Level IIb Research Articles

In Reply: Patients Who Benefit From Intracranial Pressure Monitoring Without Cerebrospinal Fluid Drainage After Severe Traumatic Brain Injury.

To the Editor: This is in response to letter to editor1 for article by Lele et al.2 The fourth edition of the Brain Trauma Foundation (BTF) guidelines3 provides level IIB evidence and recommends intracranial pressure (ICP) monitoring in patients with severe traumatic rain injury (TBI) to reduce in-hospital and 2-wk postinjury mortality. The previous edition of the BTF guidelines to which the present study is in temporal relationship recommended monitoring in all salvageable patients with a severe TBI and abnormal computed tomography (CT) scan (hematomas, contusions, swelling, herniation, or compressed basal cisterns) or normal CT scan and either age over 40 yr, unilateral or bilateral motor posturing, or systolic blood pressure (BP) < 90 mm Hg.4,5 Compliance with BTF guidelines and their impact on outcomes has been described by Alali et al,6 who demonstrated that ICP monitor placement is not routine in all severe TBI patients and that there is variation between institutions in proportion of severe TBI patients who receive ICP monitoring, but seems that those who do receive monitoring seem to experience lower mortality. Our study2 reflects real-life clinical management of patients with severe TBI, outside of any protocolized study model. The variability in critical care in severe TBI is in fact individualized care based on characteristics and demands. Abnormalities on CT may be present in isolation or may co-exist in a patient; thus, individualizing ICP monitoring to particular patient depending upon clinical and radiographic abnormalities perhaps is certainly a more practical approach. We believe that an “ICP number” should not be used in isolation when making clinical decision. Neurological trajectories and CT imaging findings may be taken into consideration prior to making the decision to place ICP monitor. However, medical and or surgical decisions may not necessarily have to wait for ICP monitoring data if CT imaging demonstrates signs associated with elevated intracranial hypertension and clinical examination corroborates. In these circumstances, having an ICP monitor allows clinicians to appreciate response to medical intervention and trend ICP over time. Multimodal physiological monitoring data points such as trends in ICP values, cerebral perfusion pressure, brain tissue oxygenation/jugular oxygenation, or microdialysis may also be valuable and may be taken into consideration to appropriately escalate the level of therapeutic intensity. However, not all of these technologies are widely available worldwide, and some still used for research purposes only. Thus, care of severe TBI patient must be individualized using the best available level of evidence within the constraints of prevailing resources. We agree that future studies examining the association between ICP monitoring and clinical outcomes must use methodological rigor as was used in our study and account for the heterogeneity in clinical and radiographic abnormalities. Disclosures Funding was from NINDS 5R21NS077444-02 (M.S.V.) and Department of Biotechnology DBT N-1349 (Mahapatra/D.G.). The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

Surgical Resection for Primary Central Nervous System Lymphoma: A Systematic Review

Primary central nervous system lymphomas (PCNSLs) account for 1%-2% of primary central nervous system tumors. Until recently, treatment has centered on biopsy, radiotherapy, and high-dose methotrexate, without a clear role for cytoreductive surgery. The objective of this article is to compare the impact of biopsy versus cytoreductive surgery in outcomes of patients with PCNSL, including postoperative complications and survival. We performed a systematic review of literature published from January 1, 1968 to May 2, 2018 related to PCNSL treatment in patients undergoing biopsy or resection. Data on morbidity, progression-free survival, and overall survival were extracted and analyzed. A total of 1291 nonduplicate citations were identified, with 244 articles selected for full-text review. Twenty-four articles were included for data abstraction including 2 level IIb studies, 4 level IIIb studies, and the remaining 18 articles representing level IVb studies. Of these articles, 15 failed to show benefit with cytoreductive surgery; most of these articles included relatively small sample sizes and predated standardization of high-dose systemic methotrexate treatment. Larger, more recent series included 9 articles providing evidence in support of cytoreductive surgery. Patient age, functional status, and treatment with chemotherapy and/or radiation were associated with improved survival across studies. The treatment of PCNSL is challenging and ever-evolving. Earlier, smaller studies failed to show the benefit of cytoreductive surgery over biopsy in patients with PCNSL. Larger, more recent series seem to show the possible benefit of cytoreductive surgery in PCNSL. Future well-designed prospective studies may help further elucidate the role of resection in the modern treatment of PCNSL.

