risk ratio and 95% CIs for developing SSI were calculated for each of the variables based on predetermined categories. Variables for which the relative risk 95% CI did not include the value of zero effect (relative risk = 1.00) were included in the multivariable model.

Results: A total of 554 patients (median age, 64 years; range, 21-95 years; 367 men [66.2%]) were included. Cancer ablation was the most frequent reason for surgery (n = 480 [86.6%]). Overall, the SSI rate was 20.9% (n = 116), with most infections involving the head and neck surgical site only (91 [78.4%]). The median time to SSI diagnosis was 11 days (range, 1-28 days). Topical antisepsis mucosal preparation was performed preoperatively in 35.2% (195) and postoperatively in 52.2% (289) of cases. Ampicillin and sulbactam was the most common systemic antibiotic prophylaxis agent used (n = 367 [66.2%]), with 24 hours being the most common duration (n = 363 [65.5%]). On multivariable analysis, preoperative topical antisepsis mucosal preparation (odds ratio [OR], 0.49; 95% CI, 0.30-0.77) and systemic prophylaxis with piperacillin and tazobactam (OR, 0.42; 95% CI, 0.21-0.84) were associated with a decreased risk of a postoperative SSI. The use of an osseous vascularized flap was associated with an increased risk of postoperative SSI (OR, 1.76; 95% CI, 1.13-2.75).

Conclusions And Relevance: Findings of this study suggest that preoperative topical antisepsis mucosal preparation was independently associated with a decreased risk of SSIs in a 12-center multi-institutional cohort. Further investigation of the association between individual perioperative practices and the incidence of postoperative SSIs is necessary to develop evidence-based protocols to reduce SSIs after UADT reconstruction.
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http://dx.doi.org/10.1001/jamaoto.2022.0684DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9047735PMC
June 2022

Assessing nonsexual transmission of the human papillomavirus (HPV): Do our current cleaning methods work?

J Med Virol 2022 Aug 21;94(8):3956-3961. Epub 2022 Apr 21.

College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania, USA.

Human papillomavirus (HPV) is thought to be sexually transmitted; however, there have been a few studies investigating a possible iatrogenic source of infection. Therefore, it is important to assess the cleaning methods of reusable medical devices. This study assessed whether cleaning methods of flexible endoscopes in an otolaryngology clinic are effective against HPV. There were 24 patients with a history of head and neck cancer in the study; however, two outliers were excluded. Nine patients were confirmed to have HPV-associated cancer. PCR was used to measure and quantify the viral genomes of samples collected before and after cleaning. After cleaning, few HPV+ samples had endoscopes with less DNA than before cleaning. Additionally, for several patients with non-HPV-associated head and neck cancer, PCR showed more DNA after cleaning than before cleaning, suggesting residual HPV DNA within the cleaning solution. There was no significant difference (p > 0.05) between pre- and post-cleaning in both cohorts. Current cleaning methods of reusable endoscopes may not be effective in completely removing viral DNA.
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http://dx.doi.org/10.1002/jmv.27769DOI Listing
August 2022

Risk factors for head and neck cancer in more and less developed countries: Analysis from the INHANCE consortium.

Oral Dis 2022 Mar 24. Epub 2022 Mar 24.

Escola Nacional de Saude Publica, Fundacao Oswaldo Cruz, Rio de Janeiro, Brazil.

Objective: We analyzed the pooled case-control data from the International Head and Neck Cancer Epidemiology (INHANCE) consortium to compare cigarette smoking and alcohol consumption risk factors for head and neck cancer between less developed and more developed countries.

Subjects And Methods: The location of each study was categorized as either a less developed or more developed country. We compared the risk of overall head and neck cancer and cancer of specific anatomic subsites associated with cigarette smoking and alcohol consumption. Additionally, age and sex distribution between categories was compared.

Results: The odds ratios for head and neck cancer sites associated with smoking duration differed between less developed and more developed countries. Smoking greater than 20 years conferred a higher risk for oral cavity and laryngeal cancer in more developed countries, whereas the risk was greater for oropharynx and hypopharynx cancer in less developed countries. Alcohol consumed for more than 20 years conferred a higher risk for oropharynx, hypopharynx, and larynx cancer in less developed countries. The proportion of cases that were young (<45 years) or female differed by country type for some HNC subsites.

Conclusion: These findings suggest the degree of industrialization and economic development affects the relationship between smoking and alcohol with head and neck cancer.
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http://dx.doi.org/10.1111/odi.14196DOI Listing
March 2022

Utility of Temporal Bone Computed Tomography in Pediatric Emergency Medicine.

West J Emerg Med 2022 Feb 9;23(2):238-245. Epub 2022 Feb 9.

The Pennsylvania State University, College of Medicine, Department of Otolaryngology - Head and Neck Surgery, Hershey, Pennsylvania.

