(NCCN) guidelines recommend routine clinical follow-up as posttreatment surveillance for patients with head and neck cancer (HNC). Human papillomavirus-associated oropharyngeal squamous cell carcinoma (HPV-associated OPSCC) is a unique subset of HNC, associated with fewer recurrences and improved survival. The utility of this guideline in this patient population is unknown. OBJECTIVE To determine adherence to the NCCN clinical follow-up guideline, frequency of recurrence detection method, classified as symptom-directed, physician-detected, or imaging-detected, and survival benefit associated with adherence to the NCCN guideline. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of patients with HPV-associated OPSCC diagnosed between January 1, 2011, and April 30, 2014, at a large integrated health care system. Multivariable analyses were conducted using the Cox proportional hazards regression model, with patient adherence to NCCN visit guidelines constructed as a time-dependent variable. All data analyses were complete on September 1, 2018. EXPOSURES Posttreatment clinical and imaging surveillance. MAIN OUTCOMES AND MEASURES Recurrence and overall survival. Secondary outcome was salvage therapy. RESULTS Of the 233 study patients with HPV-associated OPSCC, the mean (SD) age at diagnosis was 60.5 (8.7) years; 201 (86.3%) were male, 189 (81.1%) were white, and 109 (46.8%) had a positive smoking history. Median follow-up time through recurrence or all-cause mortality was 4.5 years (interquartile range, 3.8-5.6). Patients demonstrated 83.0% (180 of 217) adherence to NCCN surveillance guidelines in year 1, 52.7% (106 of 201) in year 2, 73.4% (141 of 192) in year 3, 62.3% (96 of 154) in year 4, and 52.9% (45 of 85) in year 5. A total of 3358 clinical surveillance examinations were performed with 22 patients having recurrences. There were 10 symptom-directed, 1 physician-detected, and 11 imaging-detected recurrences. Of the symptom-directed recurrences, salvage therapy was attempted in 5; at the study end date, 1 was alive. Salvage neck dissection was attempted in the physician-detected recurrence; this patient subsequently died. All locoregional recurrences occurred within the first 2 years, and all salvageable recurrences within the first year. Adherence to NCCN guidelines was not protective against all-cause mortality in the multivariable Cox proportional hazards regression model (hazard ratio, 0.76; 95% CI, 0.28-2.05). CONCLUSIONS AND RELEVANCE Among patients with HPV-associated OPSCC, clinical surveillance is of limited utility. Nearly all clinically detected recurrences were elicited by patient symptoms that prompted earlier presentation to the clinician. Adherence to the current schedule does not appear to confer survival advantage, and locoregional recurrences are almost never detected beyond 2 years. These findings support reduction of posttreatment clinical surveillance in this population.

Background Surveillance positron emission tomography‐computed tomography (PET/CT) is commonly used for treatment assessment of radiation therapy in head and neck cancer. However, human papillomavirus‐associated oropharyngeal squamous cell carcinoma (HPV+OPSCC) patients represent a unique subpopulation, for which the utility of surveillance PET/CT has not been well studied. Methods In this retrospective chart review comprising 233 HPV+OPSCC patients, we evaluated surveillance PET/CT for diagnostic accuracy, downstream clinical impact, and survival. Results Surveillance PET/CT demonstrated 100% negative predictive value and sensitivity, 59.9% specificity, and 13.4% positive predictive value. Surveillance PET/CT led to 90 imaging studies and 31 biopsies; 91.1% and 77.4% were negative for recurrence, respectively. Surveillance PET/CT led to meaningful salvage therapy in 1.6% of cases. PET/CT‐detected recurrences did not have improved survival compared to clinically detected recurrences. Conclusion For HPV+OPSCC patients, surveillance PET/CTs frequently lead to unnecessary testing and rarely to meaningful disease salvage. They have no demonstrated survival benefit and should be interpreted cautiously to prevent patient harm.

According to data reported by the American Heart Association, more than 5 million diagnostic and therapeutic catheterizations are performed each year in the United States. The number of catheterizations has tripled since 1979. It has been estimated that complications related to the access site result in more than 75,000 surgical procedures annually. Thus, improved management of the access site itself is essential to achieve the greater goals of improved care and reduced cost. Manual compression directly over the site of arterial puncture usually results in adequate hemostasis but has several significant drawbacks. Manual compression is uncomfortable for the patient, is fatiguing and time-consuming for staff, and necessitates several hours of costly in-hospital observation. In addition, it may be ineffective in achieving hemostasis, especially in the setting of systemic anticoagulation or following the use of large-bore devices. Based on the perceived need for an improved method of managing the arterial access site following catheterization, various vascular sealing devices have been developed. There are at least 8 (and the number is increasing) hemostatic vascular closure devices that are currently approved by the FDA for access site closure after femoral arterial catheterization. The chief advantage attributed to vascular sealing devices is accelerated access site hemostasis, even in the setting of anticoagulation, leading to earlier ambulation and hospital discharge following arterial catheterization. The most important drawbacks related to vascular sealing devices include the cost of the devices and the possibility of increased access site complications. Despite the paucity of properly designed studies supporting their use, it is estimated that over one million vascular sealing devices are used annually in the United States, a number that has increased dramatically in the past 5 years.In this review, we present a brief description of the design and function of the most widely used devices, describe the most common mechanisms of failure, and recommend strategies for management of access site complications including hemorrhage, arterial obstruction, and infection.

4. Laryngoscope, 1867-1873, 2018.

No abstract

The authors identified 1,800,948 patients who made 2,326,701 health care encounters eligible for HIV testing before implementation (1/08-6/12) and 1,362,479 eligible encounters after implementation (1/13-6/15). The sameday HIV testing rate increased from 36.7% to 44.1%, a significant increase. The positive test result rate increased from 0.02% to 0.04% (p < 0.001). During the postimplementation period, fewer HIVinfected patients had a CD4+ cell count below 200 and/or HIV viral load of 10,000 copies/mL or higher at diagnosis.

No abstract

Objectives Comparisons of induction chemotherapy (IC) against upfront chemoradiation (CRT) for locally advanced head and neck cancer (LA-HNSCC) have demonstrated no differences except greater toxicity with IC. Effective induction regimens that are less toxic are therefore warranted. To inform future efforts with IC, we present our institutional experience comparing a less toxic IC regimen to CRT. Methods We included patients with LA-HNSCC treated with organ-preservation CRT (+/− induction) between 2008–2011. Patients were age >18, ECOG performance status 0–1, and minimum 6 months follow-up. IC consisted of 8 weekly cycles of cetuximab, carboplatin, and paclitaxel followed by CRT. The CRT regimen was platinum-based, with cetuximab reserved for patients contraindicated to receive platinum. Results Of 118 patients, 24 (20%) received IC and 94 (80%) received CRT. Median follow-up was 17 (IC) and 19 (CRT) months (p=0.05). There were no differences in toxicity between the groups. IC patients were more likely male, with more advanced tumor and nodal stage. Even when controlling for these factors, IC was still associated with worse locoregional control (LRC) (HR 3.6 p=0.02), distant-metastasis free survival (HR 5.3, p=0.02), and overall survival (OS) (HR 5.1. p < 0.01). Conclusions IC patients had greater disease burden than those receiving CRT. IC was well-tolerated, but with significant rates of locoregional and systemic failures. Given the retrospective nature of the study, our findings are not meant to be definitive or conclusive, but rather suggestive in directing future efforts with IC. For now, we favor CRT as the standard option for treatment of inoperable LA-HNSCC.