The role of elective neck dissection for cT4aN0 glottic squamous cell carcinoma.

The indication for elective neck dissection for patients with clinically T4aN0 (cT4aN0) glottic cancer is not established. The objective of this study was to evaluate the role of elective neck dissection for patients with cT4aN0 glottic cancer. We assessed patients with cT4aN0 laryngeal squamous cell carcinoma who underwent total laryngectomy between 1998 and 2014 and conducted a retrospective analysis. We considered occult neck metastasis positive when confirmed by histological analysis. When patients with late neck metastases did not undergo therapeutic neck dissection, the presence of occult neck metastasis was judged on the basis of computed tomography. The validity of elective neck dissection for patients with cT4aN0 glottic cancer was assessed from comparisons the rates of occult neck metastases of supraglottic and subglottic cancers, which are generally recommended for elective neck dissection. The distribution of occult neck metastases in glottic cancer is described according to nodal levels. The rate of occult neck metastasis of cT4aN0 laryngeal cancer was 36% (14/39). There were no significant differences among the rates of glottic 7/21 (33%), supraglottic 3/8 (38%) and subglottic 4/10 (40%) cancers. Patients with glottic cancer did not have bilateral Level IIB and ipsilateral Level IV metastasis. One patient had contralateral Level IV metastasis. The metastases rates of ipsilateral Levels IIA, III, and VI were >10%. We think that elective neck dissection is valid for cT4aN0 glottic cancer. Ipsilateral Levels IIA, III and VI should be dissected. The omission of neck dissection for bilateral Levels IIB and IV can be considered when there is a need to avoid complications.

Abstract P3-11-03: Validation of CIN4 in the DBCG 89D clinical cohort

Abstract Background: Chromosome instability (CIN) in solid tumours is associated with poor prognosis and results in numerical and structural chromosomal aberrations. Our group previously have developed the CIN signatures and have demonstrated the CIN signatures as prognostic biomarkers in breast cancer cohorts. Furthermore, our work in the BR9601 and MA.5 clinical cohorts CIN4 provided level IIB evidence that CIN4 was predictive of anthracycline sensitivity. An analysis of the DBCG 89D clinical trial was now performed to validate the role of CIN gene expression signatures as a marker of anthracycline sensitivity. Methods: RNA was extracted from patients in DBCG 89D clinical trial analysed through NanoString technology. The prognostic and predictive values of the signatures on distant relapse-free survival (DRFS) were explored using Cox proportional hazard models. Multivariate models included menopausal status, tumour size, nodal status, ER and Her2 status, histological type and grade, and treatment regimen. Results: All of the 594 samples available from the DBCG 89D we successfully analysed. CIN25 and CIN70 gene expression signatures did not associate with any of the clinicopathological characteristics tested. In addition, CIN25 and CIN70 were not prognostic or predictive of distant relapse free or breast cancer specific survival in this clinical cohort. Low CIN4 score was associated with ER negativity (p=0.02), HER2 normal expression (p&amp;lt;0.05). Conclusion: In this study we demonstrated that CIN4 was associated with aggressive disease. We were however in DBCG 89D unable to validate the predictive value of CIN4 concerning anthracycline sensitivity. Citation Format: Spears M, Jensen M-B, Lyttle N, Liao L, Laenkholm A-V, Ejitlertsen B, Bartlett JM. Validation of CIN4 in the DBCG 89D clinical cohort [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-11-03.

