Operative management was the optimal strategy, given the outcome probabilities and patient utilities we studied. Nonoperative management was favored by increasing rates of operative complications; operative, by decreasing utility of rerupture. We advocate a model of doctor-patient shared decision-making in which both outcome probabilities and patient preferences are considered.

We evaluated reproductive function in 27 male long-term survivors of childhood cancer treated during the prepubertal and pubertal period. Sperm samples were obtained from 23 patients; four who refused to provide specimens indicated that they had fathered normal healthy children. Thirteen patients were 12 years old or younger at the time of diagnosis and initiation of therapy. Chemotherapy was calculated according to the cumulative amount of drug administered and correlated with the surface area. Sterility was associated with large doses of single alkylating agents or reduced doses administered with other agents in combination regimens. It was noted in boys treated in both the prepubertal and pubertal period. Sterility was also observed in patients who received testicular radiation alone or in combination with chemotherapy. However, it was not an inevitable consequence in all patients, despite treatment with similar or identical regimens. Fertility potential could not be predicted by clinical examination (testicular size) or gonadotrophin and testosterone values. The results were compared to published reports of treatment-induced sterility in adult males. Additional investigations are required to establish more accurate correlations of dosage with reproductive potential.

Background The phase III FLAURA2 (NCT04035486) study will evaluate efficacy and safety of first-line osimertinib with platinum–pemetrexed chemotherapy versus osimertinib monotherapy in epidermal growth factor receptor mutation-positive (EGFRm) advanced/metastatic non-small-cell lung cancer (NSCLC). The safety run-in, reported here, assessed the safety and tolerability of osimertinib with chemotherapy prior to the randomized phase III evaluation. Patients and methods Patients (≥18 years; Japan: ≥20 years) with EGFRm locally advanced/metastatic NSCLC received oral osimertinib 80 mg once daily (QD), with either intravenous (IV) cisplatin 75 mg/m 2 or IV carboplatin target area under the curve 5, plus pemetrexed 500 mg/m 2 every 3 weeks (Q3W) for four cycles. Maintenance was osimertinib 80 mg QD with pemetrexed 500 mg/m 2 Q3W until progression/discontinuation. The primary objective was to evaluate safety and tolerability of the osimertinib–chemotherapy combination. Results Thirty patients (15 per group) received treatment [Asian, 73%; female, 63%; median age (range) 61 (45-84) years]. Adverse events (AEs) were reported by 27 patients (90%): osimertinib–carboplatin–pemetrexed, 100%; osimertinib–cisplatin–pemetrexed, 80%. Most common AEs were constipation (60%) with osimertinib–carboplatin–pemetrexed and nausea (60%) with osimertinib–cisplatin–pemetrexed. In both groups, 20% of patients reported serious AEs. No specific pattern of AEs leading to dose modifications/discontinuations was observed; one patient discontinued all study treatments including osimertinib due to pneumonitis (study-specific discontinuation criterion). Hematologic toxicities were as expected and manageable. Conclusions Osimertinib–chemotherapy combination had a manageable safety and tolerability profile in EGFRm advanced/metastatic NSCLC, supporting further assessment in the FLAURA2 randomized phase.

Tracheotomy in super obese patients is a safe and effective strategy for airway management. Critically ill, super obese patients have a high likelihood of remaining dependent on a tracheotomy or ventilator at the time of discharge.

Crohn’s disease and ulcerative colitis are the primary inflammatory bowel diseases (IBDs) affecting the gastrointestinal tract. The current therapy aims at decreasing inflammation and reducing symptoms. This typically requires immune suppression by steroids, thiopurines, methotrexate, or tumor necrosis factor inhibitors. Patients may be unreceptive to medical therapy, and some may discontinue the treatment due to adverse effects. Noninvasive, transcutaneous vagus nerve stimulation (VNS) is currently used as a treatment for depression and epilepsy, and it is being investigated for the treatment of conditions such as multiple sclerosis, migraines, and Alzheimer’s disease. Recent studies have demonstrated the importance of splenic and vagus nerve functions in the inflammatory process through the production of certain cytokines. We hypothesize that using transcutaneous VNS via the auricular afferent branch could achieve a selective anti-inflammatory effect on the intestinal wall. This review examines the possibility of using vagal stimulators as a therapy for IBD. This could open the door to novel treatments for numerous vagally mediated diseases characterized by poor responses to current therapies.

The objective of this study was to create a standardized regimen for preoperative and postoperative analgesic prescribing patterns in rhinoplasty. A prospective study including patients (n = 35) undergoing rhinoplasty by a single surgeon at a tertiary hospital was conducted. Patients were enrolled in this study from August 2018 to November 2019. Patients then completed a diary documenting pain scores and analgesic use for 14 days postoperatively. Patient demographics, complications, rhinoplasty technique performed, and medical history were noted. At the second postoperative clinic visit, the diaries were submitted and pill counts were conducted to ensure accuracy. A total of 23 patients completed this study. The average age of the cohort was 39.07 ± 15.01 years, and 48% were females. The mean number of opioids consumed was 6.15 ± 4.85 pills (range: 0–18). Females consumed an average of 7.2 ± 5.2 pills and males consumed 4.5 ± 3.96 pills. The mean number of acetaminophen and ibuprofen tablets consumed were 7.48 ± 8.52 pills (range: 0–36) and 10.83 ± 10.99 pills (range 0–39), respectively. No postoperative nosebleeds were reported. Males had significantly higher pain scores than females on postoperative days 1 to 8. The mean pain score for postoperative days 8 to 14 was less than 1. Linear regression analysis showed that there was no association between the rhinoplasty technique used and the number of opioids consumed. Rhinoplasty is typically associated with mild pain even when osteotomies are included with the procedure. Our results suggest that surgeons can limit rhinoplasty opioid prescriptions to around seven pills and achieve sufficient pain control in most patients. Preoperative counseling suggesting a low postoperative pain level and the encouragement of nonsteroidal anti-inflammatory drug use will help reduce the risk and misuse of opioid prescriptions.

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Objectives Our study aims to examine the correlation between preoperative ultrasound‐guided fine‐needle aspiration and intraoperative frozen section and examine the clinical benefit of frozen section in the context of the latest national guidelines on the management of differentiated thyroid cancer. Study Design A retrospective review of thyroid frozen section from 2012 to2017 at one institution. Setting Tertiary care centre. Participants/Main Outcome Patient demographics, fine‐needle aspiration results, molecular testing results, frozen section diagnosis (classified as benign, indeterminate, or malignant), final pathologic diagnosis, initial planned surgery, actual surgery performed, need for additional surgery and complications were recorded. Complications included hematoma formation, hypocalcaemia (requiring readmission, symptomatic, or >24‐hour stay post op) and recurrent or superior laryngeal nerve damage. Results 728 total patients had an intraoperative frozen section performed. A Thy 4/Bethesda V USGFNA diagnosis (n = 55) significantly correlated with a clinically important intraoperative frozen section (n = 17, P < .01). Intraoperative management was changed by the frozen section 53 times (7.2%). Molecular testing was sent on 92 USGFNA specimens, 80 of which were deemed "suspicious." Of the 49 patients whose management was upstaged intraoperatively, 29 (59%) would not necessitate a completion thyroidectomy under the latest UK and ATA guidelines based on final pathology. Conclusion Intraoperative frozen sections rarely alter the pre‐surgical plan and indeed may result in expanded surgery that could have been avoided based on latest UK and US guidelines. Molecular testing of indeterminate fine‐needle aspiration results does not appear to predict meaningful intraoperative frozen section results.