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Background Large-scale quarantine facilities staffed with non-healthcare workers (NHCW) were instrumental in preventing community spread of COVID-19 (coronavirus disease of 2019). The objective of this study was to determine the effectiveness of a newly developed procedural skills training framework in ensuring personal protective equipment (PPE) compliance of PPE-naïve NHCWs. Materials and methods We developed a PPE procedural skills training framework for NHCWs using the Learn, See, Practice, Prove, Do, and Maintain (LSPPDM) framework and international guidelines on PPE for healthcare workers. The NHCWs underwent PPE training using this framework, conducted by a team of Infection Prevention nurses, prior to being stationed within the CCF. Effectiveness of the LSPPDM PPE training framework was assessed using: 1) competency assessment scores for NHCWs, 2) PPE compliance rates from daily audit findings, and, 3) healthcare-associated COVID-19 infection rates of NHCWs. Results A total of 883 NHCWs had completed the PPE training and demonstrated competency in PPE compliance, fulfilling 100% of the checklist requirements. Mean PPE compliance of all NHCWs during the 11-week study period was noted to be >96%. The post-implementation improvement was statistically significant when the compliance was expressed in 3-days blocks) and in bed management staff (P = < 0.05). None of the 883 NHCWs who underwent PPE training via the LSPPDM framework were diagnosed with healthcare-associated COVID-19 infection. Conclusions An evidence-based skills training framework is effective in PPE training of large numbers of NHCWs, resulting in high compliance of appropriate PPE use and prevention of healthcare-associated COVID-19 infection.

Purpose We aim to study the prevalence of olfactory and taste dysfunction (OTD) in subjects residing in a Community Care Facility (CCF), a center unique to Singapore that is dedicated to isolate foreign workers with COVID-19 infection who have mild disease with minimal or no symptoms. Methods This is a cross-sectional study analyzing data prospectively collected from COVID-19-positive subjects who were admitted into a single-center Singapore EXPO CCF from 1st May 2020 to 1st July 2020. The following variables were collected: age, gender, ethnicity, anosmia, ageusia and acute respiratory infection (ARI) symptoms. Symptoms of anosmia and ageusia were self-declared via a mandatory questionnaire administered on admission. Results A total of 1983 subjects were included. The overall prevalence of anosmia and ageusia is 3.0% and 2.6%, respectively. 58% of anosmic subjects have co-existent ageusia and 72.6% of anosmic subjects have no concurrent sinonasal symptoms. OTD is less likely to present in subjects who are asymptomatic for ARI, compared to those symptomatic for ARI (anosmia: 2.0% versus 4.4% p = 0.002; ageusia: 1.6% versus 4.2% p

During the coronavirus disease 2019 (COVID-19) pandemic, Singapore implemented large-scale institutional isolation facilities to contain outbreaks among migrant workers who contracted COVID-19 but did not have the ability to self-isolate. In this article, the authors share their experience operating one of the largest of these facilities., Singapore is one of the most densely populated small island–states in the world. During the coronavirus disease 2019 (COVID-19) pandemic, Singapore implemented large-scale institutional isolation units called Community Care Facilities (CCFs) to combat the outbreak in the community by housing low-risk COVID-19 patients from April to August 2020. The CCFs were created rapidly by converting existing public spaces and used a protocolized system, augmented by telemedicine to enable a low health care worker–patient ratio (98 health care workers for 3200 beds), to operate these unique facilities. In the first month, a total of 3758 patients were admitted to 4 halls, 4929 in-house medical consults occurred, 136 patients were transferred to a hospital, 1 patient died 2 weeks after discharge, and no health care workers became infected. This article shares the authors' experience in operating these massive-scale isolation facilities while prioritizing safety for all and ensuring holistic patient care in the face of a public health crisis and lean health care resources.