Objective: Temporal bone computed tomography (CT) requires a relatively high radiation dose to produce high-resolution images required to define surgical anatomy. In the acute setting, the need for this detailed evaluation of temporal bone pathology may not be required for nonsurgical management and clinical decision-making. We performed a retrospective review of the clinical characteristics and subsequent management of children who underwent CT of the temporal bone with the goal of optimizing clinical decision-making and mitigating the risks of radiation exposure in children.

Methods: We included pediatric patients (<18 years of age) with International Classification of Diseases (9th or 10th revision) diagnoses consistent with otitis externa, otitis media, mastoiditis, head trauma, temporal bone fracture, and otalgia who were treated in the emergency department and underwent temporal bone CT from January 1, 2012-December 31, 2016. We collected data regarding the patients' presenting symptoms, physical exam findings, indications for imaging, radiographic findings, disposition, and operative intervention within 30 days of imaging. Features of the suspected mastoiditis group were compared between operative and non-operative patients.

Results: Over the four-year study period there were 96 temporal bone CTs. Most studies (70%) were associated with a subsequent inpatient admission. Common indications for imaging included evaluation of acute mastoiditis (55%) or trauma (41%). Of the 53 patients with concern for mastoiditis, 27 (51%) required otologic surgery. Two patients in the trauma group required surgical intervention, both for facial nerve decompression. In patients with suspected mastoiditis, mental status changes (P = 0.02), auricular proptosis (P = 0.05), and fluctuance (P = 0.02) were significantly more prevalent in the operative group; however, no other findings were significantly associated with operative intervention.

Conclusion: Temporal bone CT is beneficial in guiding diagnosis and management of acute mastoiditis. We found that a majority of patients with suspected mastoiditis who underwent temporal bone CT ultimately required surgery or hospital admission. However, the potential for reduction in the use of CT still exists in this population. Fractures of the temporal bone typically do not require urgent operative intervention in the absence of complete facial nerve paralysis; thus, the utility of temporal bone CT in trauma evaluation may be limited.
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http://dx.doi.org/10.5811/westjem.2021.11.52704DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8967447PMC
February 2022

Head and neck cancer survivorship consensus statement from the American Head and Neck Society.

Laryngoscope Investig Otolaryngol 2022 Feb 30;7(1):70-92. Epub 2021 Nov 30.

Department of Surgery, Section of Otolaryngology-Head and Neck Surgery University of Chicago Pritzker School of Medicine Chicago Illinois USA.

Objectives: To provide a consensus statement describing best practices and evidence regarding head and neck cancer survivorship.

Methods: Key topics regarding head and neck cancer survivorship were identified by the multidisciplinary membership of the American Head and Neck Society Survivorship, Supportive Care & Rehabilitation Service. Guidelines were generated by combining expert opinion and a review of the literature and categorized by level of evidence.

Results: Several areas regarding survivorship including dysphonia, dysphagia, fatigue, chronic pain, intimacy, the ability to return to work, financial toxicity, lymphedema, psycho-oncology, physical activity, and substance abuse were identified and discussed. Additionally, the group identified and described the role of key clinicians in survivorship including surgical, medical and radiation oncologists; dentists; primary care physicians; psychotherapists; as well as physical, occupational, speech, and respiratory therapists.

Conclusion: Head and neck cancer survivorship is complex and requires a multidisciplinary approach centered around patients and their caregivers. As survival related to head and neck cancer treatment improves, addressing post-treatment concerns appropriately is critically important to our patient's quality of life. There continues to be a need to define effective and efficient programs that can coordinate this multidisciplinary effort toward survivorship.
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http://dx.doi.org/10.1002/lio2.702DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8823162PMC
February 2022

A Systematic Review of Oral Nutritional Supplement and Wound Healing.

Ann Otol Rhinol Laryngol 2022 Jan 19:34894211069437. Epub 2022 Jan 19.

Department of Otolaryngology - Head and Neck Surgery, Milton S. Hershey Medical Center, Hershey, PA, USA.

Objective: To explore the current literature for effects of oral nutritional supplement on wound healing rates in humans.

Methods: A systematic review of the literature was performed using the Medline and PubMed database following PRISMA guidelines. The PubMed database was searched using terms relating to oral nutritional supplement and wound healing from 1837 to March 2020. Study inclusion criteria were: (i) design: randomized controlled trials, clinical studies, observational studies, clinical trials; (ii) population: adults; and (iii) intervention: oral nutritional supplement.

Results: The search yielded 2433 studies, 313 of which were clinical trials or clinical studies. After abstract review, 28 studies qualified to be included in the review evaluating the following supplementation categories on wound healing: protein and amino acids (10), mineral, vitamin and antioxidants (9), probiotics (1), and mixed nutrients (8). Arginine and omega-3 supplement were shown to improve wound healing in head and neck cancer patients with surgical wounds by decreasing incidence of postoperative complications and reducing length of hospital stay. Mineral, vitamins, and antioxidants enriched supplements were more beneficial in increasing wound healing than non-enriched protein supplement for diabetic foot and pressure ulcers.

