Benjamin J. Greene

Self-Help Program Components and Linkage to Aftercare Following Inpatient Detoxification

ABSTRACT Many patients fail to initiate aftercare for addictive disease rehabilitation following detoxification. This study of 136 inpatients compared characteristics of those who initiated aftercare (behavior therapy or self-help programs) during the week following discharge with those who did not. Among this group of patients, 77% (91/119) linked to aftercare. Self-help treatment related components were associated with increased aftercare treatment attendance rates and included: having a copy of the “12 Steps” (81% vs. 46%, P = .002), having read self-help literature (73% vs. 42%, P = .007), and having telephone numbers of self-help program members (50% vs. 18%, P = .008). Those who initiated aftercare treatment were also more likely to have remained abstinent from drugs and alcohol (81% vs. 39%, P < .001). Having self-help treatment related components was associated with increased rates of aftercare attendance following hospital inpatient detoxification.

Effect of Overlapping Operations on Outcomes in Microvascular Reconstructions of the Head and Neck

Objective To compare outcomes after microvascular reconstructions of head and neck defects between overlapping and nonoverlapping operations. Study Design Retrospective cohort study. Setting Tertiary care center. Subjects and Methods Patients undergoing microvascular free tissue transfer operations between January 2010 and February 2015 at 2 tertiary care institutions were included (n = 1315). Patients were divided into 2 cohorts by whether the senior authors performed a single or consecutive microvascular reconstruction (nonoverlapping; n = 773, 59%) vs performing overlapping microvascular reconstructions (overlapping; n = 542, 41%). Variables reviewed were as follows: defect location, indication, T classification, surgical details, duration of the operation and hospitalization, and complications (major, minor, medical). Results Microvascular free tissue transfers performed included radial forearm (49%, n = 639), osteocutaneous radial forearm (14%, n = 182), anterior lateral thigh (12%, n = 153), fibula (10%, n = 135), rectus abdominis (7%, n = 92), latissimus dorsi (6%, n = 78), and scapula (<1%, n = 4). The mean duration of the overlapping operations was 21 minutes longer than nonoverlapping operations (P = .003). Mean duration of hospitalization was similar for nonoverlapping (9.5 days) and overlapping (9.1 days) cohorts (P = .39). There was no difference in complication rates when stratified by overlapping (45%, n = 241) and nonoverlapping (45%, n = 344) (P = .99). Subset analysis yielded similar results when minor, major, and medical complications between groups were assessed. The overall survival rate of free tissue transfers was 96%, and this was same for overlapping (96%) and nonoverlapping (96%) operations (P = .71). Conclusions Patients had similar complication rates and durations of hospitalization for overlapping and nonoverlapping operations.

Linkage to Primary Medical Care Following Inpatient Detoxification

It is important to address the medical problems of individuals admitted for detoxification by arranging for follow-up with primary care physicians after discharge. This was a prospective cohort study of 119 patients admitted for detoxification. Follow-up data were collected over the telephone one week following discharge. Among this group of patients, 72% had a primary care provider (PCP). Patients who intended to see their provider were statistically more likely to be abstinent on follow-up (OR = 4.5, CI = 1.24-16.58, p = 0.024). As compared to those patients without primary care follow-up, having a plan to see ones PCP was associated with lower rates of relapse following detoxification.

Reconstruction of midface defects with the osteocutaneous radial forearm flap: Evaluation of long term outcomes including patient reported quality of life

Maxillectomy defects significantly impair quality of life. Prosthetics can overcome some of these issues, but has limitations. The role of the osteocutaneous radial forearm free flap (OC‐RFFF) has been established for reconstruction of smaller maxillectomy defects, but its role in larger defects is not well defined. We aim to evaluate outcomes after midface reconstruction utilizing the OC‐RFFF.

Laser-Assisted Indocyanine Green Dye Angiography for Postoperative Fistulas After Salvage Laryngectomy