Effects of blood flow restriction exercise on hemostasis: a systematic review of randomized and non-randomized trials.

BackgroundBlood flow restriction (BFR) exercise has shown to induce a positive influence on bone metabolism and attenuate muscle strength loss and atrophy in subjects suffering from musculoskeletal weakness. Despite the known benefits of BFR exercise, it remains unclear whether or not the pressurization of blood vessels damages the endothelial cells or increases risk for formation of thrombi. Thus, the effects of BFR exercise on coagulation, fibrinolysis, or hemostasis, remains speculative.ObjectiveThe aim of the present study was to perform a systematic review of the short and long- term effects of BFR exercise on blood hemostasis in healthy individuals and patients with known disease (ie, hypertension, diabetes, obesity, and ischemic heart disease).Data SourcesA systematic review of English and non-English articles was conducted across PubMed, Science Direct, and Google Scholar databases, including reference lists of relevant papers. Study quality assessment was evaluated using the modified version of Downs and Black checklist. Search results were limited to exercise training studies investigating the effects of BFR exercise on blood hemostasis in healthy individuals and patients with disease. Level of evidence was determined according to the criteria described by Oxford Center for Evidence-Based Medicine.Study selectionOnly randomized controlled trials (RCTs) and non-randomized controlled trials (NRCTs) that examined the effects of exercise with BFR exercise vs exercises without BFR on blood hemostasis in healthy individuals and patients were included.Data extractionNine studies were eligible (RCT =4; NRCT =5).ResultsThe average score on the Downs and Black checklist was 11.22. All studies were classified as having poor methodological quality wherein the level of evidence provided in all reviewed studies was level IIb only (ie, poor quality RCTs).ConclusionConsidering the limitations in the available evidence, firm recommendations cannot be provided.

Metastatic involvement of level IIb nodal station in oral squamous cell carcinoma: A clinicopathological study

Background:The purpose of this study was to determine the prevalence of Level IIb metastasis in patients with oral squamous cell carcinomas (OSCCs).Materials and Methods:A total of 110 newly diagnosed oral cavity cancer patients requiring surgery as the primary modality were included in the study. Preoperative clinical examinations were done and tumor-node-metastasis staging was noted. Intraoperatively, Level IIb nodal tissue was dissected and sent separately.Results:A total of 129 neck dissections (58 SOHD, 67 modified neck dissections, and 4 radical neck dissections) were carried out in 110 patients (males = 80 and females = 30), 91 patients required unilateral neck dissection, and 19 patients required bilateral neck dissection. Out of these 129 neck dissections, only 4 (3.2%) neck dissections (in a total of 3 patients out of 110 patients) had Level IIb positive (with bilateral Level IIb involvement in one patient).Conclusions:Dissection of the Level IIb region in patients with OSCC may be required only in cases with advanced N stage, positive Level IIa lymph nodes, and extracapsular spread. Furthermore, in tongue cancers (high propensity of isolated Level II involvement), retromolar trigone, and floor of mouth cancers, routine Level IIb clearance should be considered.

Frequency of Level IIb Neck Dissections for OSCC

Introduction: Selective neck dissection (SND) is the gold standard in oncological management of the neck, it enables us to reduce the morbidity of neck dissection while maintaining the same oncological results. Spinal accessory nerve dysfunction and related shoulder disability is the commonest morbidity associated with dissection of Level IIb. This study was undertaken to ascertain the frequency of undertaking Level IIb dissection and the rate of Nodal metastasis to this level.

Neck Nodes at Level IIB in Oral Cavity Carcinoma: Can We Leave Behind Visible Nodes?

Neck Nodes at Level IIB in Oral Cavity Carcinoma: Can We Leave Behind Visible Nodes?