Conclusions: Supplementation of a variety of nutrients had variable effects on improving wound healing in different types of wounds. However, further research on the impact of nutritional supplements on surgical wound healing is necessary. The impact of multiple nutrient formulations may also need to be further evaluated for efficacy.
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http://dx.doi.org/10.1177/00034894211069437DOI Listing
January 2022

Educating School Nurses about Human Papillomavirus (HPV) Associated Cancers and the Importance of HPV Vaccination.

J Community Health Nurs 2021 Oct-Dec;38(4):201-208

College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania, USA.

Purpose: To assess and improve school nurse knowledge of HPV-associated cancers.

Design: An experimental quality improvement study.

Methods: At a continuing education regional conference, an interactive HPV education session was provided. Pre- and post-education surveys were completed by attendees.

Findings: After the educational intervention, 89.9% of nurses indicated a change in knowledge and 83.2% indicated a planned change in practice.

Conclusions: An education intervention aimed at school nurses can be impactful in broadening the understanding of HPV oncogenesis.

Clinical Evidence: Educational interventions can be a strategy to increase school nurse knowledge and subsequently patient knowledge about HPV associated cancers.
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http://dx.doi.org/10.1080/07370016.2021.1972244DOI Listing
November 2021

Recurrent Hepatic Artery Thrombosis Following Living Donor Liver Transplant as Sequelae of SARS-CoV-2 Infection-a Case Report.

SN Compr Clin Med 2021 8;3(12):2629-2634. Epub 2021 Oct 8.

Department of Anaesthesiology and Critical Care, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi, India 110076.

As the second wave of COVID-19 disease is gripping the globe, liver transplant centers are increasingly receiving patients recovered from SARS-CoV-2 infection in recent few weeks. Unexpected complications in these patients are increasingly being recognized. We performed liver transplantation on a 51-year-old gentleman with decompensated liver disease 23 days after recovering from a mild SARS-CoV-2 infection. Surprisingly, despite massive blood loss and a prolonged anhepatic phase, his thromboelastographic (TEG) parameters persistently revealed hypercoagulability. After a brief uneventful early post-operative period, he developed hepatic arterial thrombosis on the 14th post-operative day, and again after 4 days, both of which required surgical intervention. Following discharge, the artery was thrombosed again which was only picked up when he developed a cholangiolar abscess, leading to graft loss necessitating re-transplantation. There is a lot of evidence suggesting that patients with SARS-CoV-2 infection tend to be hypercoagulable. We believe that this hypercoagulability might have played a significant role in the development of hepatic arterial thrombosis and eventual graft loss in this patient. This highlights the importance of revisiting anticoagulation protocols in liver transplant recipients recovered from COVID-19 and base them on TEG rather than routine parameters such as INR and APTT, which are routinely deranged in such patients.
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http://dx.doi.org/10.1007/s42399-021-01076-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8497065PMC
October 2021

Pneumonia, urinary tract infection, bacteremia, and Clostridioides difficile infection following major head and neck free and pedicled flap surgeries.

Oral Oncol 2021 11 23;122:105541. Epub 2021 Sep 23.

Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, United States. Electronic address:

Objectives: Medical postoperative infections (MPIs) are important causes of morbidity following major head and neck free and pedicled flap reconstruction, but the incidence, time of onset, and microbiology are not well characterized.

Materials And Methods: Medical records were reviewed of all head and neck flap surgeries performed 2009-2014 at an academic medical center. Postoperative pneumonia, urinary tract infection (UTI), bloodstream infection (BSI), Clostridioides difficile (CDI), and surgical site infections (SSI) were noted. Catheter-associated UTI (CAUTI), central line-associated BSI (CLABSI), and methicillin-resistant Staphylococcus aureus (MRSA) BSI were also evaluated.

Results: Following 715 free (540) or pedicled (175) flap surgeries, 14.1% of patients developed ≥one MPI including pneumonia (10.6%), UTI (2.1%), BSI (0.7%), and CDI (2.4%). Onset was ≤7 days in 77%. The MPI incidence in free vs pedicled flaps was similar. By multivariate analysis, age ≥65 and clindamycin perioperative prophylaxis were associated with increased MPI risk, clean class surgery with decreased risk. The incidence of CAUTI (<1.0%), CLABSI (0.1%), and hospital-onset MRSA BSI (0.1%) was low. SSI rate (7.8% overall) was higher in patients who developed pneumonia (18.4 vs 6.6, p = 0.004). MPI cultures grew gram-negative bacilli or S. aureus in 75%. The length of stay was longer in patients who developed a MPI than those who did not (17.4 vs 10.4 days, p < 0.0001).