Importance Pharyngocutaneous fistula formation is an unfortunate complication after salvage laryngectomy for head and neck cancer that is difficult to anticipate and related to a variety of factors, including the viability of native pharyngeal mucosa. Objective To examine whether noninvasive angiography with indocyanine green (ICG) dye can be used to evaluate native pharyngeal vascularity to anticipate pharyngocutaneous fistula development. Design, Setting, and Participants This cohort study included 37 patients enrolled from June 1, 2013, to June 1, 2016, and follow-up was for at least 1 month postoperatively. The study was performed at the University of Alabama at Birmingham, a tertiary care center. Included patients were those undergoing salvage total laryngectomy who were previously treated with chemoradiotherapy or radiotherapy alone. Exposures The ICG dye was injected intraoperatively, and laser-assisted vascular imaging was used to evaluate the native pharyngeal mucosa after the ablative procedure. The center of the native pharyngeal mucosa was used as the reference to compare with the peripheral mucosa, and the lowest mean ICG dye percentage of mucosal perfusion was recorded for each patient. Main Outcomes and Measures The primary outcome was the formation of a postoperative fistula, which was assessed by clinical and radiographic assessment to test the hypothesis formulated before data collection. Results A total of 37 patients were included (mean [SD] age, 62.3 [8.5] years; 32 [87%] male and 5 [14%] female); 20 had a history of chemoradiotherapy, and 17 had history of radiotherapy alone. Thirty-four patients (92%) had free flap reconstruction, and 3 had primary closure (8%). Ten patients (27%) developed a postoperative fistula. No significant difference was found in fistula rate between patients who underwent neck dissection and those who did not and patients previously treated with chemoradiotherapy and those treated with radiotherapy alone. A receiver operator characteristic curve was generated to determine the diagnostic performance of the lowest mean ICG dye percentage of mucosal perfusion determined by fluorescence imaging, which was found to be a threshold value of 26%. The area under the curve was 0.85 (95% CI, 0.73-0.97), which was significantly greater than the chance diagonal. The overall mean lowest ICG dye percentage of mucosal perfusion was 31.3%. The mean lowest ICG dye percentage of mucosal perfusion was 22.0% in the fistula group vs 34.9% in the nonfistula group (absolute difference, 12.9%; 95% CI, 5.1%-21.7%). Conclusions and Relevance Patients who developed postoperative fistulas had lower mucosal perfusion as detected by ICG dye angiography when compared with patients who did not develop fistulas.

A standardized model for predicting flap failure using indocyanine green dye

Techniques that provide a non-invasive method for evaluation of intraoperative skin flap perfusion are currently available but underutilized. We hypothesize that intraoperative vascular imaging can be used to reliably assess skin flap perfusion and elucidate areas of future necrosis by means of a standardized critical perfusion threshold. Five animal groups (negative controls, n=4; positive controls, n=5; chemotherapy group, n=5; radiation group, n=5; chemoradiation group, n=5) underwent pre-flap treatments two weeks prior to undergoing random pattern dorsal fasciocutaneous flaps with a length to width ratio of 2:1 (3 x 1.5 cm). Flap perfusion was assessed via laser-assisted indocyanine green dye angiography and compared to standard clinical assessment for predictive accuracy of flap necrosis. For estimating flap-failure, clinical prediction achieved a sensitivity of 79.3% and a specificity of 90.5%. When average flap perfusion was more than three standard deviations below the average flap perfusion for the negative control group at the time of the flap procedure (144.3±17.05 absolute perfusion units), laser-assisted indocyanine green dye angiography achieved a sensitivity of 81.1% and a specificity of 97.3%. When absolute perfusion units were seven standard deviations below the average flap perfusion for the negative control group, specificity of necrosis prediction was 100%. Quantitative absolute perfusion units can improve specificity for intraoperative prediction of viable tissue. Using this strategy, a positive predictive threshold of flap failure can be standardized for clinical use.

Utility of the Surgical Apgar Score in Head and Neck Squamous Cell Carcinoma.

Objectives To recognize the utility of the surgical Apgar score (SAS) in a noncutaneous head and neck squamous cell carcinoma (HNSCC) population. Study Design Retrospective case series with chart review. Setting Academic tertiary medical center. Subjects and Methods Patients (n = 563) undergoing noncutaneous HNSCC resection between April 2012 and March 2015 were included. Demographics, medical history, intraoperative data, and postoperative hospital summaries were collected. SASs were calculated following the published schema. The primary outcome was 30-day postoperative morbidity. A 2-sample t test, analysis of variance, and χ2 (or Fisher exact) test were used for statistical comparisons. A multivariable logistic regression analysis was conducted to identify independent predictors of 30-day morbidity. Results Mean SAS was 6.2 ± 1.5. SAS groups did not differ in age, sex, or race. Sixty-five patients (11.6%) had a SAS between 0 and 4, with 40 incidences of morbidity (61.5%), while 31 (5.5%) patients with SAS from 9 to 10 had 3 morbidity occurrences (9.7%). Results show that 30-day postoperative morbidity is inversely related to increasing SAS (P < .0001). Furthermore, lower SAS was associated with significantly increased operative time (SAS 0-4: 9.3 ± 2.6 hours vs SAS 9-10: 3.0 ± 1.1 hours) and lengths of stay (SAS 0-4: 10.0 ± 7.3 days vs SAS 9-10: 1.6 ± 1.0 days), P < .0001. SAS remained highly significant after adjusting for potential confounding variables in the multivariable analysis (P < .0001). Conclusions An increasing SAS is associated with significantly lower rates of 30-day postoperative morbidities in a noncutaneous HNSCC patient population.

