Paul Kerr

Parathyroid Hormone: An Early Predictor of Postthyroidectomy Hypocalcemia

Objective To determine whether there is a correlation between the level of parathyroid hormone (PTH) soon after thyroidectomy and the development of hypocalcemia.

Phase III randomized study: Oral pilocarpine versus submandibular salivary gland transfer protocol for the management of radiation-induced xerostomia

Xerostomia is a serious morbidity of radiation treatment in head and neck cancer.

Radiofrequency tissue reduction of the palate in patients with moderate sleep-disordered breathing.

OBJECTIVE Radiofrequency volumetric reduction of the palate has been advocated as a treatment for mild sleep-disordered breathing (SDB). Our study examines the efficacy of this procedure on patients with mostly moderate SDB. DESIGN Prospective, nonrandomized, consecutive series. SETTING St. Boniface Hospital, Sleep Disorders Centre, University of Manitoba, Winnipeg. METHOD Twelve patients with polysomnographically proven moderate SDB were given a total of 2400 to 3600 joules of radiofrequency energy to their soft palate over two to three treatments. Follow-up examined the effect of treatment on subjective and objective parameters including the Epworth Sleepiness Scale, loudness of snoring, Apnea-Hypopnea Index (AHI), and Arousal Index. RESULTS Two of 12 patients had a good objective response to treatment in that their AHI dropped by more than 50% and to a value of less than 20. However, none of the patients claimed to have a satisfactory subjective response. There was a slight reduction in the mean AHI from 31.2+/-5.1 to 25.3+/-4.2 (p < .05), but no clinically significant difference was found between pre- and post-treatment groups with respect to other sleep parameters. There was no improvement in daytime sleepiness or snoring. CONCLUSIONS Radiofrequency tissue ablation of redundant soft palate tissues lacks clinical efficacy in patients with moderate SDB.

Prediction of hypocalcemia after using 1- to 6-hour postoperative parathyroid hormone and calcium levels:an analysis of pooled individual patient data from 3 observational studies

Parathyroid hormone (PTH) levels up to 6 hours postthyroidectomy have been shown to have excellent predictive power in determining hypocalcemia. In this study, we investigate the usefulness of combining calcium and PTH to increase the predictive power.

Optimal Perioperative Care in Major Head and Neck Cancer Surgery With Free Flap Reconstruction: A Consensus Review and Recommendations From the Enhanced Recovery After Surgery Society

Importance Head and neck cancers often require complex, labor-intensive surgeries, especially when free flap reconstruction is required. Enhanced recovery is important in this patient population but evidence-based protocols on perioperative care for this population are lacking. Objective To provide a consensus-based protocol for optimal perioperative care of patients undergoing head and neck cancer surgery with free flap reconstruction. Evidence Review Following endorsement by the Enhanced Recovery After Surgery (ERAS) Society to develop this protocol, a systematic review was conducted for each topic. The PubMed and Cochrane databases were initially searched to identify relevant publications on head and neck cancer surgery from 1965 through April 2015. Consistent key words for each topic included “head and neck surgery,” “pharyngectomy,” “laryngectomy,” “laryngopharyngectomy,” “neck dissection,” “parotid lymphadenectomy,” “thyroidectomy,” “oral cavity resection,” “glossectomy,” and “head and neck.” The final selection of literature included meta-analyses and systematic reviews as well as randomized controlled trials where available. In the absence of high-level data, case series and nonrandomized studies in head and neck cancer surgery patients or randomized controlled trials and systematic reviews in non–head and neck cancer surgery patients, were considered. An international panel of experts in major head and neck cancer surgery and enhanced recovery after surgery reviewed and assessed the literature for quality and developed recommendations for each topic based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. All recommendations were graded following a consensus discussion among the expert panel. Findings The literature search, including a hand search of reference lists, identified 215 relevant publications that were considered to be the best evidence for the topic areas. A total of 17 topic areas were identified for inclusion in the protocol for the perioperative care of patients undergoing major head and neck cancer surgery with free flap reconstruction. Best practice includes several elements of perioperative care. Among these elements are the provision of preoperative carbohydrate treatment, pharmacologic thromboprophylaxis, perioperative antibiotics in clean-contaminated procedures, corticosteroid and antiemetic medications, short acting anxiolytics, goal-directed fluid management, opioid-sparing multimodal analgesia, frequent flap monitoring, early mobilization, and the avoidance of preoperative fasting. Conclusions and Relevance The evidence base for specific perioperative care elements in head and neck cancer surgery is variable and in many cases information from different surgerical procedures form the basis for these recommendations. Clinical evaluation of these recommendations is a logical next step and further research in this patient population is warranted.

