Citations

Abstract Objective Untreated obstructive sleep apnea (OSA) in the perioperative period confers significant cardiopulmonary risk. However, many otolaryngologists defer restarting positive airway pressure (PAP) therapy following functional endoscopic sinus surgery (FESS) due to perceived risk of epistaxis, mucosal injury, and wound healing. Thus, the objective of this study was to evaluate the immediate resumption of PAP therapy in OSA patients undergoing FESS. Study Design Multicenter prospective controlled study. Setting Academic medical centers. Methods Patients with a history of OSA on PAP therapy scheduled for FESS were prospectively enrolled (OSA/PAP group) along with a control group of non‐OSA FESS patients (non‐OSA group). Patients in the OSA/PAP group restarted PAP therapy on post‐operative Day #0 or #1. The primary outcome was change in Lund‐Kennedy endoscopic scores (LKES); secondary outcomes of interest included change in post‐operative SNOT‐22 scores, Pittsburgh Sleep Quality Index (PSQI) scores, complications, and epistaxis severity scores. Results A total of 100 patients were enrolled, of whom 49 were in the OSA/PAP group, and 51 were in the non‐OSA group. In multivariate adjusted models, early PAP resumption was not independently associated with higher LKES compared to the control group at POV1 or POV2, higher SNOT‐22 compared to the control group at POV1 or POV2, or higher postoperative epistaxis scores compared to the control group. There were no PAP‐related complications such as orbital emphysema or pneumocephalus. Conclusion Early resumption of PAP in OSA patients undergoing FESS does not appear to be associated with worsened post‐operative endoscopic scores, quality‐of‐life scores, or an increased risk of post‐operative epistaxis.

Background Caregiver burden assessments lack clinical uniformity in palliative care. Existing evidence-based interventions often impose resource demands that are prohibitive for smaller programs. Objectives (1) Demonstrate the practical utility of routine caregiver screening paired with an interdisciplinary team (IDT) response protocol. (2) Identify patient and caregiver factors influencing burden. Design Setting: Cross-sectional study in a US outpatient palliative care clinic. Measure ments: The 12-item Zarit Burden Interview (ZBI-12) was administered by a nurse or social worker. Scores guided immediate, point-of-care IDT interventions. Results Of 81 approached caregivers, 74 completed the ZBI-12 (72% female; median age 56). Burden was stratified into mild (n = 37), mild-moderate (n = 22), and high (n = 15) tiers, with median scores increasing significantly (6 vs 16 vs 28; P < 0.001). General counseling was consistent across tiers (∼54%). However, high-intensity supportive interventions rose significantly with burden severity: social work telephone follow-ups increased (0% vs 13.6% vs 33.3%; P < 0.001), support group referrals rose (2.7% vs 31.8% vs 46.7%; P < 0.001), and psychotherapy referrals increased (0% vs 4.5% vs 13.3%; P = 0.030). Multivariable linear regression showed lower patient Palliative Performance Scale (PPS) scores independently predicted higher caregiver burden. Each 10-point decrease in PPS correlated with a 2.4-point increase in total ZBI-12 score (β = −0.240; 95% CI, −0.433 to −0.048; P = 0.015). Conclusion This workflow provides a replicable roadmap to transition caregivers from “invisible patients” to actively supported extensions of the care unit, reinforcing dyadic assessments as standard practice in outpatient palliative medicine.