Conclusions: One-seventh of major head and neck flap surgeries were complicated by MPIs, three-quarters of infections developed within 1 week postoperatively. Gram-negative bacilli and S. aureus were the predominant pathogens.
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http://dx.doi.org/10.1016/j.oraloncology.2021.105541DOI Listing
November 2021

Color Change of Intranasal Fluorescein Cannot Detect Cerebrospinal Fluid Leaks.

World Neurosurg 2021 12 17;156:e243-e248. Epub 2021 Sep 17.

Department of Otolaryngology-Head and Neck Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania, USA. Electronic address:

Background: The color change of topical intranasal fluorescein has been used to confirm the presence of cerebrospinal fluid (CSF) during endoscopic endonasal surgery. We aimed to validate the use of topical intranasal fluorescein for CSF detection.

Methods: Blood, CSF, saliva, and normal saline were combined with decreasing fluorescein concentrations (from 10% to 0.1%). The solutions were photographed in high definition on nasal pledgets and in 1.5-mL Eppendorf tubes. The color difference (ΔE) was objectively measured via the International Commission on Illumination coordinates. Four otolaryngologists who were unaware of the study parameters also evaluated the samples for perceptible color differences. The human eye cannot detect color differences at an International Commission on Illumination ΔE of <5.

Results: All otolaryngologists agreed a color difference could be seen with blood across all fluorescein concentrations. However, a perceptible color difference between the experimental samples that excluded blood was not appreciable. Objectively, the ΔE was <5 on average for all nonblood samples when mixed with 5% and 10% fluorescein in the Eppendorf experiment. The ΔE for the nonblood samples was >5 for the remaining tested. Similarly, the average ΔE for the nonblood samples in the pledget experiment was >5 across all fluorescein concentrations. The blood ΔE was consistently >50 throughout all fluorescein concentrations in the Eppendorf experiment and >20 throughout the pledget experiment, correlating with the subjective ease of discernment between blood and the control sample in both groups.

Conclusions: Color change alone is not sufficient to determine a difference between CSF, saliva, and saline. Blood, however, is readily identified using this method. Adjunct characteristics, in addition to the color change, are necessary to properly identify an active CSF leak.
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http://dx.doi.org/10.1016/j.wneu.2021.09.042DOI Listing
December 2021

Prognostic Impact of Adverse Pathologic Features in Sinonasal Squamous Cell Carcinoma.

J Neurol Surg B Skull Base 2021 Jul 19;82(Suppl 3):e114-e119. Epub 2020 May 19.

Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, United States.

 This study aimed to describe the impact of adverse clinical and pathologic features in sinonasal squamous cell carcinoma (SCC).  This study is designed with retrospective chart review.  The present study is conducted at a tertiary care institution.  All patients treated surgically for sinonasal SCC at our tertiary care institution between January 2006 and December 2013.  Overall survival (OS) and disease free survival (DFS) are the final measurement of this study.  Forty-eight patients were identified. Mean age at surgery was 65.8 years, and mean follow-up time was 40.7 months. Eighteen patients (38%) had T1-T3 disease, while 30 patients (63%) had T4 disease. Seven patients (8.3%) had nodal disease at presentation. At 2, 5, and 10 years, OS was 71, 54, and 48%, respectively, while DFS was 64, 51, and 45%, respectively. Twelve patients (25%) experienced local recurrences with mean time to recurrence of 15.3 months. Twenty-five patients (52%) had positive margins, 24 (50%) had high-grade tumors, 18 (38%) had perineural invasion (PNI), and 15 (31%) had lymphovascular invasion (LVI). In the univariate analysis, T4 disease (risk ratio [RR] = 2.7) and high grade (RR = 2.4) had a significant association with DFS. In the multivariate analysis, high grade (RR = 4.0 and 4.5) and LVI (RR = 4.1 and 4.7) had a significant association with OS and DFS.  Our single-institution experience of 48 patients suggests that high grade and LVI are independently associated with survival outcomes in sinonasal SCC, while PNI and microscopically positive margins do not have a significant impact.
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http://dx.doi.org/10.1055/s-0040-1710516DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8289517PMC
July 2021

Mental health disorders in newly diagnosed non-functional pitutary adenoma under initial observation: an observational cohort study using the nationwide MarketScan database.

Pituitary 2022 Feb 16;25(1):85-91. Epub 2021 Jul 16.

College of Medicine, The Pennsylvania State University, 500 University Dr., Hershey, PA, 17033, USA.

Purpose: Nonfunctioning pituitary adenomas account for 15-30% of pituitary tumors. Studies exploring the role of an intracranial tumor diagnosis, specifically nonfunctioning pituitary adenomas, on mental health disorders (MHDs) in patients have been limited. We characterize the incidence and factors affecting the development of MHDs in untreated pituitary adenomas.