Impact of use of frozen section assessment of operative margins on survival in oral cancer

OBJECTIVE This study looked at the independent impact of intraoperative frozen section assessment of the adequacy of margins of excision on disease control and survival. STUDY DESIGN The design was a review of outcome of historical cohort of 416 surgically treated oral cancer patients at a comprehensive cancer center. Status of the margins at permanent sections, disease failure at the primary site, and survival data of 229 patients who had frozen sections were compared by univariate and multivariate analysis with 197 patients who did not have frozen sections. RESULTS Failure at the primary site was independently influenced by age at diagnosis (P < .001), T stage (P = .016), N stage (P = .042), and status of margins on paraffin sections (P = .005). Chance of achieving clear margins on paraffin sections was, however, not significantly improved by the use of frozen sections. On multivariate analysis, the use of frozen sections did not independently have an impact on local failure or survival. CONCLUSIONS Frozen section assessment of mucosal margins has not improved the disease outcome.

Primary extramedullary plasmacytoma of the salivary glands

Primary extramedullary plasmacytomas (PEMP) are uncommon plasma cell neoplasms that generally occur in the submucosal tissue of the upper airway. Salivary gland PEMP is an extremely rare condition. This report describes a unique case of PEMP in the parotid gland associated with pulmonary amyloidosis. A review of all salivary gland PEMPs suggests that they behave similarly to PEMPs in other locations. The treatment of choice for localized disease is radiotherapy which should include regional lymphatics. Local control can be achieved in the majority of cases. The minority of patients develop systemic metastases and die from their disease. Chemotherapy can control disseminated disease and may induce remission.

Paranasal sinus teratocarcinosarcoma with intradural extension.

Teratocarcinosarcoma, although a rare neoplastic entity, should be considered as a differential diagnosis in any middle-aged adult presenting with a history of intermittent unilateral epistaxis and nasal obstruction. Tissue biopsy may fail to reveal a full spectrum of histologic heterogeneity in these tumours, and definitive diagnosis is usually made with tumour resection. Aggressive treatment including surgery followed by adjuvant radiation therapy is advocated and confers a better rate of survival than radiotherapy alone. Our current report is unique in two respects. First, disease recurrence is usually manifested very early on, leading some authors to conclude that a neoplastic-free interval of 3 years or longer probably indicates a good chance of being cured. Our patient, in contrast, experienced a disease-free interval of 4 years before evidence of recurrence emerged. Second, intracranial extension with brain parenchymal involvement has not been previously reported despite the tumours proximity to the anterior cranial fossa and its locally aggressive behaviour with frequent bony invasion. Despite intracranial invasion, our patient experienced a long disease-free interval. As such, even advanced disease should be treated aggressively.

Validation of 1-hour post-thyroidectomy parathyroid hormone level in predicting hypocalcemia

No abstract

Effect of severe gastroesophageal reflux on sleep stage in patients with aperistaltic esophagus

Polysomnography and esophageal pH studies were conducted in 13 patients with an aperistaltic esophagus; seven of these had scleroderma and six were patients treated for achalasia. The percentage total time of pH <4.0 when recumbent exceeded 30% for both groups. There was a total of 51 reflux events for both groups. There were 22 reflux events recorded for both groups that were less than 5 min in length and 29 events greater than 5 min. In 26 of 32 (81%) instances, patients either began awake and went to sleep during a reflux event or did not awake during a reflux event. Only six of 32 (19%) reflux events caused sleep disruption. We conclude that even the severe reflux demonstrated in this subset of patients does not always disrupt sleep. Patients may have severe prolonged reflux and not arouse.