JAMA otolaryngology-- head & neck surgery最新文献

Importance: The benefit of adenoidectomy on otologic outcomes after tympanostomy tube (TT) insertion is unclear. Results from prior work are challenging to interpret due to small sample sizes, heterogeneous study designs, and varying outcome measures.

Objective: To evaluate the association between adenoidectomy and otologic outcomes using a US population-level sample of children who received TTs, producing generalizable results for widespread clinical application.

Design, setting, and participants: A matched cohort study was conducted using claims data from the Merative MarketScan Research Databases. The study included 601 848 children who received TTs between January 1, 2007, and December 31, 2021. Children who received adenoidectomy and TTs simultaneously (Ad+TT) were identified irrespective of the number of prior TTs. Control participants who received TTs without adenoidectomy were matched based on sex, age at the time of the procedure, and the number of prior TT procedures.

Exposures: Adenoidectomy without tonsillectomy was the primary exposure.

Main outcomes and measures: The primary outcomes were repeat TT insertion and subsequent oral antibiotic prescriptions after TT insertions. Multivariable logistic regression was used to quantify the effects of adenoidectomy and covariates on each outcome. Stratified analyses were performed in children younger than 4 years and 4 years or older.

Results: Overall, 601 848 children (median [IQR] age, 2 [1-4] years; range, 0-11 years; 351 078 [58.3%] male) who received TTs were identified. The Ad+TT cohort included 201 932 children, with an equal number in the matched cohort. In children younger than 4 years, Ad+TT was common and was associated with lower odds of subsequent oral antibiotics (odds ratio [OR], 0.59; 95% CI, 0.58-0.60) but higher odds of repeat TT insertions (OR, 1.24; 95% CI, 1.22-1.27). In children 4 years or older, Ad+TT was associated with lower odds of repeat TT insertions (OR, 0.78; 95% CI, 0.75-0.81) and subsequent oral antibiotics (OR, 0.63; 95% CI, 0.62-0.65).

Conclusions and relevance: This study found that in children younger than 4 years, Ad+TT was commonly performed and may have had a secondary benefit of reducing subsequent oral antibiotic courses; however, it was not associated with a reduction in the risks of repeat TT insertions. In children 4 years or older, Ad+TT was associated with a reduction in the risk of repeat TT insertions and subsequent oral antibiotics. Given these findings, Ad+TT may be offered in children 4 years or older to improve otologic outcomes.

Importance: Understanding the clinical course and malignant transformation rate of oral potentially malignant disorders (OPMDs)-including oral leukoplakia, oral erythroplakia, oral submucous fibrosis, and oral lichen planus-is crucial for early detection and improved survival rates in patients with oral cancer.

Objective: To evaluate the progression of oral cancer from OPMDs using a large US electronic medical database.

Design, setting, and participants: This retrospective cohort study used data from the University of California, San Francisco's PatientExploreR database between January 1973 and March 2024. Patients with oral leukoplakia, oral erythroplakia, oral submucous fibrosis, and oral lichen planus were identified using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, codes and keywords. Demographics, tobacco and alcohol use, HIV status, and other known risk factors for oral cancer were recorded to identify factors associated with malignant transformation. Logistic regression and descriptive analyses were used.

Exposure: Diagnosis of oral leukoplakia, oral erythroplakia, oral submucous fibrosis, or oral lichen planus.

Main outcomes and measures: Incidence of oral cancer, malignant transformation rate, median time to progression, and associations between demographics and risk factors and the development of oral cancer.

Results: Among 4 225 251 individuals in the database, 4371 were diagnosed with oral cancer (median [IQR] age, 63 [53-71] years; 2610 [59.9%] male; 0.1% of the cohort), and 110 (2.5%) had a preceding OPMD. Oral leukoplakia was found in 1124 patients, with 94 (8.4%) undergoing malignant transformation (median [IQR] time to progression, 25 [7-129] months). HIV-positive patients with oral leukoplakia were more likely to develop oral cancer (odds ratio, 3.80; 95% CI, 1.35-10.70). Of 22 patients with oral erythroplakia, 11 (50.0%) developed oral cancer (median [IQR] time to progression, 3.7 [0.2-334] months). Those who smoked tobacco with oral erythroplakia showed a higher malignant transformation rate (odds ratio, 3.75; 95% CI, 0.54-26.05). Of the 78 patients with oral submucous fibrosis, 4 (5.1%) underwent malignant transformation (median [IQR] time to progression, 36 [36-48] months). Only 1 patient with oral lichen planus developed oral cancer after 5 years.