Methods: Utilizing a large-scale private payor database, MarketScan, we performed a retrospective study of patients with an untreated pituitary adenomas and corresponding MHD.

Results: We found that in patients diagnosed with an untreated pituitary adenomas, approximately 15% were newly diagnosed with a MHD within 1 year of the pituitary adenoma diagnosis. Independent risk factors included female gender and substance abuse. Headaches, visual symptoms, and higher Charlson Co-morbidity indexes were also independently associated with a subsequent diagnosis of MHD. On multivariable analysis, patients in the pituitary tumor cohort were more likely to be diagnosed with a MHD than those in the matched cohort (aOR: 1.31, CI: 1.19-1.44).

Conclusion: By identifying risk factors, advanced screening can focus on non-operative pituitary adenoma patients at high-risk for the development of MHD.
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http://dx.doi.org/10.1007/s11102-021-01172-1DOI Listing
February 2022

HPi: A Novel Parameter to Predict Graft-related Outcome in Adult Living Donor Liver Transplant.

Transplantation 2022 04;106(4):767-780

Liver Transplant and Hepato-Pancreatico-Biliary Surgery (LTHPS) Unit, Indraprastha Apollo Hospital, New Delhi, India.

Background: Portal hyperperfusion is frequently associated with early allograft dysfunction (EAD). It is imperative to identify patients who would require portal inflow modulation. We aimed to identify factors associated with hyperperfusion-related graft injury and develop a predictive index for the same.

Methods: Prospectively maintained database was queried to identify 135 adult living donor liver transplant recipients between September 2016 and July 2020. According to the calculated sample size, 96 patients were randomly selected for "test cohort". The remaining 39 patients made the "validation cohort." EAD was defined according to the A2ALL study. "Hyperperfusion index (HPi)," defined as posttransplant portal pressure gradient (ΔPpost)/graft-to-recipient splenic volume ratio (GRSVR), was devised on the basis of laws of flow dynamics and regression analysis.

Results: Overall, 40 patients (29.6%) had EAD, six 90-d mortalities (4.4%) were attributable to EAD. In the test cohort, EAD patients (n = 29, 30.2%) had lower GRSVR (1.00 versus 2.22, P < 0.001), higher ΔPpost (14.8 versus 11.9, P = 0.004), and HPi (20.89 versus 8.67, P < 0.001). Multivariate analysis revealed GRSVR, ΔPpost, and HPi as significant factors to predict EAD. Receiver operating characteristic determined cutoff of HPi ≥9.97 could predict EAD with sensitivity of 90% and specificity of 73% (F-score = 0.712). HPi ≥16.25 predicted 90-d mortality with sensitivity of 100% and specificity of 78.9%. Patients with higher HPi had delayed graft-related recovery. Non-EAD patients had a higher 1-y (96% versus 79%) and 2-y (88% versus 79%) survival. The cutoff of HPi was validated well in the validation cohort (F-score = 0.645) (Hosmer-Lemeshow test, P = 0.89).

Conclusions: While predicted GRSVR may help identify at-risk patients preoperatively, intraoperatively calculated HPi is more accurate in identifying patients who would require portal inflow modulation. Achieving an HPi below target cutoff significantly decreases the risk of EAD even in low-GRSVR patients.
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http://dx.doi.org/10.1097/TP.0000000000003890DOI Listing
April 2022

Clinical manifestations of hereditary angioedema and a systematic review of treatment options.

Laryngoscope Investig Otolaryngol 2021 Jun 3;6(3):394-403. Epub 2021 Apr 3.

Department of Otolaryngology-Head and Neck Surgery Penn State College of Medicine, Penn State University 500 University Drive Hershey Pennsylvania MC H091 USA.

Objective: This study systematically reviews the existing literature on the management of hereditary angioedema (HAE) and provides an update on the clinical presentation and specific therapies.

Methods: A literature search of PubMed and Embase databases was conducted from start of the database to February 2021. Inclusion criteria included relevant systematic reviews, randomized control clinical trials, prospective and retrospective cohort studies, and outcomes research published in English and available in full-text. Out of 310 candidate articles, a total of 55 articles were included in our study.

Results: The most common genetic form of HAE in up to 85% of cases is caused by low levels of C1 esterase inhibitor (C1-INH) protein, leading to a bradykinin-mediated increase in vascular permeability. During an attack of HAE, abortive treatment with C1-INH replacement is most commonly described, however, icatibant, ecallantide, or fresh frozen plasma are also used. Long-term prophylaxis in the form of C1-INH replacement (subcutaneous or intravenous), monoclonal antibodies targeting plasma kallikrein, attenuated androgens, and transexemic acid should be considered for those who suffer from frequent, severe attacks.

