JAMA otolaryngology-- head & neck surgery最新文献

Importance: Venous thromboembolism (VTE) is a severe complication after microsurgical free tissue transfer (FTT) to the head and neck. Hypothermia during surgery is a modifiable risk factor, and avoiding it may reduce the postoperative VTE rate.

Objective: To assess the association between hypothermia (temperature <36 °C) and postoperative VTE and free flap pedicle thrombosis rates after head and neck reconstruction with FTT.

Design, setting, and participants: This retrospective cohort study in a tertiary academic referral center used prospective and retrospective database and medical record data collected for patients who underwent head and neck reconstruction with FTT between January 1, 2012, and August 31, 2023. Temperature over time was classified as normothermia (temperature ≥36 °C), hypothermia (<36 °C) for more than 30 minutes and less than 120 minutes, and hypothermia for 120 minutes or more.

Exposure: Venous thromboembolism.

Main outcomes and measures: The study outcomes were VTE events and thrombosis of the free flap pedicle that required revision surgery. Univariable and multivariable regressions were used to test the association between the outcomes and clinical factors.

Results: A total of 1078 patients (mean [SD] age, 61.3 [12.6] years; 724 males [67.2%]; mean [SD] Caprini score, 6.4 [2.1]) were included. The VTE and pedicle thrombosis rates were 3.2% (35 patients) and 2.2% (24 patients), respectively. In a multivariable model controlled for Caprini score and chemoprophylaxis, VTE was associated with hypothermia of more than 30 minutes and less than 120 minutes (odds ratio [OR], 3.82; 95% CI, 0.99-14.07) and hypothermia of 120 minutes or longer (OR, 3.55; 95% CI, 1.05-11.95). Free flap pedicle thrombosis was not associated with hypothermia (OR, 0.61; 95% CI, 0.26-1.43).

Conclusions and relevance: These findings suggest that preventing hypothermia during microsurgical FTT to the head and neck may decrease the postoperative rate of VTE. Future studies should explore the optimal intraoperative body temperature range that may prevent the development of VTE without compromising patient safety.

Importance: Genome-wide association studies have identified germline variants associated with the development of papillary thyroid carcinoma (PTC) that can be used to construct a polygenic score (PGS). It is important to determine whether patients with higher germline genetic risk, as summarized using PGS, present with more aggressive disease and/or develop worse clinical outcomes.

Objective: To assess whether germline risk defined by PGS is associated with clinicopathologic features and survival outcomes for patients with PTC.

Design, setting, and participants: This retrospective cohort study included patients with newly diagnosed PTC who presented to The University of Texas MD Anderson Cancer Center for treatment between 1999 and 2014, with a median follow-up of 12 years. Data were analyzed from December 2023 to April 2024.

Exposure: Germline risk, as defined by PGS.

Main outcomes and measures: Genomic DNA was extracted from buffy coat cells isolated from peripheral blood samples, and genotyping for germline polymorphisms was performed. Germline risk for PTC was estimated with a previously validated PGS calculated from 10 single-nucleotide variations identified through genome-wide association studies. Stage; PTC-specific survival, defined as the time from PTC diagnosis to death caused by PTC; and overall survival, defined as the time from PTC diagnosis to death by any cause, were analyzed.

Results: A total of 366 patients were included in the study (261 women [71.3%]; mean [SD] age at diagnosis, 44.3 [13.8] years). There was a statistically significant association between higher PGS and multifocality (β [SE], 0.40 [0.23]; P = .045) and cervical lymph node involvement (N stage) (β [SE], 0.62 [0.35]; P = .009) at diagnosis. PGS was associated with PTC-specific survival (hazard ratio, 2.66; 95% CI, 1.03-6.85; P = .04), but this association was not independent of age and overall stage. There was not a statistically significant association between PGS and overall survival.

Conclusions and relevance: Findings of this cohort study suggest that patients with a higher germline risk of PTC, as estimated by PGS, present with more aggressive clinicopathologic features. These results contribute to the current understanding of inherited risk in PTC and how germline variants could potentially contribute to disease presentation and clinical outcomes.

Importance: Retrograde cricopharyngeus dysfunction (R-CPD) is an emerging disorder associated with disabling symptoms. The origin of R-CPD remains unknown.

Objective: To investigate the development of symptoms, diagnosis approach, and therapeutic outcomes of R-CPD in patients treated with in-office botulinum toxin injection (BTI) into the cricopharyngeus.

Design, setting, and participants: This was a case series including patients with R-CPD who were consecutively and prospectively recruited from April 2022 to May 2024 in an academic hospital. Semistructured interviews were conducted to collect and analyze data on each patient's clinical history, potential causes or factors associated with R-CPD development, diagnostic approaches, and symptom presentation.

Intervention: Clinic-based (in-office) BTI into the cricopharyngeus.

Outcomes and measures: Associations with laryngopharyngeal reflux disease, patients' Reflux Symptom Score-12 (RSS-12), and BTI effectiveness, revisions, and complications were evaluated.

Results: The case series comprised 106 patients with R-CPD treated with BTI (52 females [49.1%] and 54 males [51.9%]). Their mean (SD) age at symptom onset was 13.6 (7.7) years, and at diagnosis, 30.4 (6.4) years. Sixty-eight patients (64.2%) had potential congenital R-CPD, according to the parents' testimonies. A family history was reported in 18 of 62 cases (29.0%). In 105 cases (99.1%), patients made the diagnosis themselves despite medical consultations (n = 162), empirical treatments (n = 113), and additional examinations (n = 92). The cumulative success rate of BTI was 90.6% (96 of 106 patients). In 26 cases (24.5%), additional injections were administered to address the symptoms. Family history of R-CPD was a negative predictor of single-BTI success. Dysphagia was the primary adverse effect occurring after 89 of 126 BTIs (70.6%) and lasted a mean (SD) of 16.3 (12.0) days. In 10 cases, operating-room BTI was administered after primary in-office BTI.

Conclusions and relevance: R-CPD is an emerging and poorly known disorder associated with high rates of ineffective consultations, additional examinations, and self-diagnosis by patients. In-office BTI was associated with a high rate of partial or total symptom relief and long-term effectiveness.