Results of a randomized controlled trial of level IIb preserving neck dissection in clinically node-negative squamous carcinoma of the oral cavity

BackgroundThe lymphatic spread from the cancers of the oral cavity follows an orderly progression and involvement of lower nodes without involvement of upper nodes and skip metastasis is rare. Selective neck dissections are increasingly being performed for node-positive patients; however, in node-negative patients the options of wait and watch, prophylactic radiotherapy, and prophylactic elective node dissections are debated. Quality of life and shoulder functions are important to choose the appropriate therapeutic modality.Patients and methodsPatients with oral squamous carcinoma with clinically and radiologically negative neck were randomized to IIb preserving superselective neck dissection or conventional supraomohyoid neck dissection. The primary end point of the study was recurrence of disease (clinical or radiological) and shoulder function as demonstrated by the clinical examination and electromyography. The secondary end point was quality of life as measured by the FACT-HN version 4 questionnaire at the end of 1 year follow-up.ResultsThe mean number of lymph node harvested per patient was 25.6 (range 8–85). Of the 32 patients, 3 had histologically positive node in level Ib, one of these patients had single positive node while the remaining two had three positive nodes in level Ib. At median follow-up of 36 months disease-free survival in IIb, sparing group was 83% compared to 91% in control arm, the difference in survival between two groups was statistically not significant (p = 0.694). EMG of the shoulder showed denervation pattern in 45% patients undergoing IIb preserving surgery at 1 month follow-up compared to 95% in conventional surgery group, this recovered in all patients but one at 3 months and 100% recovery was seen at 6 months.ConclusionsThe results of the present study indicate that superselective IIb preserving neck dissections are technically feasible and appear to be oncologically safe procedures when performed as elective prophylactic procedures in highly select group of patients. A significant number of occult metastasis seen in the present study suggests prophylactic dissection to be better than wait and watch policy. Results also show initial higher shoulder morbidity at 1 month in patients undergoing IIb preserving dissections; however, at the end of 1 year recovery is complete and both procedures are comparable.Trial registrationThe trial is registered at clinicaltrials.gov with registration no NCT00847717; registered on February 19, 2009.

Human Papillomavirus-Associated Oropharyngeal Cancer: Patterns of Nodal Disease.

To characterize patterns of neck lymph node (LN) metastases in human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma, represented by p16 positivity (p16+OPSCC). Case series with chart review. Tertiary care center. Neck dissection (ND) specimens of nonirradiated p16+OPSCC patients were analyzed for frequencies of clinically evident and occult LNs by neck level. Local, regional, and distant recurrences were reviewed. Seventy p16+OPSCC patients underwent primary site transoral robotic surgery and 82 NDs of varying levels. Metastatic pathologic LNs were found at the following frequencies: 0% (0/28) in level I, 75.6% (62/82) in level II with 57.4% (35/61) in level IIA and 13.1% (8/61) in level IIB, 22.0% (18/82) in level III, 7.0% (5/71) in level IV, and 6.3% (1/16) in level V. The level V LN was clinically evident preoperatively. Five of 21 (23.8%) elective NDs contained occult LNs, all of which were in level II and without extranodal extension. Twenty-seven (38.6%) patients underwent adjuvant radiation; 19 (27.1%) patients underwent adjuvant chemoradiation. With a mean follow-up of 29 months, 3 patients had developed recurrences, with all but 1 patient still alive. All patients who recurred had refused at least a component of indicated adjuvant treatment. For p16+OPSCC, therapeutic NDs should encompass any levels bearing suspicious LNs and levels IIA-B, III, and IV, while elective NDs should be performed and encompass at least levels IIA-B and III. These selective ND plans, followed by indicated adjuvant treatment, are associated with a low nodal recurrence rate.

The efficacy of kinesiology taping for improving gross motor function in children with cerebral palsy: A systematic review.