Utility of the Modified Surgical Apgar Score in a Head and Neck Cancer Population

Objective The Surgical Apgar Score (SAS) is a validated postoperative complication prediction model. The purpose of this study was to investigate the utility of the SAS in a diverse head and neck cancer population and to compare it with a recently developed modified SAS (mSAS) that accounts for intraoperative transfusion. Study Design Case series with chart review. Setting Academic tertiary care medical center. Subjects and Methods This study comprised 713 patients undergoing surgery for head and neck cancer from April 2012 to March 2015. SAS values were calculated according to intraoperative data obtained from anesthesia records. The mSAS was computed by assigning an estimated blood loss score of zero for patients receiving intraoperative transfusions. Primary outcome was 30-day postoperative morbidity. Results Mean SAS and mSAS were 6.3 ± 1.5 and 6.2 ± 1.7, respectively. SAS and mSAS were significantly associated with 30-day postoperative morbidity, length of stay, operative time, American Society of Anesthesiologists status, race, and body mass index (P < .05); however, no significant association was detected for age, sex, and smoking status. Multivariable analysis identified SAS and mSAS as independent predictors of postoperative morbidity, with the mSAS (P = .03) being a more robust predictor than the SAS (P = .15). Strong inverse relationships were demonstrated for the SAS and mSAS with length of stay and operative time (P < .0001). Conclusion The SAS serves as a useful metric for risk stratification of patients with head and neck cancer. With the inclusion of intraoperative transfusion, the mSAS demonstrates superior utility in predicting those at risk for postoperative complications.

Intraoperative Fluorescence Angiography for Head and Neck Reconstruction

Purpose of ReviewReconstruction of head and neck defects that cannot be closed primarily often requires the use of complex locoregional, pedicled, or microvascular flaps. Success of the reconstruction relies on the vascular supply of these flaps to prevent major and sometimes life-threatening wound complications. Intraoperative fluorescence angiography is an emerging aspect of the field that can be used as an adjunct to other methods to identify vascular compromise before, during, and after reconstruction.Recent FindingsLaser-assisted near-infrared angiography with intravenous indocyanine green (ICG) dye has been used to perform optical angiography in plastic surgery to help determine the recipient tissue perfusion at the defect site as well as the perfusion of the tissue used for reconstruction. This method allows for quantification of perfusion in skin and soft tissue reconstruction.SummaryLaser-assisted near-infrared angiography with intravenous ICG dye is fast, reliable, safe and can have many uses in head and neck reconstruction including the ability to quantitatively assess perfusion in perforators and angiosomes in flap design, prior to completion of harvest, during, and after the microvascular anastomosis, and in the distal edges of rotational and pedicled flaps. It can also be used to objectively view the native tissue prior to reconstruction, especially in patients with a history of radiation or chemotherapy.

A Large Submucosal Mass With Prominent Superficial Vessels

A man in his 40s presented with a multiple-year history of difficulty breathing throughhis left nostril. Severalmonthsprior topresentation, he began to experience left-sided epistaxis occurring up to 10 times per month, which was controlled with direct pressure. More recently, a friend noticed bulging of his left lateral nasal sidewall. Physical examination revealed a large submucosal mass with prominent superficial vessels within the mucosa almost completely filling the left anterior nasal cavity. Axial computed tomography (CT) showed a well-circumscribedoval-shaped lesionwith intermediate attenuation in the left anterior nasal cavity that shifted the septum to the right with remodelingof thenasalbone (Figure, A). The lesionhadmostlyhigh signalonaxialT2-weightedmagnetic resonance imaging(MRI)within which therewas a reticular pattern of septawith low signal (Figure, B). The lesionhadheterogeneous,mostly low signal on coronal fatsuppressed T1-weighted imaging (Figure, C), as well as prominent heterogeneous contrast enhancement using the same sequence (Figure,D).The lesionwas resectedviaanendoscopicendonasal approach andwas found to be originating from the left superior nasal septumwithnoextensionbeyond the left lateral nasalwallmucosa or the right septal mucosa. What is your diagnosis? A B