Conclusions and relevance: This cohort study showed that OPMDs have notable but varying propensities to progress to oral cancer. Early detection and monitoring of OPMDs are crucial for improving patient outcomes. However, the risk, etiopathogenesis, and clinical presentation vary for each OPMD and should, therefore, be considered distinct diseases.

Importance: The Expert Center of Palliative Care for head and neck cancer offers structural attention to patients' complex physical and psychosocial care needs. Patients are offered remote care, including digital monitoring using patient-reported outcome measures, to enable them to stay as long as possible in their trusted home environment. There is limited literature on qualitative feedback and patient-reported experiences with palliative head and neck cancer care, especially for remote care. To provide optimal palliative care, more information on this is needed.

Objective: To provide insight into the experiences of patients with head and neck cancer and their next of kin with a hybrid palliative care pathway.

Design, setting, and participants: A mixed-methods quality improvement study was conducted at a tertiary cancer center. The experiences of patients with head and neck cancer in the palliative phase as of June 2022 and next of kin of patients who had died between June 2021 and March 2022 were evaluated using a patient-reported experience measure that included open-ended questions.

Exposures: Hybrid palliative care pathway.

Main outcomes and measures: Experiences of patients and next of kin.

Results: Of 105 included participants, 54 (51.4%) were male, and the mean (SD) age was 67.2 (12.7) years. A total of 56 participants were patients and 49 were next of kin. The face-to-face consultations on the day of the palliative diagnosis were positively experienced by most patients and next of kin. A total of 42 of 102 participants (41%) and 24 of 79 participants (30%) missed at least 1 topic during consultations with their physician and oncology nurse, respectively, such as discussing life expectancy. During the remote follow-up, 71 of 92 (77%) felt safe with this care: they were able to sufficiently clarify their problems, and if necessary, timely action was taken. However, 17 of 48 patients (35%) and 21 of 46 next of kin (46%) considered the provided psychosocial support to be insufficient.

Conclusions and relevance: In this quality improvement study, patients and next of kin were satisfied with most aspects of the hybrid palliative care pathway, and remote care seemed to be a promising means of delivery. Key areas needing attention are discussing life expectancy and providing psychosocial support. These insights represent the initial steps toward gaining a deeper understanding of patients' needs during specific moments in a hybrid palliative trajectory. They may support health care professionals in optimizing personalized and value-based palliative care delivery.

Importance: Upper airway stimulation (UAS) was recently approved to treat persistent obstructive sleep apnea in pediatric patients with Down syndrome. Appropriate titration of the UAS implantable device is essential to achieve optimal outcomes, but standardized titration protocols for young patients are lacking.

Objective: To develop and share a UAS titration protocol for pediatric patients with Down syndrome.

Design, setting, and participants: This small cohort study of pediatric patients with Down syndrome presents a standardized UAS stimulation titration protocol for conducting postimplantation polysomnograms. The protocol was developed through a multidisciplinary collaboration at a tertiary children's hospital with a dedicated pediatric polysomnogram laboratory. The initial titration polysomnogram was performed on the night of device activation, with subsequent titration polysomnograms performed at 1 month, 2 to 3 months, 6 months, and 12 months after implantation. The initial titration goal is acclimation, promoting AHI optimization in later polysomnograms. Pediatric patients with Down syndrome and persistent obstructive sleep apnea who have undergone UAS titration from June 2022 to January 2024 participated in this study.

Exposure: A novel standardized UAS titration polysomnogram protocol.

Main outcomes and measures: The main outcomes were apnea-hypopnea index (AHI) change and nightly device use in hours.

Results: This study included 5 pediatric patients with Down syndrome who have undergone UAS implantation. Three patients were male, and 4 identified as White. The median (range) age at implantation was 15 years (12-20 years), and the median (range) preoperative AHI was 20.1 (15.6-38.8). The median (range) incoming voltage for a 1-month postimplant UAS titration polysomnogram was 1.7 V (0.4-1.7 V). All 5 patients completed UAS titration polysomnograms at the aforementioned postoperative time course; all patients also experienced an AHI reduction from baseline and adequate tolerance of UAS (ie, nightly device use of more than 6 hours). A titration protocol for UAS in pediatric patients with Down syndrome, a sample polysomnogram report form, and general information for sleep technologists are provided.

Conclusions and relevance: In this study, a standardized UAS protocol for device titration during polysomnogram promoting acclimation and optimized AHI reduction demonstrated UAS efficacy in pediatric patients with Down syndrome. The protocol can be used as a model for other institutions creating programs for UAS titration in pediatric patients with Down syndrome. As more pediatric patients undergo UAS device implants, protocols can be refined to ensure optimal outcomes.