BackgroundKinesiology taping is an increasingly popular technique used as an adjunct to physiotherapy intervention for children with cerebral palsy (CP), but as yet we do not have a review of the available evidence as to its efficacy.ObjectivesTo critically appraise and establish best available evidence for the efficacy of truncal application of kinesiology taping combined with physiotherapy, versus physiotherapy alone, on gross motor function (GMF) in children with CP.MethodSeven databases were searched using the terms CP, kinesio taping and/or kinesiology tape and/or taping, physiotherapy and/or physical therapy and GMF. Only randomised controlled trials (RCTs) were included and appraised using the PEDro scale. Revman© Review Manager was used to combine effects for GMF in sitting, standing and activities of daily living.ResultsFive level IIB RCTs that scored 3–6/8 on the PEDro scale were included. Meta-analysis showed that taping was effective for improving GMF in sitting and standing as measured by the Gross Motor Function Measure (B) (p < 0.001) and (D) (p < 0.001), respectively.ConclusionThere is moderate evidence to support kinesiology taping applied to the trunk as an effective intervention when used as an adjunct to physiotherapy to improve GMF in children with CP, especially those with GMF Classification Scale levels I and II, and particularly for improving sitting control.Clinical implicationsKinesiology taping is a useful adjunct to physiotherapy intervention in higher functioning children with CP. Current evidence however is weak and further research into methods of truncal application is recommended.

A prospective analysis of prevalence of metastasis in levels IIB and V neck nodes in patients with operable oral squamous cell carcinoma

ObjectivesThe present study was designed to know and analyze the prevalence of pathological involvement of level IIB and V neck nodes in operable oral cavity squamous cell carcinomas. Materials and methodsAll treatment naïve, willing biopsy proven patients of age group 18–70 years with oral cavity squamous cell carcinomas undergoing surgery from May 2015 to December 2016 in a single tertiary care Institute were prospectively analyzed for level IIb and V involvement. ResultsA total of 199 patients met the selection criteria of the study. Most common site was buccal mucosa, majority were cT2 lesions and 90% underwent Modified neck dissection. 63% of patients had pN0 disease. The rate of involvement of level II b and V nodes was 3% and was associated with higher T size, disease burden in proximal basin and lymphovascular invasion. There was no skip metastasis to level IV. Only one patient had skip metastasis to levels V and IIB each. ConclusionTo conclude our data strongly supports omission of level IIb and level V nodal dissection routinely in patients with cT1 and T2 buccal cancers. However, a randomized controlled study to evaluate the morbidity as well as recurrence pattern between the selective and super-selective approach is warranted.

Analysis of lymph node metastasis for hypopharyngeal carcinoma based on computed tomography

