Jason A. Diaz

Risk Factors for Unplanned Hospital Readmission in Otolaryngology Patients

Objective Identify the risk factors that predict 30-day unplanned readmission in hospitalized otolaryngology patients. Study Design Retrospective cohort study. Setting Single academic hospital. Subjects and Methods All otolaryngology admissions for the 1-year period between January 1, 2011, and December 31, 2011, at an academic hospital were reviewed. Univariate logistic regression and multivariate logistic regression, employing a backward elimination stepwise approach, were performed to identify risk factors for unplanned readmission to the hospital within 30 days of discharge from the otolaryngology service. Results There were 1058 patients that accounted for 1271 hospital admissions. The 30-day unplanned readmission rate for patients discharged from the otolaryngology service was 7.3% (93/1271). Significant predictors identified on univariate analysis were used to build a multivariable logistic regression model of risk factors for unplanned readmission. These risk factors included presence of a complication (odds ratio [OR] = 11.60, 95% confidence interval [CI], 7.11-18.93), new total laryngectomy (OR = 4.72, 95% CI, 1.58-14.10), discharge destination of skilled nursing facility (OR = 2.70, 95% CI, 1.21-6.02), severe coronary artery disease or chronic lung disease (OR = 2.33, 95% CI, 1.38-3.93), and current illicit drug use (OR = 2.60, 95% CI, 1.27-5.34). The discriminative ability of the multivariate regression model to predict unplanned readmissions, as measured by the c-statistic, was 0.85. Conclusion Otolaryngology patients have unique risk factors that predict unplanned readmission within 30 days of discharge. These data identify specific patient characteristics and care processes that can be targeted with quality improvement interventions to decrease unplanned readmissions.

Patients Undergoing Total Laryngectomy: An At-Risk Population for 30-Day Unplanned Readmission

IMPORTANCE Patients undergoing total laryngectomy are at high risk for hospital readmission. Hospital readmissions are increasingly scrutinized because they are used as a metric of quality care and are subject to financial penalties. OBJECTIVE To determine the rate of, reasons for, and risk factors that predict 30-day unplanned readmission for patients undergoing total laryngectomy. DESIGN, SETTING, AND PATIENTS Retrospective cohort study at a single academic tertiary referral medical center. The study population comprised 155 patients who underwent total laryngectomy with or without flap closure between January 2007 and December 2012 as either a primary treatment or salvage treatment for prior nonsurgical management. INTERVENTIONS Total laryngectomy. MAIN OUTCOMES AND MEASURES Rate of 30-day unplanned readmission, readmission diagnoses, and risk factors for unplanned readmission. Univariable and multivariable logistic regression were performed to identify risk factors for unplanned readmission within 30 days of discharge. RESULTS The 30-day unplanned readmission rate for patients following discharge after total laryngectomy was 26.5% (41 of 155). The most common readmission diagnoses were pharyngocutaneous fistula (27% of readmissions; n = 11) and stomal cellulitis (16% of readmissions; n = 7). The median time to unplanned readmission was 7 days. Thirty-four percent of readmissions (14 of 41) occurred within 3 days of discharge. Significant predictors of 30-day unplanned readmission on multivariable analysis were postoperative complication after discharge (odds ratio [OR], 11.50; 95% CI, 4.10-32.28), visit to the emergency department within 30 days after discharge (OR, 5.25; 95% CI, 1.84-14.99), salvage total laryngectomy (OR, 3.52; 95% CI, 1.56-13.12), and chyle fistula during the index hospitalization (OR, 5.25; 95% CI, 0.86-29.92). The discriminative ability of the model to predict unplanned readmission, as measured by the C statistic, was 0.88. CONCLUSIONS AND RELEVANCE Patients undergoing total laryngectomy are an at-risk patient population with a high rate of unplanned readmission within 30 days of discharge. By identifying the risk factors that predict 30-day unplanned readmission, these data can be used to design and implement quality-improvement interventions to decrease readmissions.