Objective: Breast cancer is the most common cancer in women across all ethnicities, accounting for almost one in three incident cancers in female, and the leading cause of mortality in Singapore. Literature reveals that survivors of breast cancer have many concerns, and these concerns can linger on for decades. The primary aim of this secondary analysis was to establish the concerns of breast cancer survivors and use the data to inform practice. Methods: The present report was part of a bigger data designed to evaluate the concerns of cancer survivors (top six cancers) across the survivorship trajectory. Data of 438 breast cancer survivors were derived from a cross-sectional survey of the self-reported concerns of 1107 cancer survivors, using the questionnaire adopted from the Mayo Clinic Cancer Centre's Cancer Survivors Survey of Needs. Logistic regression models were fitted to estimate the odds ratios to assess the association of various variables with the presence of ≥1 concerned or very concerned issue among patients. Linear regression models were fitted to identify the variables associated with quality of life (QOL). Results: A total of 438 breast cancer survivors responded to this survey. The top five concerns were cancer treatment and recurrence risk (55.5%), followed by fear of recurrence (FOR) (54.6%), long-term effects of treatment (53.4%), osteoporosis/bone health (39.0%), and keeping primary care physicians informed (37.4%). Cancer treatment and recurrence risk, FOR, and long-term treatment effects were among the top concerns across the survivorship trajectory. The mean QOL was 7.5 on a scale of 0–10. Conclusions: Irrespective of the cancer trajectory, survivors of breast cancer have serious concerns that warrant attention. Designing patient care delivery that addresses these concerns identified is critical in assisting them in their coping process and enhancing their QOL.

Highlights • The eACS service described provides 24/7 coverage of trauma, acute general surgery and critical care. • There were no patient/staff cross infections of COVID-19. • The eACS service reduced length of stay, mortality and costs to the organisation. • Staff felt the service prioritised their safety from COVID-19., Background As the COVID-19 pandemic sweeps across the world, healthcare departments must adapt to meet the challenges of service provision and staff/patient protection. Unlike elective surgery, acute care surgery (ACS) workloads cannot be artificially reduced providing a unique challenge for administrators to balance healthcare resources between the COVID-19 surge and regular patient admissions. Methods An enhanced ACS (eACS) model of care is described with the aim of limiting COVID-19 healthcare worker and patient cross-infection as well as providing 24/7 management of emergency general surgical (GS) and trauma patients. The eACS service comprised 5 independent teams covering a rolling 1:5 24-hr call. Attempts to completely separate eACS teams and patients from the elective side were made. The service was compared to the existing ACS service in terms of clinical and efficiency outcomes. Finally, a survey of staff attitudes towards these changes, concerns regarding COVID-19 and psychological well-being was assessed. Results There were no staff/patient COVID-19 cross-infections. Compared to the ACS service, eACS patients had reduced overall length of stay (2-days), time spent in the Emergency Room (46 min) and time from surgery to discharge (2.4-hours). The eACS model of care saved financial resources and bed-days for the organisation. The changes were well received by team-members who also felt that their safety was prioritised. Conclusion In healthcare systems not overwhelmed by COVID-19, an eACS model may assist in preserving psychological well-being for healthcare staff whilst providing 24/7 care for emergency GS and trauma patients.

Objectives/hypothesis Our study aimed to review the impact of preoperative radiotherapy (RT) and other factors on the lymph node count of neck dissection (ND) specimens from patients with head and neck cancer (HNC). A retrospective study was conducted on all patients with head and neck cancers who had undergone NDs in Singapore General Hospital between 1992 and 2013. Study design Retrospective study. Methods Patients were categorized into two groups: patients treated with RT with or without chemotherapy before ND and patients who had undergone ND surgery without previous history of RT. The primary endpoint for this study would be the lymph node count from ND. Results The study cohort consists of 1,024 NDs on 829 patients. There were 597 (58.3%) radical/modified radical NDs involving levels I-V. Within this group, 75 (12.6%) NDs had preoperative RT. Preoperative RT and age were found to significantly reduce nodal yield in both univariate and multivariate analysis in the radical/modified radical ND subgroup. In our multivariate analysis, preoperative RT was shown to decrease the nodal yield by 7.464 (P = .0002, 95% confidence interval [CI]: -11.35 to -3.58). Advanced age independently decreases nodal yield, even after accounting for the effect of RT (P = .0002, 95% CI: -0.27 to -0.08). In addition, preoperative RT has a more pronounced effect in reducing lymph node count in the older age group. Conclusions Preoperative RT and advanced age are independent and synergistic factors that reduce nodal count from NDs in patients with head and neck cancers. Level of evidence 4 Laryngoscope, 130: 1947-1953, 2020.

