Nonopioid perioperative analgesia in head and neck cancer surgery: A systematic review

ObjectiveManagement of postoperative pain after head and neck cancer surgery is a complex issue, requiring a careful balance of analgesic properties and side effects. The objective of this review is to discuss the efficacy and safety of multimodal analgesia (MMA) for these patients.MethodsPubmed, Cochrane, Embase, Scopus, and clinicaltrials.gov were systematically searched for all comparative studies of patients receiving MMA (nonsteroidal anti‐inflammatory drugs (NSAIDs), acetaminophen, anticonvulsants, local anesthetics, and corticosteroids) for head and neck cancer surgeries. The primary outcome was additional postoperative opioid usage, and secondary outcomes included subjective pain scores, complications, adverse effects, and 30‐day outcomes.ResultsA total of five studies representing 592 patients (MMA, n = 275; non‐MMA, n = 317) met inclusion criteria. The most commonly used agents were gabapentin, NSAIDs, and acetaminophen (n = 221), NSAIDs (n = 221), followed by corticosteroids (n = 35), dextromethorphan (n = 40), and local nerve block (n = 19). Four studies described a significant decrease in overall postoperative narcotic usage with two studies reporting a significant decrease in hospital time. Subjective pain scores widely varied with two studies reporting reduced pain at postoperative day 3. There were no differences in surgical outcomes, medical complications, adverse effects, or 30‐day mortality and readmission rates.ConclusionMMA is an increasingly popular strategy that may reduce dependence on opioids for the treatment of postoperative pain. A variety of regimens and protocols are available for providers to utilize in the appropriate head and neck cancer patient.     

护士长领导力现状及培训需求调查分析

目的 了解某二级甲等医院护士长领导力现状及培训需求情况,以采取针对性的改进措施。方法 采用护士长领导力测量表和护士长培训方式、培训项目需求量表,全院318名护士对21名护士长进行领导力问卷调查,同时对21名护士长进培训方式和培训项目需求问卷调查。结果 护士长职称与任职年限对于护士长领导力的14项评价指标的影响没有统计学上的意义,而护士长年龄> 36岁的各项评价指标平均值大于年龄≤35岁的平均值,原始学历是本科及以上各项指标的平均值大于大专及以下学历的平均值,有统计学上的意义,说明原始学历与领导力呈正相关。护士长喜欢案例分析等实战性培训方式,迫切需要接受的培训项目与护士长领导力的各项指标相关。结论 在选拔护士长任职资格,分层次培训,以新护士长进行导师制培养,做好后备护士长的选拔等方面采取针对性的措施。     

Immune checkpoint inhibitors in head and neck squamous cell carcinoma: A systematic review of phase-3 clinical trials

BACKGROUNDThe outcomes of patients diagnosed with head and neck squamous cell carcinoma (HNSCC) who are not candidates for local salvage therapy and of those diagnosed with recurrent or metastatic disease are dismal. A relatively new systemic therapy option that emerged in recent years in the treatment of advanced HNSCC is immunotherapy using immune checkpoint inhibitors (ICIs). The safety profile and anti-tumor activity of these agents demonstrated in early phase clinical trials paved the way to the initiation of several promising phase-3 trials in the field.AIMTo evaluate the evidence on the effectiveness of ICIs in HNSCC, based on published phase-3 clinical trials.METHODSWe searched PubMed, Cochrane Library, Embase, and Scopus to identify published literature evaluating immunotherapy using ICIs in recurrent or metastatic HNSCC (R/M HNSCC) and locally advanced head and neck squamous cell carcinoma (LAHNSCC). We used a combination of standardized search terms and keywords including head and neck squamous cell carcinoma, recurrent, metastatic, locally advanced, immunotherapy, immune checkpoint inhibitors, monoclonal antibodies, programmed cell death protein-1 (PD-1), programmed death-ligand 1 (PD-L1), cytotoxic T- lymphocyte associated protein-4 (CTLA-4), and phase-3 clinical trial. A sensitive search filter was used to limit our results to randomized controlled trials.RESULTSFive phase-3 clinical trials have reported the data on the effectiveness of immunotherapy in HNSCC so far: Four in R/M HNSCC and one in LAHNSCC. In patients with R/M HNSCC, anti-PD-1 agents nivolumab and pembrolizumab demonstrated improved survival benefits in the second-line treatment setting compared to the standard of care (standard single-agent systemic therapy). While the net gain in overall survival (OS) with nivolumab was 2.4 mo [hazard ratio (HR) = 0.69, P = 0.01], that with pembrolizumab was 1.5 mo (HR = 0.80 nominal P = 0.0161). The anti-PD-L1 agent durvalumab with or without the anti-cytotoxic T- lymphocyte associated protein-4 agent tremelimumab did not result in any beneficial outcomes. In the first-line setting, in R/M HNSCC, pembrolizumab plus platinum-based chemotherapy resulted in significant improvement in survival with a net gain in OS of 2.3 mo (HR = 0.77, P = 0.0034) in the overall population and a net gain in OS of 4.2 mo in the PD-L1 positive (combined positive score > 20) population compared to standard of care (EXTREME regime). In patients with PD-L1 positive R/M HNSCC, monotherapy with pembrolizumab also demonstrated statistically significant improvement in survival compared to EXTREME. In LAHNSCC, immunotherapy using avelumab (an anti-PD-L1 agent) along with standard chemoradiation therapy did not result in improved outcomes compared to placebo plus chemoradiation therapy.CONCLUSIONAnti-PD-1 agents provide survival benefits in R/M HNSCC in the first and second-line settings, with acceptable toxicity profiles compared to standard therapy. There is no proven efficacy in the curative setting to date.     