Nab-paclitaxel-based compared to docetaxel-based induction chemotherapy regimens for locally advanced squamous cell carcinoma of the head and neck

We previously reported that nab‐paclitaxel‐based induction chemotherapy (IC) and concurrent chemoradiotherapy resulted in low relapse rates (13%) and excellent survival in head and neck squamous cell carcinoma (HNSCC). We compare the disease‐specific survival (DSS) and overall survival (OS) between patients given nab‐paclitaxel, cisplatin, and fluorouracil with cetuximab (APF‐C) and historical controls given docetaxel, cisplatin, and fluorouracil with cetuximab (TPF‐C). Patients with locally advanced HNSCC were treated with APF‐C (n = 30) or TPF‐C (n = 38). After 3 cycles of IC, patients were scheduled to receive cisplatin concurrent with definitive radiotherapy. T and N classification and smoking history were similar between the two groups and within p16‐positive and p16‐negative subsets. The median duration of follow‐up for living patients in the APF‐C group was 43.5 (range: 30–58) months versus 52 (range: 13–84) months for TPF‐C. The 2‐year DSS for patients treated with APF‐C was 96.7% [95% Confidence Interval (CI): 85.2%, 99.8%] and with TPF‐C was 77.6% (CI: 62.6%, 89.7%) (P = 0.0004). Disease progression that resulted in death was more frequent in the TPF‐C group (39%) compared with the APF‐C group (3%) when adjusted for competing risks of death from other causes (Grays test, P = 0.0004). In p16 positive OPSCC, the 2‐year DSS for APF‐C was 100% and for TPF‐C was 74.6% (CI: 47.4%, 94.6%) (P = 0.0019) and the 2‐year OS for APF‐C was 94.1% (CI: 65.0%, 99.2%) and for TPF‐C was 74.6% (CI: 39.8%, 91.1%) (P = 0.013). In p16 negative HNSCC, the 2‐year DSS for APF‐C was 91.7% (CI: 67.6%, 99.6%) and for TPF‐C was 82.6% (CI: 64.4%, 94.8%) (P = 0.092). A 2‐year DSS and OS were significantly better with a nab‐paclitaxel‐based IC regimen (APF‐C) compared to a docetaxel‐based IC regimen (TPF‐C) in p16‐positive OPSCC.

Pre-radiotherapy feeding tube identifies a poor prognostic subset of postoperative p16 positive oropharyngeal carcinoma patients

BackgroundThis study explores variables associated with poor prognosis in postoperative p16 positive oropharyngeal squamous cell carcinoma (OPSCC) patients undergoing adjuvant radiotherapy or chemoradiotherapy. Specifically, analysis was done related to timing of feeding tube insertion relative to radiotherapy.MethodsFrom 1997–2009, of 376 consecutive patients with OPSCC, 220 received adjuvant IMRT, and 97 were p16 positive and eligible. Of these, 23 had feeding tube placement before IMRT (B-FT), 32 during/after IMRT (DA-FT), and 42 had no feeding tube (NO-FT). Feeding tubes were not placed prophylactically. These three groups were analyzed for differential tumor, patient, treatment, and feeding tube characteristics, as well as differences in overall survival (OS), disease free survival (DFS), and distant metastasis free survival (DMFS).ResultsPre-RT FT insertion was associated with higher tumor size and depth, T (but not N) and overall stage, comorbidities, presence of chemotherapy, and less use of transoral laser microsurgery/transoral bovie. Additionally, time from surgery to IMRT completion was also statistically longer in the B-FT group. The feeding tube was permanent in 52% of patients in the B-FT group versus 16% in the DA-FT group (p = 0.0075). The 5-year OS for the NO-FT, DA-FT, and B-FT groups was 90%, 86%, and 50%, respectively. The 5-year DFS for the NO-FT, DA-FT, and B-FT groups was 87.6%, 83.6%, and 42.7%, respectively. Multivariate analysis showed that for OS and DFS, feeding tube placement timing and smoking history were statistically significant.ConclusionDue to the poor prognosis of early FT insertion, the presence of FTs at time of radiotherapy consultation can be used as an alternate marker to identify a subset of p16 positive OPSCC patients that have a poor prognosis.

Locoregional and free flap reconstruction of the lateral skull base

Lateral temporal bone reconstruction after ablative surgery for malignancy, chronic infection, osteoradionecrosis, or trauma presents a challenge for the reconstructive surgeon. This complexity is due to the 3D nature of the region, potential dural exposure, and the possible need for external surface repair. Successful reconstruction therefore requires achieving separation of the dura, obliteration of volume defect, and external cutaneous repair. There is significant institutional bias on the best method of reconstruction of these defects. In this review, the advantages and disadvantages of reconstructive options will be discussed as well as the potential pitfalls and complications.