Objective To explore the pattern of lymph node metastasis and provide guidance for the delineation of clinical target volume for patients diagnosed with hypopharyngeal squamous cell carcinoma (HSCC). Methods A total of 123 patients who were initially diagnosed with HSCC by electrolaryngoscope and computed tomography (CT) of the head and neck in Shandong Tumor Hospital between 2014 and 2017 were recruited in this study. The lymph node metastasis was evaluated based on the diagnostic criteria of CT scan. The lymphatic metastasis ratio (LMR) at each node level was calculated. Analysis of variance (ANOVA) and χ2 test were used to analyze the relationship between LMR and primary tumors. Results Among 123 patients, primary tumors were originated from the pyriform sinus (PS) in 101 cases (82.1%), posterior pharyngeal wall (PPW) in 15(12.2%) and postcricoid (PC) in 7(5.7%), respectively. The overall LMR was calculated as 84.6%(n=104), in detail, 84.2% for patients with primary tumors originating from PS, 93.3% for those from PPW and 71.4% for patients from PC, respectively. For PS-derived tumors, the ipsilateral neck LMR at the level Ⅰa, Ⅰb, Ⅱa, Ⅱb, Ⅲ, Ⅳ, Ⅴ, Ⅵa, Ⅵb, and Ⅶ was 0, 3.0%, 66.3%, 42.6%, 46.5%, 10.9%, 5.0%, 2.0%, 7.9%, and 11.9%, respectively, and 0, 0, 14.9%, 5.0%, 3.0%, 2.0%, 0, 0, 3.0%, and 2.0% for the contralateral neck. For PPW tumors, the ipsilateral neck LMR at the level Ⅰa, Ⅰb, Ⅱa, Ⅱb, Ⅲ, Ⅳ, Ⅴ, Ⅵa, Ⅵb, and Ⅶ was 6.7%, 6.7%, 66.7%, 46.7%, 46.7%, 20.0%, 0, 13.3%, 33.3%, and 60.0%, respectively, and 6.7%, 6.7%, 33.3%, 26.7%, 20.0%, 20.0%, 0, 0, 13.3%, and 33.3% for the contralateral neck. For PC tumors, the ipsilateral neck LMR at the level Ⅱa, Ⅱb, Ⅲ, Ⅳ, Ⅴ and Ⅵb was 71.4%, 28.6%, 14.3%, 14.0%, 14.0%, and 14.3%, respectively, and the LMR at the level Ⅱa was 14.3% for the contralateral neck. No lymph node metastasis occurred in other lymph node levels. The mean levels of lymph node metastasis for the T1-T4 stage tumors were 2.4, 1.9, 2.2, 3.3 with statistical significance (P=0.023), and 2.2, 4.5 and 1.6 for patients with the tumors originated from PS, PPW and PC (P=0.000). The PPW invasion was significantly correlated with the level Ⅶ metastasis (P=0.000), and PC or esophageal invasion was intimately correlated with the level Ⅵ metastasis (P=0.002 and 0.001). Conclusions The most common lymphatic metastasis includes ipsilateral neck Ⅱa, Ⅲ, and Ⅱb, whereas the level Ⅰ and Ⅴ are rarely observed. For PPW-derived tumors, the LMR at the level Ⅶ is up to 60.0%. The incidence of PC or esophageal invasion enhances the risk of level Ⅵ lymph node metastasis. Key words: Hypopharyngeal carcinoma; Lymph node; Clinical target volume

The incidence of Sublevel IIb Lymph Nodes Metastasis in Oral Cavity Squamous Cell Carcinoma: A Prospective Study

Purpose: Lymph node metastasis has an important influence on patient survival after oral cancer. This study aimed to evaluate the incidence of metastasis to Sublevel IIb lymph nodes in patients with squamous cell carcinoma of the oral cavity. Materials and methods: Thirty patients with Oral Cavity Squamous Cell Carcinoma (SCC) were included in this study. They were selected from the out-patient clinic in the National Cancer Institute, Cairo University. All cases were subjected to surgical resection of the primary site with safety margin according to the standard protocol for each specific site. Functional neck dissection (ND) for neck lymph nodes and dissection for sublevel IIb lymph nodes were preformed separately. Histopathological examination of the specimens of the primary tumor sites, the neck lymph nodes and the level IIb lymph nodes was performed separately.Results: In all thirty neck dissections, examination of the level IIb provided a negative result, except in only one case (3.3%). This case was SCC of the tongue. The metastasis at sublevel IIb in this case was observed without metastasis at levels IIa, III or IV. Neck Lymph node metastasis was found in 53.3% of the patients who underwent therapeutic neck dissection for oral SCC. Conclusions: Based on our study we concluded that metastatic spread of oral cavity SCC to level IIb in cases of clinically positive neck (cN+) is rare.

Dual-task training effects on motor and cognitive functional abilities in individuals with stroke: a systematic review

