AHNS Series – Do you know your guidelines? Principles of treatment for glottic cancer: A review of the National Comprehensive Cancer Network guidelines

This article is a continuation of the “Do You Know Your Guidelines” series, an initiative of the American Head and Neck Society's Education Committee to increase awareness of current best practices pertaining to head and neck cancer. The National Comprehensive Cancer Network (NCCN) guidelines for primary and adjuvant treatment of cancer of the glottic larynx are reviewed here in a systematic fashion according to stage.     

Alterations to the Gut Microbiome Impair Bone Strength and Tissue Material Properties

Alterations in the gut microbiome have been associated with changes in bone mass and microstructure, but the effects of the microbiome on bone biomechanical properties are not known. Here we examined bone strength under two conditions of altered microbiota: (1) an inbred mouse strain known to develop an altered gut microbiome due to deficits in the immune system (the Toll‐like receptor 5–deficient mouse [TLR5KO]); and (2) disruption of the gut microbiota (ΔMicrobiota) through chronic treatment with selected antibiotics (ampicillin and neomycin). The bone phenotypes of TLR5KO and WT (C57Bl/6) mice were examined after disruption of the microbiota from 4 weeks to 16 weeks of age as well as without treatment (n = 7 to 16/group, 39 animals total). Femur bending strength was less in ΔMicrobiota mice than in untreated animals and the reduction in strength was not fully explained by differences in bone cross‐sectional geometry, implicating impaired bone tissue material properties. Small differences in whole‐bone bending strength were observed between WT and TLR5KO mice after accounting for differences in bone morphology. No differences in trabecular bone volume fraction were associated with genotype or disruption of gut microbiota. Treatment altered the gut microbiota by depleting organisms from the phyla Bacteroidetes and enriching for Proteobacteria, as determined from sequencing of fecal 16S rRNA genes. Differences in splenic immune cell populations were also observed; B and T cell populations were depleted in TLR5KO mice and in ΔMicrobiota mice (p < 0.001), suggesting an association between alterations in bone tissue material properties and immune cell populations. We conclude that alterations in the gut microbiota for extended periods during growth may lead to impaired whole‐bone mechanical properties in ways that are not explained by bone geometry. © 2017 American Society for Bone and Mineral Research.     

The incidence and costs of bacteremia due to lack of gentamicin lock solutions for dialysis catheters

The use of antibiotic lock solutions as prophylaxis for catheter‐associated blood stream infection (CRBSI) has been shown to be effective in previous randomized controlled trials. However, the cost‐effectiveness of this approach had not been studied. In 2012, the routine gentamicin‐heparin lock solution used in Auckland City Hospital was withdrawn from the market, leading to a change to heparin‐only lock. This was then replaced with gentamicin‐citrate lock in 2014. This situation allowed review of the CRBSI rate and financial impact of different catheter lock solutions. A retrospective audit was performed from 1 January 2011 to 31 December 2015 to investigate the rate of culture‐proven CRBSI in patients with tunneled cuffed dialysis catheters. There were 89 cases of CRBSI involving 64 patients in the 5‐year period. In comparison with the heparin‐only lock, both gentamicin‐heparin and gentamicin‐citrate locks had a significantly lower rate of bacteremia, with rate ratios of 0.46 (confidence interval 0.30‐0.72) and 0.11 (confidence interval 0.05‐0.22), respectively. The inpatient costs as a consequence of the CRBSI were NZ$27 792 per 1000 catheter days for heparin‐only lock, NZ$10 608.56 per 1000 catheter days for gentamicin‐heparin lock, and NZ$ 1898.45 per 1000 catheter days for gentamicin‐citrate lock. The lack of antibiotic lock solutions led to an increase in bacteremia rates and higher financial cost for inpatient management of bacteremia. Our findings highlight the importance of consistent supply of pharmaceuticals.     

Femoral Implant Design Modification Decreases the Incidence of Patellar Crepitus in Total Knee Arthroplasty

Background

Patellar crepitus is a complication most commonly seen in patients implanted with a posterior-stabilized total knee arthroplasty (TKA). Recently, design changes in the patellofemoral geometry and the intercondylar box ratio have been optimized in newer TKA designs. A comparative study was performed to analyze the incidence of patellar crepitus between a historical vs modern TKA design.

Authorship Trends in 30 Years of the Journal of Arthroplasty

Background

While various studies have investigated trends in characteristics of authors in other medical literature, no study has examined these characteristics in the field of arthroplasty.

Combining immunotherapies for the treatment of prostate cancer

Sipuleucel-T, a therapeutic dendritic-cell vaccine, was Food and Drug Administration–approved for prostate cancer in 2010. No new immunotherapies for prostate cancer have been approved since. However, novel agents and combination approaches offer great promise for improving outcomes for prostate cancer patients. Here we review the latest developments in immunotherapy for prostate cancer. Sipuleucel-T has demonstrated a survival advantage of 4.1 months in metastatic castration-resistant prostate cancer. PSA-TRICOM (PROSTVAC), a prostate-specific antigen–targeted vaccine platform, showed evidence of clinical and immunologic efficacy in early-phase clinical trials, and results from a phase III trial in advanced disease are pending. While immune checkpoint inhibitors appear to have modest activity as monotherapy, preclinical and clinical data suggest that they may synergize with vaccines, poly [ADP-ribose] polymerase inhibitors, and other agents. Several clinical studies that combine these therapies are underway.Combining prostate cancer vaccines with immune checkpoint inhibitors has great potential for improving clinical outcomes in prostate cancer. Such combination approaches may create and then recruit tumor-specific T cells to tumor while also increasing their effector function. Other emerging agents may also enhance immune-mediated tumor destruction.     