Implications of Crop Rotation and Fungicide on Fusarium and Mycotoxin Spectra in Manitoba Barley, 2017–2019

Fusarium head blight (FHB) is one of the most important diseases of barley in Manitoba province (western Canada), and other major barley producing regions of the world. Little is known about the Fusarium species and mycotoxin spectra associated with FHB of barley in Manitoba. Hence, barley grain samples were collected from 149 commercial fields from 2017 to 2019, along with information on respective cropping history, and analyzed with respect to Fusarium species spectra, abundance, chemotype composition, and mycotoxin profiles. Fusarium poae was the predominant Fusarium species associated with FHB of barley in Manitoba, followed by F. graminearum, and F. sporotrichioides; F. equiseti and F. avenaceum were also detected but at low levels. F. poae strains with the nivalenol (NIV) chemotype and F. graminearum strains with 3-acetyl deoxynivalenol (3-ADON) and 15-acetyl deoxynivalenol (15-ADON) chemotypes were commonly detected in the barley grain samples. Nivalenol (597.7, 219.1, and 412.4 µg kg⁻¹) and deoxynivalenol (DON) (264.7, 56.7, and 65.3 µg kg⁻¹) were the two most prevalent mycotoxins contaminating Manitoba barley in 2017, 2018 and 2019, respectively. A substantially higher DON content was detected in grain samples from barley fields with cereals as a preceding crop compared to canola and flax. Furthermore, F. poae proved less sensitive to four triazole fungicides (metconazole, prothioconazole+tebuconazole, tebuconazole, and prothioconazole) than F. graminearum. Findings from this research will assist barley producers with improved understanding of FHB threat levels and optimizing practices for the best management of FHB in barley.     

介入治疗激素性股骨头坏死的实验研究

目的评价介入治疗股骨头坏死的可行性。材料与方法采用中国白兔２０只，随机分成３组。Ａ组为注射激素组，Ｂ组为注射激素后进行介入治疗组，Ｃ组为对照组。介入治疗是将溶栓药物、扩血管药物及改善微循环药物直接注入股骨头供血动脉。对股骨头进行Ｘ线摄片和显微镜观察，研究股骨头的Ｘ线平片表现及病理变化。结果Ｂ组股骨头空缺的骨陷窝数及骨髓腔内脂肪细胞平均直径虽没达到正常水平，但有明显的改善，软骨下区血管数目基本达到正常，血管直径明显增大，Ｘ线平片可见股骨头明显修复。结论通过介入方法治疗股骨头坏死是一种能在临床上广泛应用的新方法。     

高血糖对中重型颅脑损伤患者预后的影响

目的了解高血糖与颅脑损伤严重程度之间的关系以及控制血糖对颅脑损伤预后的影响。方法我们前瞻性地研究了146例中重型颅脑损伤患者(格拉斯哥昏迷评分GCS3~12分)的血糖,并将血糖高于11.1mmol/L的患者随机分为两组,一组接受强化胰岛素治疗,将血糖控制在6.11mmol/L以下,另一组不接受胰岛治疗,以明确血糖水平同损伤严重程度之间的关系以及控制血糖对预后的影响。结果重型颅脑损伤患者的血糖水平明显高于中型颅脑损伤患者,并且颅内压水平同血糖水平显著相关。同血糖水平高于11.1mmol/L的患者相比,血糖控制在6.11mmol/L以下的患者预后明显改善。结论早期高血糖是颅脑损伤后应激反应的一个组成部分,是预测损伤严重度的一个重要指标,控制血糖可改善颅脑损伤患者的预后。     

重型颅脑损伤病人的临床评估

对６８例重型脑外伤患者的评分和预后评估进行分析，提出以重型脑外伤病人的血压、脉搏、呼吸、神智（ＧＣＳ）、瞳孔５项指标作为评估指数进行评分（简称重型脑外伤评估指数），总分为２５分，最低分５分。结果表明：评分在７分以下，持续２～４ｈ者，抢救意义不大；８～１３分，抢救４～６ｈ无效者，其死亡、残废率很高；计分在１４分以上者，有抢救意义，尤以１８分以上者，抢救意义明显增大