Conclusion: Progressively distal involvement of the upper airway, especially the larynx, has been shown to pose an increased risk of asphyxiation and death in the acute presentation of HAE. Evaluation by an otolaryngologist is often sought during the emergent clinical management of HAE; therefore, it is prudent that the consulting physician is well-versed in the prompt recognition, triage of patients, and appropriate treatment modalities.

Level Of Evidence: 1A.
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http://dx.doi.org/10.1002/lio2.555DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8223449PMC
June 2021

Review of aerosolized hydrogen peroxide, vaporized hydrogen peroxide, and hydrogen peroxide gas plasma in the decontamination of filtering facepiece respirators.

Am J Infect Control 2022 02 25;50(2):203-213. Epub 2021 Jun 25.

Penn State College of Medicine, Hershey, PA. Electronic address:

Background: Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has led to over 170?million cases worldwide with over 33.2?million cases and 594,000 deaths in the US alone as of May 31st, 2021. The pandemic has also created severe shortages of personal protective equipment, particularly of filtering facepiece respirators (FFRs). The Centers for Disease Control and Prevention (CDC) has issued recommendations to help conserve FFRs, as well as crisis standards, including four criteria required for decontamination of the traditionally single use respirators. This review is designed to provide an overview of the current literature on vaporized hydrogen peroxide (vHP), hydrogen peroxide gas plasma (HPGP), and aerosolized hydrogen peroxide (aHP) with respect to each of the four CDC decontamination criteria.

Methods: PubMed and Medrxiv were queried for relevant articles. All articles underwent a title and abstract screen as well as subsequent full text screen by two blinded reviewers if indicated.

Results: Searches yielded 195 papers, of which, 79 were found to be relevant. Of those, 23 papers presented unique findings and 8 additional articles and technical papers were added to provide a comprehensive review. Overall, while there are potential concerns for all 3 decontamination methods, we found that vHP has the most evidence supporting its use in FFR decontamination consistent with CDC recommendation.

Conclusions: Future research is recommended to evaluate biological inactivation and real world fit failures after FFR reuse.
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http://dx.doi.org/10.1016/j.ajic.2021.06.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8233052PMC
February 2022

Novel Use of the Buccal Fat Pad for Sinocutaneous Fistulae Closure and a Review of Reconstructive Options.

Ann Otol Rhinol Laryngol 2022 Mar 25;131(3):295-302. Epub 2021 May 25.

Department of Otolaryngology-Head and Neck Surgery, Penn State Hershey Medical Center, Hershey, PA, USA.

Background: Sinocutaneous fistulae (SCF) are abnormal communications between the paranasal sinuses and the overlying skin. They may be difficult to manage due to facial geometry, scar contraction, and poor tissue vascularity. We describe a novel use of the buccal flap and review the literature to examine management options for this disease process.

Methods: A PubMed/MEDLINE literature search was performed for studies published between January 1, 1950 and April 29, 2020 that describe management strategies for SCF. The clinical record, imaging, and operative reports were reviewed of the case in which the buccal fat flap was used in reconstruction.

Results: A total of 359 articles were retrieved. After removing duplicate articles, non-English studies, animal studies, duplicate articles and studies that mentioned SCF without specific mention of management strategies, 51 articles were reviewed. Management paradigms throughout the articles include (1) removal of infection, (2) ensuring patency of sinus outflow tracts, (3) tensionless multilayered closure using well vascularized tissue, and (4) prevention or minimization of future risk factors for fistula formation.

Conclusion: This article informs surgeons on reconstructive options for sinocutaneous fistulae including a novel description of the buccal fat flap.
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http://dx.doi.org/10.1177/00034894211014299DOI Listing
March 2022

A preliminary assessment of guideline adherence and clinical variation in oral cancer treatment: a MarketScan database study.

BMC Oral Health 2021 05 17;21(1):270. Epub 2021 May 17.

Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Bronx, NY, USA.

Background: To assess variations in adherence to guideline-recommended processes of care for oral cavity cancer patients.

Methods: Retrospective study using a U.S. healthcare research database (MarketScan). Index diagnoses were considered from 2010 to 2012 with follow-up from 2013 to 2014. Diagnostic and procedure codes were utilized to identify oral cavity patients with a defined treatment modality. Compliance with guideline-recommended processes of care, which included pre-treatment imaging, thyroid-function testing (TFTs), multidisciplinary consultation and gastrostomy-tube insertion rates, were assessed.

Results: A total of 2752 patients were identified. Surgery alone was the most common treatment (60.8%), followed by surgery with adjuvant chemoradiotherapy (20.4%) and surgery with adjuvant radiotherapy (18.8%). Head/neck and chest imaging were obtained in 60% and 62.5% of patients respectively. Significant geographical differences in head and neck imaging were observed between North-central (64%), South (58.4%) and West (56.1%) regions (p = 0.026). Differences in chest imaging were also present between North-east (65%) and West (56.8%; p = 0.007). TFTs were obtained in 54.4% of the patients after radiation treatment, and 18.6% of patients had multidisciplinary consultation during the 6 months before and 3 months after initiation of treatment. During the year after treatment initiation, 21.2% of patients underwent G-tube placement, with significantly higher rates in patients receiving triple modality treatment (58%) when compared to surgery plus radiation (27%) and surgery alone (15%; p < 0.01).