Introduction: We investigated knowledge, attitudes, and practice (KAP) about COVID-19 and related preventive measures in Singaporeans aged > 60 years. Methods: This was a population-based, cross-sectional, mixed-methods study (13 May 2020–9 June 2020) of participants aged >60 years. Self-reported KAP about ten COVID-19 symptoms and six government-endorsed preventive measures were evaluated. Multivariable regression models identified sociodemographic and health-related factors associated with knowledge, attitudes and practices in our sample. Associations between knowledge/attitude scores, and practice categories were determined using logistic regression. 78 participants were interviewed qualitatively about practice of additional preventive measures and data were analysed thematically. Results: Mean awareness score of the symptoms was 7.2/10. Fever (93.0%) and diarrhoea (33.5%) were the most- and least-known symptoms, respectively. Most knew all six preventive measures (90.4%), perceived them as effective (78.7%), and practiced ‘wear a mask’ (97.2%). Indians, Malays, and those in smaller housing had poorer mean knowledge of COVID-19 symptoms scores. Older participants had poorer attitudes towards preventive measures. Compared to Chinese, Indians had lower odds of practicing 3/6 recommendations. A one-point increase in knowledge of and attitudes towards preventive measures score had higher odds of always practicing 3/6 and 2/6 measures, respectively. Qualitative interviews revealed use of other preventive measures, e.g. maintaining a healthy lifestyle. Conclusions: Elderly Singaporeans displayed high levels of KAP about COVID-19 and related preventive measures, with a positive association between levels of knowledge/attitude, and practice. However, important ethnic and socioeconomic disparities were evident, suggesting key vulnerabilities remain, requiring immediate attention.

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Background Multidisciplinary team meetings or tumor boards (TBs) form a pivotal component of oncology practice. The crux of a TB revolves around making treatment decisions based on succinct head and neck cancer (HNC) patient data presentations, which can be challenging and complex. Apart from meticulous TB presentations, discussions and treatment plan documentation is equally important. The aim of this study was to structure an electronic synoptic TB data presentation to address all these areas. The overarching benefits of systematic TB data collection include facilitating audits and research. Methods We utilized a secure web‐based tool that was used for common scientific research purposes but customized to store HNC patient data. The data points were tabulated across eight TB pages: (a) TB scheduling, (b) patient biodata, (c) diagnosis details, (d) index presentation, (e) images, (f) management and histopathology, (g) TB presentation, and (h) TB discussion and decisions. Each data point leads to additional fields by branching logic to permit further relevant data entry. This was integrated within the patient electronic medical records allowing for a direct internal trajectory to recall TB data. Results From October 2015 to October 2018, we recorded over 2000 presentations for 1279 individual patients. This is a quality improvement initiative, and hence, the results are more of a broad analysis of our TB presentation process. The most common cancers were squamous cell (523, 41%), thyroid (207, 16%), and nasopharyngeal (139, 11%) carcinomas. Importantly, this system has formed the basis for a number of clinical and translational research projects and audit outcomes. Conclusion Despite TBs being vital to oncologic practice, little attempt has been made to report TB data management. In this study, we present an efficient system that permits the integration of dual functions: TB data presentation and oncologic data collection for research, recall, and audit purposes.

Ultrasonic or bipolar radiofrequency energy devices are routinely used for dissection and hemostasis during thyroidectomy. We report a single-center, prospective, randomized controlled trial comparing the utility and outcomes of Harmonic Focus, an ultrasonic coagulating shear device (UCSD), versus Ligasure Small Jaw, an electrothermal bipolar vessel sealer (EBVS) in thyroidectomy (NCT01765686). Between December 2012 to January 2016, eligible patients were randomized to undergo hemithyroidectomy using either a UCSD or an EBVS. The primary outcome was duration of surgery. Secondary outcomes included blood loss, postoperative complications, ease of device use, ease of device set-up, vocal cord function, postoperative wound drainage, pain score, and adverse events. Of 110 patients assessed for eligibility, 100 were randomly allocated (UCSD: 49 patients; EBVS: 51 patients) and analyzed by intention-to-treat. There were no differences in specimen delivery time, total duration of surgery, wound drainage, and adverse events between the two groups. The UCSD group had a greater proportion of patients with higher postoperative pain scores in the first 72 h (8.1% vs. 2.0%, p = 0.043). Surgeons reported greater ease of use for the UCSD (49% vs. 27%; p = 0.005), while operating room staff favored the EBVS (60% vs. 33%, p = 0.005). Energy devices are equally effective in reducing thyroidectomy operative times, with no differences in the duration of surgery, drainage, or adverse events. Use of the UCSD was associated with higher postoperative pain scores, but was favored by the surgeons, likely due to the ability to perform fine dissection with the device itself.