Introduction There is uncertainty about the number of shark bites on humans in Florida (FL). Methods The International Shark Attack File (ISAF) and Global Shark Attack File (GSAF) databases (2016–2024) were compared with the non-inpatient FL Ambulatory and Emergency Department Patient Data database (AHCA) (2018–2023) and the National Emergency Medical Services (EMS) Information System (NEMSIS) (2016–2024). Results Between 2016–2024 there were 244 FL shark encounters reported in ISAF (mean 27.1 per year), 214 in GSAF (mean 23.8 per year), and 293 in a merged ISAF and GSAF (mean 32.6 per year). Between 2020–2023, there were 373 FL shark encounters reported in AHCA (mean 62.2 per year) compared with 114 encounters reported in NEMSIS (mean 22.8 per year) for 2020–2024. The rate ratio for AHCA FL shark encounters compared to the merged ISAF and GSAF was 1.91 (95% CI 1.64–2.23); p < .001. The percentage of shark encounters in Volusia County, FL, compared with all of FL shark encounters showed no significant differences between the ISAF and GSAF (40.2% and 33.6%, respectively) ( p = .16) and between the AHCA and NEMSIS (7.2% and 7.5%, respectively) ( p = 1.0). However, when comparing either ISAF or GSAF with either AHCA or NEMSIS, there were significant differences ( p < .001 for all). Discussion The AHCA dataset identified about twice as many shark bites as either the ISAF or GSAF. Many FL shark encounters did not require EMS or admission to the hospital. The discrepancy in the number of shark encounters attributed to Volusia County, FL, varied based on the dataset being examined.

Abstract Objective In 2024, the US News and World Report (USNWR)'s Best Hospitals began reporting complications following elective outpatient otolaryngology procedures in its ears, nose, and throat (ENT) ranking. However, this methodology has not been clinically adjudicated in a peer‐reviewed domain. We aimed to conduct manual health record adjudication to assess whether the USNWR methodology accurately attributes complications following elective outpatient otolaryngology procedures. Study Design Case‐cohort. Setting A case‐cohort of n = 80 elective, outpatient otolaryngology procedure/complication pairings from January 2019 to October 2023 across four academic medical centers using the 2024 USNWR otolaryngology procedure subgroups and Solventum Ambulatory Potentially Preventable Complications (AM‐PPC) software. Methods We used the AM‐PPC‐defined complication types as our standard of comparison for our clinical adjudication. Using the electronic health record, we adjudicated: (1) Was there agreement (yes/no) on complication type between our clinical adjudication and the Solventum AM‐PPC software? (2) Was the complication clinically related to, or a sequela of, the index otolaryngology procedure (yes/no)? Results The clinical adjudication agreed on complication type in 59/80 (74%) of patients, and 63/80 (79%) were judged to be clinically related to the index otolaryngology procedure. In total, 50/80 (63%) complications were adjudicated to be in agreement on both the complication type and clinical relatedness to the index procedure, while 9/80 (11%) complications did not agree with the complication type nor were clinically related to the index procedure. Conclusion Outpatient complications reported in the USNWR ENT rating lack the specificity to exclude patients whose complications are sequelae of chronic underlying conditions or related to concurrent, non‐otolaryngology procedures.

ABSTRACT Objective Pituitary carcinoma (PC) is defined by the presence of metastasis from a pituitary tumour. PC is rare, therefore information regarding survival and factors influencing survival are limited. We sought to assess overall survival following the diagnosis of PC and to determine factors associated with outcome. Design Retrospective case series. Patients Patients with PC who attended the Mayo clinic between 1997 and 2025. Measurements Information regarding patient demographics, tumour characteristics, management and outcomes were extracted. Results In total 25 patients (11 women, 44%) were diagnosed with PC (median age 56 years, range, 44–78). The most common cell type was a corticotroph tumour ( n = 15, 60%). All but one patient had pituitary directed surgery and all received pituitary adenoma (PA) directed radiation therapy. Metastases were identified a median 6 years (range, 1–32) after initial PA diagnosis. At last follow‐up, 10 (40%) patients were alive, 12 (48%) died of PC, and 3 (12%) died from other causes. The median survival time of patients from PC diagnosis was 3 years. The 1‐, 5‐ and 10‐year survival rates were 59%, 37% and 15%, respectively. Increased survival probability was associated with temozolomide treatment ( n = 9) at some point in treatment plan ( p = 0.026), the use of systemic therapy vs locoregional treatment ( p = 0.045), female sex ( p = 0.011), and in nonfunctional tumours ( p = 0.023). Conclusion PC carries a poor prognosis, with a median survival of only 3 years. Improved survival was associated with temozolomide exposure, female sex, and nonfunctional tumour subtype and underscores the prognostic relevance of tumour biology and treatment approach.