Conclusion: Adherence to evidence-based practices was low based on the database coding. These data suggest a potential to improve adherence and increase the routine use of practices delineated in national clinical practice guidelines.

Clinical Relevance: This study reflects a suboptimal adherence to guidelines based on the database employed. This study should be considered by healthcare providers and efforts should be maximized to follow the processes of care which have proven to impact on patient's outcomes.
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http://dx.doi.org/10.1186/s12903-021-01616-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8130137PMC
May 2021

Surgical Margin Determination in the Era of HPV-Positive Oropharyngeal Cancer.

Laryngoscope 2021 10 1;131(10):E2650-E2654. Epub 2021 Apr 1.

Department of Otolaryngology-Head and Neck Surgery, The Pennsylvania State University, Hershey, Pennsylvania, USA.

Objectives/hypothesis: The goal of head and neck cancer surgery is the complete resection of tumor with a cuff of healthy tissue. A 5-mm margin is optimal but not always achievable in the oropharynx. We aimed to identify a consensus of definition and management of close margins for human papilloma virus (HPV)-associated oropharyngeal cancer without other risk factors.

Study Design: Descriptive survey.

Methods: A survey of the American Head and Neck Society (AHNS) was conducted to evaluate the abovementioned objectives by presenting hypothetical scenarios and asking questions regarding management.

Results: One-hundred fifty-five AHNS members completed the survey (18% response rate). Close margins were defined as <5 mm, <3 mm, and <1 mm by 27.7%, 32.3%, and 32.3% of respondents. There was no significant difference in margin determination with experience level (P = .186). In an HPV-positive tumor with close margins, 51% chose postoperative observation. The remainder chose adjuvant radiation (22.6%), chemoradiation (1.9%), or re-excision of the wound bed (19.4%). There was no association between postoperative close margin management and experience level (P = .80).

Conclusion: Heterogeneity exists in the definition and management of close margins in HPV-mediated oropharyngeal carcinoma (OPSCC). Establishing a standard regarding close margins in HPV-mediated OPSCC may allow for the optimization of outcomes and help define best practices.

Level Of Evidence: 5 Laryngoscope, 131:E2650-E2654, 2021.
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http://dx.doi.org/10.1002/lary.29533DOI Listing
October 2021

Doppler-derived renal resistive index helps predict acute kidney injury in patients undergoing living-related liver transplantation.

Clin Transplant 2021 05 4;35(5):e14263. Epub 2021 Mar 4.

Department of Anesthesiology and Critical Care, Indraprastha Apollo Hospital, New Delhi, India.

Background: Acute kidney injury (AKI) is commonly associated with increased postoperative morbidity in liver transplant (LT) recipients. The aim of this study was to identify the role of renal resistive index (RRI) in predicting AKI and to study the factors associated with AKI in LT recipients.

Patients And Methods: We performed a single-center, prospective study, including adult living donor LT recipients at our center between January 2018 and September 2019 with no preoperative renal dysfunction. RRI was calculated on ultrasound doppler once preoperatively, and once daily in the postoperative period through postoperative day (POD) six. Patients were grouped into AKI and non-AKI groups for comparison.

Results: Fifty patients were included in the study (mean age, 44 years; 20% females). AKI developed in 25 patients (50%). Both groups were similar in baseline characteristics. RRI of ≥ 0.69 on POD 2 predicted AKI (sensitivity 88%; specificity 92%). RRI on the day before AKI diagnosis (0.71 vs. 0.65) and on the day of diagnosis (0.72 vs. 0.65) were significantly increased relative to preoperative baseline.

Conclusions: Doppler-derived RRI is a rapid, non-invasive, and bedside procedure capable of predicting the occurrence of postoperative AKI in LT recipients.
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http://dx.doi.org/10.1111/ctr.14263DOI Listing
May 2021

Pediatric Liver Transplantation in India: 22 Years and Counting.

Indian Pediatr 2020 12;57(12):1110-1113

Hepatobiliary and Pancreatic Surgery Unit, Indraprastha Apollo Hospitals, New Delhi, India.

Liver transplantation in India has grown exponentially in the last decade with 135 centers now performing between 1500-2000 transplants a year, 10% of which are pediatric. Survival rate surpassing 90% has been achieved, and India is now an important regional liver transplant hub in South and South-East Asia. The indications have expanded to include increasing number of liver-based metabolic disorders that may or may not cause liver disease. Recipients, who were previously considered non-transplantable such as those with pre-existing portal vein thrombosis, can be successfully managed with innovative microvascular techniques. The donor pool has grown with the use of marginal grafts and ABO incompatible organs. Financial constraints are being overcome by crowd funding and increasing philanthropic efforts.
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December 2020

Mental health disorders in patients with untreated meningiomas: an observational cohort study using the nationwide MarketScan database.