Long-term Functional Outcomes of Total Glossectomy With or Without Total Laryngectomy

IMPORTANCE The optimal reconstruction of total glossectomy defects with or without total laryngectomy is controversial. Various pedicled and free tissue flaps have been advocated, but long-term data on functional outcomes are not available to date. OBJECTIVES To compare various total glossectomy defect reconstructive techniques used by multiple institutions and to identify factors that may lead to improved long-term speech and swallowing function. DESIGN, SETTING, AND PARTICIPANTS A multi-institutional, retrospective review of electronic medical records of patients undergoing total glossectomy at 8 participating institutions between June 1, 2001, and June 30, 2011, who had a minimal survival of 2 years. INTERVENTION Total glossectomy with or without total laryngectomy. MAIN OUTCOMES AND MEASURES Demographic and surgical factors were compiled and correlated with speech and swallowing outcomes. RESULTS At the time of the last follow-up, 45% (25 of 55) of patients did not have a gastrostomy tube, and 76% (42 of 55) retained the ability to verbally communicate. Overall, 75% (41 of 55) of patients were tolerating at least minimal nutritional oral intake. Feeding tube dependence was not associated with laryngeal preservation or the reconstructive techniques used, including flap suspension, flap innervation, or type of flap used. Laryngeal preservation was associated with favorable speech outcomes, such as the retained ability to verbally communicate in 97% of those not undergoing total laryngectomy (35 of 36 patients) vs 44% (7 of 16) in those undergoing total laryngectomy (P < .001), as well as those not undergoing total laryngectomy achieving some or all intelligible speech in 85% (29 of 34 patients) compared with 31% (4 of 13) undergoing total laryngectomy achieving the same intelligibility (P < .001). CONCLUSIONS AND RELEVANCE In patients with total glossectomy, feeding tube dependence was not associated with laryngeal preservation or the reconstructive technique, including flap innervation and type of flap used. Laryngeal preservation was associated with favorable speech outcomes such as the retained ability to verbally communicate and higher levels of speech intelligibility.

Biomarker and Tumor Responses of Oral Cavity Squamous Cell Carcinoma to Trametinib: A Phase II Neoadjuvant Window of Opportunity Clinical Trial

Purpose: Ras/MEK/ERK pathway activation is common in oral cavity squamous cell carcinoma (OCSCC). We performed a neoadjuvant (preoperative) trial to determine the biomarker and tumor response of OCSCC to MEK inhibition with trametinib. Experimental Design: Patients with stage II–IV OCSCC received trametinib (2 mg/day, minimum 7 days) prior to surgery. Primary tumor specimens were obtained before and after trametinib to evaluate immunohistochemical staining for p-ERK1/2 and CD44, the primary endpoint. Secondary endpoints included changes in clinical tumor measurements and metabolic activity [maximum standardized uptake values (SUVmax) by F-18 fluorodeoxyglucose positron emission tomography/CT), and in tumor downstaging. Drug-related adverse events (AE) and surgical/wound complications were evaluated. Results: Of 20 enrolled patients, 17 (85%) completed the study. Three patients withdrew because of either trametinib-related (n = 2: nausea, duodenal perforation) or unrelated (n = 1: constipation) AEs. The most common AE was rash (9/20 patients, 45%). Seventeen patients underwent surgery. No unexpected surgical/wound complications occurred. Evaluable matched pre- and posttrametinib specimens were available in 15 (88%) of these patients. Reduction in p-ERK1/2 and CD44 expression occurred in 5 (33%) and 2 (13%) patients, respectively. Clinical tumor response by modified World Health Organization criteria was observed in 11 of 17 (65%) evaluable patients (median 46% decrease, range 14%–74%). Partial metabolic response (≥25% reduction in SUVmax) was observed in 6 of 13 (46%) evaluable patients (median 25% decrease, range 6%–52%). Clinical-to-pathologic tumor downstaging occurred in 9 of 17 (53%) evaluable patients. Conclusions: Trametinib resulted in significant reduction in Ras/MEK/ERK pathway activation and in clinical and metabolic tumor responses in patients with OCSCC. Clin Cancer Res; 23(9); 2186–94. ©2016 AACR.