Objective: This systematic review aimed to examine the effects of dual-task balance and mobility training in people with stroke. Methods: An extensive electronic databases literature search was conducted using MEDLINE, PubMed, EBSCO, The Cochrane Library, Web of Science, SCOPUS, and Wiley Online Library. Randomized controlled studies that assessed the effects of dual-task training in stroke patients were included for the review (last search in December 2017). The methodological quality was evaluated using the Cochrane Collaboration recommendation, and level of evidence was determined according to the criteria described by the Oxford Center for Evidence-Based Medicine. Results: About 13 articles involving 457 participants were included in this systematic review. All had substantial risk of bias and thus provided level IIb evidence only. Dual-task mobility training was found to induce more improvement in single-task walking function (standardized effect size = 0.14–2.24), when compared with single-task mobility training. Its effect on dual-task walking function was not consistent. Cognitive-motor balance training was effective in improving single-task balance function (standardized effect size = 0.27–1.82), but its effect on dual-task balance ability was not studied. The beneficial effect of dual-task training on cognitive function was provided by one study only and thus inconclusive. Conclusion: There is some evidence that dual-task training can improve single-task walking and balance function in individuals with stroke. However, any firm recommendation cannot be made due to the weak methodology of the studies reviewed.

Locoregional extension and patterns of failure for nasopharyngeal carcinoma with intracranial extension

ObjectiveTo evaluate the locoregional extension and patterns of failure for nasopharyngeal carcinoma (NPC) with intracranial extension to improve clinical target volume (CTV) delineation. Patients and methodsA total of 205 NPC patients with intracranial extension by magnetic resonance imaging (MRI) were retrospectively reviewed. ResultsAccording to the cumulative incidence rates of tumor invasion, we initially classified anatomic sites surrounding the nasopharynx into three risk grades: high risk (≥35%), medium risk (≥10–35%), and low risk (<10%). It was concluded that the anatomic sites at high risk of tumor invasion were the middle/posterior skull base and the anatomic sites adjacent to the nasopharynx. The rate of lymph node (LN) metastasis was 90.2% (185/205). Retropharyngeal region (RP) and level IIb were the most frequently involved regions. Skip metastasis occurred in only 1.6% (3/185). At their last follow-up visit, 53 patients (25.9%) had developed treatment failure. Of the 18 local failures, 12 were considered in-field failure; the other 5 were marginal; one of the patients had outside-field failure. Among the 5 patients with marginal failures, 4 occurred mainly intracranially, and 1 occurred in the floor and the left lateral wall of the nasopharynx. Of the 11 regional failures, 10 were considered in-field failures and most of them (8/10) occurred in the unilateral upper neck. ConclusionFor NPC with intracranial extension, primary disease and regional LN spread follow an orderly pattern and LN skipping was unusual. Clinical target volume reduction may be feasible for selected patients.

Intraoperative Brief Electrical Stimulation of the Spinal Accessory Nerve (BEST SPIN) for prevention of shoulder dysfunction after oncologic neck dissection: a double-blinded, randomized controlled trial

BackgroundShoulder dysfunction is common after neck dissection for head and neck cancer (HNC). Brief electrical stimulation (BES) is a novel technique that has been shown to enhance neuronal regeneration after nerve injury by modulating the brain-derived neurotrophic growth factor (BDNF) pathways. The objective of this study was to evaluate the effect of BES on postoperative shoulder function following oncologic neck dissection.MethodsAdult participants with a new diagnosis of HNC undergoing Level IIb +/− V neck dissection were recruited. Those in the treatment group received intraoperative BES applied to the spinal accessory nerve (SAN) after completion of neck dissection for 60 min of continuous 20 Hz stimulation at 3-5 V of 0.1 msec balanced biphasic pulses, while those in the control group received no stimulation (NS). The primary outcome measured was the Constant-Murley Shoulder (CMS) Score, comparing changes from baseline to 12 months post-neck dissection. Secondary outcomes included the change in the Neck Dissection Impairment Index (ΔNDII) score and the change in compound muscle action potential amplitude (ΔCMAP) over the same period.ResultsFifty-four patients were randomized to the treatment or control group with a 1:1 allocation scheme. No differences in demographics, tumor characteristics, or neck dissection types were found between groups. Significantly lower ΔCMS scores were observed in the BES group at 12 months, indicating better preservation of shoulder function (p = 0.007). Only four in the BES group compared to 17 patients in the NS groups saw decreases greater than the minimally important clinical difference (MICD) of the CMS (p = 0.023). However, NDII scores (p = 0.089) and CMAP amplitudes (p = 0.067) between the groups did not reach statistical significance at 12 months. BES participants with Level IIb + V neck dissections had significantly better ΔCMS and ΔCMAP scores at 12 months (p = 0.048 and p = 0.025, respectively).ConclusionsApplication of BES to the SAN may help reduce impaired shoulder function in patients undergoing oncologic neck dissection, and may be considered a viable adjunct to functional rehabilitation therapies.Trial registrationClinicaltrials.gov (NCT02268344, October 17, 2014).