Neurooncol Pract 2020 Oct 20;7(5):507-513. Epub 2020 May 20.

The Pennsylvania State University, College of Medicine.

Background: Meningiomas are the most common primary tumor of the CNS. Studies investigating the impact of a brain tumor diagnosis on mental health disorders (MHDs) in patients have been limited. The objective of this work is to characterize the incidence and factors affecting the presence of MHDs in untreated meningiomas.

Methods: Using a large-scale private payer database, MarketScan, we performed a retrospective study of patients with an untreated meningioma and corresponding MHD.

Results: We found that in patients diagnosed with an untreated meningioma, approximately 16% were diagnosed with an MHD within 1 year of the diagnosis of the meningioma.

Conclusion: By identifying risk factors, appropriate screening can focus on patients at high-risk for the development of MHD.
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http://dx.doi.org/10.1093/nop/npaa025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7516114PMC
October 2020

A model for classification of invasive fungal rhinosinusitis by computed tomography.

Sci Rep 2020 07 28;10(1):12591. Epub 2020 Jul 28.

Department of Diagnostic Radiology, College of Medicine, The Pennsylvania State University, 500 University Drive, MB CG533, P.O. Box 850, Hershey, PA, 17033-0850, USA.

Our purpose was to classify acute invasive fungal rhinosinusitis (AIFR) caused by Mucor versus Aspergillus species by evaluating computed tomography radiological findings. Two blinded readers retrospectively graded radiological abnormalities of the craniofacial region observed on craniofacial CT examinations obtained during initial evaluation of 38 patients with eventually pathology-proven AIFR (13:25, Mucor:Aspergillus). Binomial logistic regression was used to analyze correlation between variables and type of fungi. Score-based models were implemented for analyzing differences in laterality of findings, including the 'unilateral presence' and 'bilateral mean' models. Binary logistic regression was used, with Score as the only predictor and Group (Mucor vs Aspergillus) as the only outcome. Specificity, sensitivity, positive predictive value, negative predictive value and accuracy were determined for the evaluated models. Given the low predictive value of any single evaluated anatomical site, a 'bilateral mean' score-based model including the nasal cavity, maxillary sinuses, ethmoid air cells, sphenoid sinus and frontal sinuses yielded the highest prediction accuracy, with Mucor induced AIFR correlating with higher prevalence of bilateral findings. The odds ratio for the model while integrating the above anatomical sites was 12.3 (p < 0.001). PPV, NPV, sensitivity, specificity and accuracy were 0.85, 0.82, 0.92, 0.69 and 0.84 respectively. The abnormal radiological findings on craniofacial CT scans of Mucor and Aspergillus induced AIFR could be differentiated based on laterality, with Mucor induced AIFR associated with higher prevalence of bilateral findings.
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http://dx.doi.org/10.1038/s41598-020-69446-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7387465PMC
July 2020

Laryngectomy Care in the COVID-19 Era.

JAMA Otolaryngol Head Neck Surg 2020 08;146(8):776

Department of Otolaryngology-Head and Neck Surgery, The Pennsylvania State University, College of Medicine, Hershey.

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http://dx.doi.org/10.1001/jamaoto.2020.1523DOI Listing
August 2020

Facial Plastic and Reconstructive Surgery During the COVID-19 Pandemic: Implications in Craniomaxillofacial Trauma and Head and Neck Reconstruction.

Ann Plast Surg 2020 08;85(2S Suppl 2):S166-S170

From the Department of Otolaryngology-Head and Neck Surgery, College of Medicine, The Pennsylvania State University, Hershey, PA.

Background: The global COVID-19 pandemic has had a profound impact on facial plastic and reconstructive surgery. Our review serves as a safety resource based on the current literature and is aimed at providing best-practice recommendations. Specifically, this article is focused on considerations in the management of craniomaxillofacial trauma as well as reconstructive procedures after head and neck oncologic resection.

Methods: Relevant clinical data were obtained from peer-reviewed journal articles, task force recommendations, and published guidelines from multiple medical organizations utilizing data sources including PubMed, Google Scholar, MEDLINE, and Google search queries. Relevant publications were utilized to develop practice guidelines and recommendations.

Conclusions: The global COVID-19 pandemic has placed a significant strain on health care resources with resultant impacts on patient care. Surgeons operating in the head and neck are particularly at risk of occupational COVID-19 exposure during diagnostic and therapeutic procedures and must therefore be cognizant of protocols in place to mitigate exposure risk and optimize patient care.
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http://dx.doi.org/10.1097/SAP.0000000000002492DOI Listing
August 2020
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