Background The Operating Theatre (OT) is the largest cost centre as well as the main revenue generator in most hospitals. One of the common problems affecting optimal OT utilization is the cancellation of scheduled surgeries. The goal of this study was to identify factors associated with cancellation within 24 h of scheduled surgeries in a tertiary hospital. Methods All elective surgeries performed on adults 18 years and above between June 2015 and December 2016 were included. Cancellations ≤24 h from the scheduled start time of the surgery were recorded, with their reasons for cancellation. Data relating to the patient, surgeon and planned surgery were obtained from the hospital operational database. Univariate analysis and multivariable analysis were conducted using logistic regression. Results A total of 4060 scheduled surgeries were included, of which 398 (9.8%) were cancelled within 24 h of surgery. On multivariate analysis, cancellation within 24 h of surgery was associated with history of heart failure (Adjusted odds ratio, AOR1.65; 95%CI 1.08–2.50), advanced chronic kidney disease (AOR2.33; 95%CI 1.58–3.39), or a history of hip fracture (AOR2.29; 95%CI 1.33–3.80), low socio-economic status (on Medifund financing, AOR3.16; 95%CI 1.37–6.72), history of ≥4 cancelled surgeries in the past 3 years (AOR2.38; 95%CI 1.30–4.19), and scheduled time in the afternoon (AOR1.83; 95%CI 1.44–2.32) and evening (AOR2.09; 95%CI0.73–5.13), compared to the morning. Attendance at preoperative anaesthesia assessment clinic was associated with reduced likelihood of cancellation (AOR0.55; 95%CI0.43–0.72). Conclusions Several patient and system factors can be used to identify scheduled surgeries that are at high likelihood of cancellation within 24 h of surgery, which may inform strategies to improve the efficiency of OT utilization, including having a dedicated preoperative anaesthesia assessment clinic.

Background Haemorrhoids is a common chronic disease that can significantly impact patients’ quality of life. Yet, few studies have evaluated health-related quality of life (HRQoL) of patients with haemorrhoids before and after treatment. This study investigated the HRQoL of patients with haemorrhoids before and after treatment and the change in HRQoL from baseline. Methods A prospective observational study of patients with haemorrhoids was conducted at two public hospitals in Kandy, Sri Lanka. Two questionnaires assessing symptom severity and haemorrhoid-specific QoL were administered at initial consultation and at 4- and 8-week follow-ups after treatment (sclerotherapy, rubber band ligation (RBL), haemorrhoidectomy or evacuation of haematoma). The primary outcome was the least squares (LS) change of HRQoL score from baseline, measured using the Short Health Scale adapted for Haemorrhoidal Disease (4 domains: symptom load, interference with daily activities, concern, general well-being). Results In 48 patients selected for this study, LS mean change from baseline showed significant improvement in HRQoL across all domains and total Short Health Scale adapted for Haemorrhoidal Disease score at 4- and 8-week follow-ups (P Conclusion Patients with haemorrhoids had improved HRQoL after invasive treatment. Haemorrhoid-specific QoL is an important component of the extent of disease and can serve as an aid to guide treatment, assess outcomes and monitor disease.

Objective This study assessed the improvement in Quality of Life (QoL) of Chronic Venous Disease (CVD) patients in Sri Lanka following treatment. Methods This was a prospective observational study of 58 newly or previously diagnosed CVD patients. QoL was assessed by the 14-item ChronIc Venous dIsease quality of life Questionnaire (CIVIQ-14) at 4 and 8 weeks after treatment. Results At 8 weeks, the improvement in Global score from baseline was greatest in the surgical group with adjusted least squares mean of 23.5 (p Conclusion Both surgical and non-surgical treatments improved QoL of CVD patients.