Oral Levetiracetam as Add-On Therapy in Refractory Neonatal Seizures.

Seizure is the most common signs of nervous system disease in neonates. The first line of treatments in neonatal seizures (after ruling out and emergency treatment of electrolyte imbalance and hypoglycemia) are phenobarbital and phenytoin. We aimed to evaluate drugs that are more effective on neonatal seizure. Patients admitted to neonatal wards & NICUs (level IIa&IIb) in Qom hospitals (2015-2017), central Iran with presentation of seizure, were enrolled in this clinical trial study. After ruling out electrolyte imbalance and hypoglycemia these neonates were managed by intravenous phenobarbital, then if no response was seen we added intravenous phenytoin and for remaining neonates with refractory seizure we applied oral levetiracetam as add on therapy. The study was registered as code number of IRCT2016051527896N1. Initially, 245 neonates were enrolled. According to exclusion criteria, 12 cases were excluded, and phenobarbital was prescribed to the remaining patients. Out of these, 86 patients did not respond, and phenytoin was prescribed for them. Forty two patients who were not responding to phenytoin were finally treated with oral levetiracetam. Finally, 95.3% of seizures were controlled with oral levetiracetam but 4.7% were not cured. When the intravenous form of levetiracetam is not available and neonatal seizure does not respond to first line classic drugs, oral levetiracetam as add on therapy maybe effective.

When should a level IIB neck dissection be performed in treatment of head and neck squamous cell carcinoma?

When should a level IIB neck dissection be performed in treatment of head and neck squamous cell carcinoma?

Cervical level IIb metastases in squamous cell carcinoma of the oral cavity: a systematic review and meta-analysis.

PurposeThe aim of this study was to clarify whether level IIb dissection should be performed or avoided in the treatment of oral squamous cell carcinoma by meta-analysis.Materials and methodsArticles that were published before June 2017 were searched electronically in four databases (Web of Science, PubMed, Ovid and China National Knowledge Infrastructure) without any date or language restrictions by two independent reviewers. s and full-text papers which investigated the cervical metastases to level IIb from primary head and neck cancers and were deemed potentially relevant were screened. Data were analyzed using RevMan 5.3.ResultsFour hundred and fifty-five abstracts and 129 full-text papers were screened, and 22 studies were included in the analysis. Among the 2001 patients included, 112 patients had level IIb metastases, the pooled frequency of which was 6% (95% confidence interval [CI]: 4.0–7.0). Among the 400 patients with tongue squamous cell carcinoma from 12 studies, 37 patients had level IIb metastases, the pooled incidence of which was 7% (95% CI: 5.0–10.0). Metastases to level IIb always went together with level IIa, and only three patients were found to have isolated level IIb metastases without involving the other levels.ConclusionDue to the low frequency of level IIb nodal metastases in oral squamous cell carcinoma patients and rare occurrence of isolated level IIb, level IIb dissection could be avoided when the primary lesions were in early stages (T1 and T2), with the exception of tongue cancer. It is recommended to dissect level IIb tongue cancers without considering the stages of primary lesions and the lymph nodes status. It is also suggested that level IIb dissection should be performed in patients preoperatively or intraoperatively found with multilevel neck metastasis, especially level IIa metastasis.