What Are the Benefits of Hip Resurfacing in Appropriate Patients? A Retrospective,Propensity Score-Matched Analysis

Background

Hip arthritis is one of the major causes of disability worldwide. Hip resurfacing arthroplasty (HRA) has emerged in recent years as an alternative to total hip arthroplasty (THA), but complications of HRA have limited the patient population to younger male patients with primary osteoarthritis and large hip anatomy. How the functional benefits of HRA in this population compare with those of THA is not entirely clear.

Questions/Purposes

The primary aim of this study was to determine whether there were differences in hip disability and patient satisfaction with surgery between these two groups at 2 years after surgery, using patient-reported outcome measures (PROMs) and subjective measures of patient satisfaction. Additionally, we sought to determine whether there were differences in post-operative discharge disposition, revision rates, or adverse events.

Methods

We searched an institutional database to identify patients undergoing unilateral HRA or THA between January 2007 and July 2011 who met today’s recommended criteria for HRA: younger male patients with large-enough hip anatomy to make surgery viable (a femoral head of at least 48 mm in HRA patients and, in THA patients, an acetabular shell size of 54 mm, the minimum outer shell size that could accommodate a femoral head component of 48 mm; for matching purposes, acetabular shell size in THA was used as a surrogate for the femoral head size used in HRA). We used propensity score matching to control for potentially confounding pre-operative variables and administered the Hip Disability and Osteoarthritis Outcome Score (HOOS) survey, including its subdomains, at the 2-year mark. We also assessed differences between groups in Lower Extremity Activity Scale scores, 12-item Short Form Health Survey results, and answers regarding satisfaction with surgery. We calculated minimal detectable change, minimum clinically important change, and substantial clinical benefit using anchor-based techniques for multiple outcome measures.

Results

There were 251 patients in each group. HRA patients scored significantly higher than THA patients on the 2-year HOOS sports and recreation (92 versus 87, respectively) and on rates of overall satisfaction (94% versus 89%, respectively). The HRA group also had a greater chance of achieving minimum clinically important change (18.75 points) in the HOOS sports and recreation subdomains than the THA group (97% versus 91%). No significant difference was found in 6-month adverse event rates. HRA patients also had a significantly shorter mean hospital stay, a higher rate of discharge to home, and a lower incidence of a “significant” limp after surgery.

Conclusion

HRA may provide a functional benefit in sports and recreation and greater satisfaction in patients who meet the current criteria for HRA. Because these benefits may be small, pre-operative counseling should focus on balancing the possible functional benefits against the longer-term risks associated with metal-on-metal bearings.

     

Using Session RPE to Monitor Different Methods of Resistance Exercise

The purpose of this study was to compare session rating of perceived exertion for different resistance training techniques in the squat exercise. These techniques included traditional resistance training, super slow, and maximal power training. Fourteen college-age women (Mean ± SD; age = 22 ± 3 years; height = 1.68 ± 0. 07 m) completed three experimental trials in a randomized crossover design. The traditional resistance training protocol consisted of 6 sets of 6 repetitions of squats using 80% of 1-RM. The super slow protocol consisted of 6 sets of 6 repetitions using 55% of 1-RM. The maximal power protocol consisted of 6 sets of 6 repetitions using 30% of 1-RM. Rating of perceived exertion (RPE) measures were obtained following each set using Borg’s CR-10 scale. In addition, a session RPE value was obtained 30 minutes following each exercise session. When comparing average RPE and session RPE, no significant difference was found. However, power training had significantly lower (p < 0.05) average and session RPE (4.50 ± 1.9 and 4.5 ± 2.1) compared to both super slow training (7.81 ± 1.75 and 7.43 ± 1.73) and traditional training (7.33 ± 1.52 and 7.13 ± 1.73). The results indicate that session RPE values are not significantly different from the more traditional methods of measuring RPE during exercise bouts. It does appear that the resistance training mode that is used results in differences in perceived exertion that does not relate directly to the loading that is used. Using session RPE provides practitioners with the same information about perceived exertion as the traditional RPE measures. Taking a single measure following a training session would appear to be much easier than using multiple measures of RPE throughout a resistance training workout. However, practitioners should also be aware that the RPE does not directly relate to the relative intensity used and appears to be dependent on the mode of resistance exercise that is used.

Key Points

• The present study showed that session RPE values are not significantly different from the more traditional methods of measuring RPE during exercise bouts.
• Power training had significantly lower average and session RPE compared to both super slow training and traditional training
• It does appear that the resistance training mode that is used results in differences in perceived exertion that does not relate directly to the loading that is used.

Key words: Weight lifting, non-traditional resistance training