ABSTRACT Periprosthetic joint infection (PJI) is a devastating complication of total joint arthroplasty that can be challenging to diagnose and treat. Neutrophils are a prominent feature in PJI, with neutrophil extracellular traps (NETs) known to be present; little is known, however, about the physiology of PJI-associated NETs. Here, the proteomes of PJI and non-infectious arthroplasty failure (NIAF), analyzed using liquid chromatography tandem mass-spectrometry (LC-MS/MS) and proximity extension assay (PEA)-based profiling of fluids derived from sonication of arthroplasty components removed from patients who had undergone revision arthroplasty, were compared, with a focus on NET formation. In addition, in vitro effects of synovial fluid components on Staphylococcus aureus- induced NET formation were characterized. LC-MS/MS (PJI n = 85, NIAF n = 26) and PEA (PJI n = 95, NIAF n = 39) showed NET formation and neutrophil degranulation to be associated with PJI, with the complement cascade and platelet activation pathways identified as potential contributors. In vitro studies showed delayed NET formation in artificial synovial fluid compared to standard cell culture media conventionally used to evaluate NETs. Together, these results demonstrate the presence of NETs in PJI, identify potential pathways involved in PJI-associated NETosis, and point to an influence of synovial components on NET formation during PJI. IMPORTANCE Periprosthetic joint infection (PJI) is a major complication of joint replacement, placing a significant burden on patients and the healthcare system. Our research reveals that neutrophils and their antimicrobial “traps” are dominant features of the immune response at the infection joint site. Importantly, we found that the unique environment of the joint delays the formation of these traps, potentially contributing to the pathogenesis of PJI. By establishing a new experimental platform tailored for the infected joint, this work provides a foundational platform for probing these mechanisms and supports the development of improved diagnostic and therapeutic strategies.

Purpose: This study examined whether phoneme-level posterior probabilities generated by an articulatory-informed deep learning model (Phonet) can serve as interpretable and sensitive markers of articulatory impairment in motor speech disorders (MSDs). The goal was to determine whether these features distinguish individuals with and without MSDs and reflect varying severity levels of articulatory impairment. Method: A total of 676 participants (199 with MSDs, 477 without MSDs) completed a remotely captured word repetition task. Speech recordings were phonetically aligned, and posterior probabilities were extracted using a retrained version of the Phonet model, which estimates frame-level probabilities for 23 phonological classes. Segment-level posterior values were computed and compared across groups and severity levels using linear mixed-effects regression models. Results: Posterior probabilities were significantly reduced in the MSD group across all phoneme types. Within the MSD group, posterior probabilities decreased progressively with greater clinical severity, as measured by both perceptual sound distortion ratings and a cumulative articulation error score. Segment-specific analyses revealed systematic differences across phoneme classes, indicating that posterior probabilities capture distinct patterns of articulatory degradation associated with motor speech impairment. Conclusions: Phoneme-level posterior probabilities serve as interpretable, segment-specific indicators of articulatory impairment in MSDs. These features differentiate clinical status and reflect gradations of severity, making them promising tools for augmenting traditional perceptual speech assessments. Their linguistic transparency and scalability support future clinical applications in diagnosis, monitoring, and targeted intervention.

ABSTRACT Background and Objectives Among patient with early‐stage breast cancer, breast conservation surgery (BCS) is the most performed surgery, utilized in approximately two‐thirds of patients. While 5‐year overall‐survival rates are strong—typically above 90%—additional re‐excisions can occur in up to 25% of patients who undergo index BCS and some patients will require subsequent surgery for new breast cancer or recurrences. As such, these additional procedures can complicate patients’ pathway to survivorship, negatively impact quality of life, and lead to excess healthcare costs. Methods This retrospective cohort study used linked claims and an electronic healthcare record database to (1) characterize patients at higher risk for additional breast oncologic surgery (aBOS) following BCS, and (2) quantify the long‐term financial impact of aBOS after BCS. In total, 87,190 patients with breast cancer, who had an index BCS between January 1, 2012, to March 31, 2023, were followed for up to 5‐years post‐operatively. Patients with and without aBOS were analyzed, comparing demographics, tumor characteristics, healthcare utilization, and per‐person‐per‐month (PPPM) costs. Results Twenty‐three percent ( n = 20,212) of patients underwent aBOS. These patients were younger, had higher tumor grades and larger tumor sizes, and incurred greater healthcare costs compared to patients who did not undergo a secondary surgery. Conclusion This study highlights significant factors influencing BCS outcomes and healthcare utilization, underscoring the need for tailored therapeutic strategies for patients with breast cancer.