Importance Three-dimensionally printed nasopharyngeal swabs (3DP swabs) have been used to mitigate swab shortages during the coronavirus disease 2019 (COVID-19) pandemic. Clinical validation for diagnostic accuracy and consistency, as well as patient acceptability, is crucial to evaluate the swab’s performance. Objective To determine the accuracy and acceptability of the 3DP swab for identifying severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Design, Setting, and Participants A diagnostic study was conducted from May to July 2020 at 2 tertiary care centers in Singapore with different reference swabs (FLOQSwab [COPAN Diagnostics] or Dacron swab [Deltalab]) and swab processing techniques (wet or dry) to evaluate the performance of the 3DP swab compared with traditional, standard-of-care nasopharyngeal swabs used in health care institutions. The participants were patients with COVID-19 in the first 2 weeks of illness and controls with acute respiratory illness with negative test results for SARS-CoV-2. Paired nasopharyngeal swabs were obtained from the same nostril and tested for SARS-CoV-2 by reverse-transcriptase polymerase chain reaction. The sequence of swabs was randomized based on odd and even participant numbers. Main Outcomes and Measures Primary outcome measures were overall agreement (OA), positive percentage agreement (PPA), and negative percentage agreement of the 3DP swab compared with reference swabs. Secondary outcome measures were the correlation of cycle threshold (Ct) values of both swabs. Results The mean (SD) age of participants was 45.4 (13.1) years, and most participants were men (87 of 89 [97.8%]), in keeping with the epidemiology of the COVID-19 pandemic in Singapore. A total of 79 patients with COVID-19 and 10 controls were recruited. Among the patients with COVID-19, the overall agreement and PPA of the 3DP swab was 91.1% and 93.5%, respectively, compared with reference swabs. The PPA was 100% for patients with COVID-19 who were tested within the first week of illness. All controls tested negative. The reverse-transcriptase polymerase chain reaction Ct values for theORF1abandE-genetargets showed a strong correlation (intraclass correlations coefficient, 0.869-0.920) between the 3DP and reference swab on independent testing at each institution despite differences in sample processing. Discordant results for both gene targets were observed only at high Ct values. Conclusions and Relevance In this diagnostic study of 79 patients with COVID-19 and 10 controls, the 3DP swab performed accurately and consistently across health care institutions and could help mitigate strained resources in the escalating COVID-19 pandemic.

PURPOSE:We present the strategy of a comprehensive cancer center organized to make operations pandemic proof and achieve continuity of cancer care during the COVID-19 pandemic.METHODS:Disease Outbreak Response (DORS) measures implemented at our center and its satellite clinics included strict infection prevention, manpower preservation, prudent resource allocation, and adaptation of standard-of-care treatments. Critical day-to-day clinical operations, number of persons screened before entry, staff temperature monitoring, and personal protection equipment stockpile were reviewed as a dashboard at daily DORS taskforce huddles. Polymerase chain reaction swab tests performed for patients and staff who met defined criteria for testing of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection were tracked. Descriptive statistics of outpatient attendances and treatment caseloads from February 3 to May 23, 2020, were compared with the corresponding period in 2019.RESULTS:We performed COVID-19 swabs for 80 patients and 93 staff, detecting three cancer patients with community-acquired COVID-19 infections with no nosocomial transmission. Patients who required chemotherapy, radiotherapy, or surgery and patients who are on maintenance treatment continued to receive timely treatment without disruption. The number of intravenous chemotherapy treatments was maintained at 97.8% compared with 2019, whereas that of weekly radiotherapy treatments remained stable since December 2019. All cancer-related surgeries proceeded without delay, with a 0.3% increase in workload. Surveillance follow-ups were conducted via teleconsultation, accounting for a 30.7% decrease in total face-to-face clinic consultations.CONCLUSION:Through the coordinated efforts of a DORS taskforce, it is possible to avoid nosocomial SARS-CoV-2 transmissions among patients and staff without compromising on care delivery at a national cancer center.

Purpose: Survivors of cancer deal with a myriad of acute, chronic, and late effects of cancer and its treatment which can linger on for decades and inadvertently affect their quality of life (QOL). The aim of this study is to determine the main concerns of survivors at various stages of the cancer survivorship, and to assess whether these concerns have any effect on their QOL. Methods: A cross-sectional survey was conducted on cancer survivors diagnosed with colorectal, breast, lung, gynaecological, prostate or liver cancers (top 6 cancers in Singapore) who were seen at the National Cancer Centre Singapore between 11 April and 12 July 2017. Eligible study participants self-completed a questionnaire adapted from the Mayo Clinic Cancer Centre’s Cancer Survivors Survey of Needs. QOL was rated by participants on a scale of 0-10, with higher ratings denoting higher level of QOL. Results: A total of 1107 cancer survivors filled in the questionnaire. The top 5 concerns among all survivors were cancer treatment and recurrence risk (51%), followed by long-term treatment effects (49%), fear of recurrence (47%), financial concerns (37%) and fatigue (37%). Cancer treatment and recurrence risk, long-term treatment effects and fear of recurrence were amongst the top concerns across the survivorship trajectory. Mean QOL was 7.3 on a scale of 0-10. Completed treatment patients had higher QOL score than the newly diagnosed and on treatment patients and the patients dealing with recurrence or second cancer patients. Predictors for QOL included the economic status and housing type of patients and whether patients were concerned with pain and fatigue. Conclusion: This study reveals that cancer survivors in Singapore face multiple challenges and had various concerns at various stages of cancer survivorship, some of which negatively affect their QOL. It is critical to design patient care delivery systems that appropriately address their key concerns at different stages of their cancer trajectory so as to enhance their coping skills throughout their cancer journey.