Pathology quiz case 2. Primary signet ring carcinoma of the eyelid.

A 73-YEAR-OLD MAN PRESENTED TO HIS PHYsician with right eyelid swelling without pain or discharge. His medical history and a review of systems were otherwise noncontributory. Physical examination showed swelling and induration of the right lower eyelid, without tenderness. The ipsilateral parotid gland and cervical lymph nodes appeared normal. Magnetic resonance imaging of the patient’s face and neck showed an enhancing soft-tissue mass along the inferior right eyelid, without underlying bony abnormality or extension into the orbit (Figure 1). A biopsy specimen obtained at an outside hospital was positive for carcinoma. The patient was referred to our institution for treatment. There was no evidence of distant disease on metastatic workup. Surgical resection of the lower eyelid and a 1-cm strip of adjoining malar skin and soft tissue was performed. Frozen-section consultation revealed diffusely infiltrating malignant single cells at all surgical margins. Some cells had a signet ring appearance (Figure 2). Additional margins were obtained and submitted as permanent sections, and the procedure was terminated. Four of the 8 additional skin margins, as well as periorbital fat, showed involvement by tumor. Immunohistochemical staining showed strong tumor cell expression of cytokeratin (CK) 7, E-cadherin, and gross cystic disease fluid protein 15 (Figure 3) and no expression of CK20, CD34, melan-A, or p63. Orbital exenteration was performed as a second-stage procedure, given the involvement of deep soft tissues. Adjuvant external beam radiation therapy was administered to the primary site and the nodal drainage basin because of concern for locoregional recurrence. What is your diagnosis?

Multiple Myeloma Presenting as Massive Amyloid Deposition in a Parathyroid Gland Associated with Amyloid Goiter: A Medullary Thyroid Carcinoma Mimic on Intra-operative Frozen Section

Clinical examples of amyloid deposition in parathyroid glands are exceedingly rare and usually present as an incidental finding in a patient with amyloid goiter. Here, we present the first histologically documented case of parathyroid amyloid deposition that presented as a mass. The patient did not have hyperparathyroidism. The parathyroid gland was submitted for intra-operative frozen section and concern for medullary thyroid carcinoma was raised. An important histologic clue arguing against medullary thyroid carcinoma was the evenly dispersed nature of the amyloid. Histologic perinuclear clearing and parathyroid hormone immunohistochemistry confirmed parathyroid origin on permanent sections. The patient was also found to have associated amyloid goiter. Mass spectrometry of the amyloid showed it to be composed of kappa light chains. On further work-up, the patient was diagnosed with multiple myeloma. Awareness of parathyroid amyloid deposition is important as it is a histologic mimic of medullary thyroid carcinoma, especially on frozen section. Amyloid typing with evaluation for multiple myeloma in any patient with kappa or lambda light chain restriction is also important.

Lower Trapezius Flap for Reconstruction of Posterior Scalp and Neck Defects after Complex Occipital-Cervical Surgeries.

Objectives To review the indications, techniques, and outcomes for a series of patients in whom the lower trapezius flaps was used for repair of complex posterior scalp and neck defects after posterior occipital-cervical surgeries. Design Retrospective case series. Setting Tertiary academic hospital. Participants A retrospective review of cases that required complex occipital-cervical repair was performed to identify patients who underwent reconstruction using the lower trapezius flap. Data collected included demographics, clinical presentations, surgical anatomy, operative techniques, and outcomes with review of the pertinent literature. Outcomes Nine patients who underwent reconstruction using the lower trapezius flap were identified. Prior surgical interventions included five complex tumor resections, two patients with multiple instrumented cervical spine surgeries, one patient with a craniotomy for attempted extracranial to intracranial arterial bypass for a basilar aneurysm repair, and a posterior occipital-cervical decompression after trauma. During the median follow-up period of 7 months, all nine single-stage reconstructions resulted in successful healing without major surgical complications. Conclusion Lower trapezius island flaps provide a reliable option for the reconstruction of complex scalp and neck defects that develop after complex occipital-cervical surgeries.