Purpose This study aimed to develop and validate a tool to predict the primary tumor site in patients with metastatic cancer of unknown primary using demographic and clinical variables, including imaging-derived sites of metastasis, without pathology or laboratory data. Methods In this population-based study, data were extracted from the SEER database. Patients diagnosed between 2010 and 2020 with a known primary cancer site, metastatic staging, and metastasis in the bone, liver, brain, and lungs were included. Patients were randomly split into training (70%) and/or testing (30%) sets. A total of 27 primary tumor sites were included. A gradient boosting model was trained to predict the primary tumor site, with random forest and classification tree models evaluated as comparators. Random guess and frequency-weighted guessing models were used for baseline comparison. Results A total of 689,715 patients were included from 9,208,295 queried. The most common primary cancer sites were non–small cell lung cancer (NSCLC) (n = 211,338), intestines (n = 64,187), and pancreas (n = 60,310). The baseline models achieved Top-5 accuracies of 0.179 for a random guess and 0.476 for a frequency-weighted guess. The gradient boosting model achieved Top-1, Top-3, and Top-5 accuracies of 0.40 ± 0.001, 0.680 ± 0.001, and 0.790 ± 0.001, respectively, across 100 Monte-Carlo replicates. Top-5 accuracy was highest for primary NSCLC (0.990 ± 0.001) and intestinal cancer (0.900 ± 0.003). Our model was most influenced by sex (gain = 0.27) and metastasis to bone (gain = 0.20). A web app was constructed: primarycancerpredictor.netlify.app. Conclusion This study developed and evaluated a gradient boosting machine learning model and a user-friendly web tool to aid in the diagnosis of cancer of unknown primary.

PURPOSE Patients with breast cancer requiring postmastectomy radiation therapy (PMRT) often desire breast reconstruction. Reconstructions can be adversely affected by PMRT, and fear of reconstruction complications has discouraged adoption of short-course radiation therapy used after lumpectomy. To fill the evidence gap, we conducted a noninferiority trial of hypofractionated versus conventional PMRT in patients undergoing breast reconstruction. The primary outcome was reconstruction complication rate, a composite of wound healing, readmission, capsular contracture, unplanned reoperation, and reconstruction failure. METHODS Women with unilateral invasive breast cancer with planned immediate or delayed reconstruction and PMRT were randomly assigned (1:1) to 50 Gy (25 fractions/5 weeks) or 42.56 Gy (16 fractions/3 weeks). This study was designed with a noninferiority margin of 10%, assuming a 2-year reconstruction complication rate of 25% with conventional PMRT. Randomization was stratified by immediate versus delayed and autologous versus implant-only reconstruction. RESULTS Between 2018 and 2021, 898 patients enrolled with a median follow-up of 3.9 years; 825 patients were evaluable for the primary end point. The 24-month reconstruction complication rates were 12.3% (52/422) with hypofractionated PMRT and 10.2% (41/403) with conventional PMRT, corresponding to an estimated difference of -2.1% (95% CI, -6.5 to 2.2). The complication rate was higher (regardless of arm) with implant-only versus autologous reconstruction (odds ratio = 1.65). There was no statistically significant difference in 36-month locoregional recurrence rates: 1.5% (95% CI, 0.7 to 3.2) with hypofractionated and 2.2% (95% CI, 1.1 to 4.3) with conventional PMRT. Acute and late toxicity rates were not statistically different. CONCLUSION A 16-fraction course of hypofractionated PMRT is safe and noninferior to conventional PMRT in women undergoing breast reconstruction after mastectomy.