Aim The long-term stress, anxiety and job burnout experienced by healthcare workers (HCWs) are important to consider as the novel coronavirus disease (COVID-19) pandemic stresses healthcare systems globally. The primary objective was to examine the changes in the proportion of HCWs reporting stress, anxiety, and job burnout over six months during the peak of the pandemic in Singapore. The secondary objective was to examine the extent that objective job characteristics, HCW-perceived job factors, and HCW personal resources were associated with stress, anxiety, and job burnout. Method A sample of HCWs (doctors, nurses, allied health professionals, administrative and operations staff; N = 2744) was recruited via invitation to participate in an online survey from four tertiary hospitals. Data were gathered between March-August 2020, which included a 2-month lockdown period. HCWs completed monthly web-based self-reported assessments of stress (Perceived Stress Scale-4), anxiety (Generalized Anxiety Disorder-7), and job burnout (Physician Work Life Scale). Results The majority of the sample consisted of female HCWs (81%) and nurses (60%). Using random-intercept logistic regression models, elevated perceived stress, anxiety and job burnout were reported by 33%, 13%, and 24% of the overall sample at baseline respectively. The proportion of HCWs reporting stress and job burnout increased by approximately 1·0% and 1·2% respectively per month. Anxiety did not significantly increase. Working long hours was associated with higher odds, while teamwork and feeling appreciated at work were associated with lower odds, of stress, anxiety, and job burnout. Conclusions Perceived stress and job burnout showed a mild increase over six months, even after exiting the lockdown. Teamwork and feeling appreciated at work were protective and are targets for developing organizational interventions to mitigate expected poor outcomes among frontline HCWs.

Introduction We aimed to study anxiety and burnout among Division of Radiological Sciences (RADSC) staff during the COVID‐19 pandemic and identify potential risk and protective factors. These outcomes were compared with non‐RADSC staff. Methods A cross‐sectional online study was conducted between 12 March and 20 July 2020 in the largest public tertiary hospital receiving COVID‐19 cases. Burnout and anxiety were assessed with the Physician Work‐Life Scale and the Generalized Anxiety Disorder‐7 Scale, respectively. Workplace factors were examined as potential risk and protective factors using multivariable ordinary least squares regression analyses, adjusting for pertinent demographic characteristics. Results RADSC staff (n = 180) and non‐RADSC staff (n = 1458) demonstrated moderate‐to‐severe anxiety rates of 6.7 and 13.2 % and burnout rates of 17.8 and 23.9 %, respectively. RADSC staff reported significantly lower anxiety (mean ± SD: 4.0 ± 3.7 vs 4.9 ± 4.5; P‐value

Introduction. The Stanford Biodesign process is a needs-driven approach to innovation which begins in the clinical setting and environment and is championed by practicing clinicians and surgeons. Here, our team applied the Stanford Biodesign process through clinical immersion to identify potential unmet clinical needs in the field of head and neck surgery, brainstormed and prototyped solutions to solve the top unmet need, and developed a commercialized medical device. Methods. The team underwent the 3 phases of the Biodesign process: identify, invent, and implement. The team underwent clinical immersion and followed head and neck surgeons from the Department of Head and Neck Surgery for a duration of 1 month. The needs identified were then filtered through a structured process using predefined filters, and a top need was chosen. After multiple rounds of brainstorming and prototyping, a final concept was developed. Results. The team collected 111 unmet needs and designed the in vivo surgical lighting concept that eventually led to the development of the KLARO™ in vivo surgical lighting device with a commercial partner. KLARO™ is a fully flexible 4.6-mm diameter light-emitting diode light strip that is freely bendable to be safely placed into deep cavities during open surgeries. Conclusion. The Biodesign process provides a standardized way to turn these needs into solution to advance the field of head and neck surgery and improve the outcome of patients.

This study aims to examine the information seeking behaviours and experiences of cancer survivors at various stages of the cancer survivorship trajectory in Singapore. Data was collected via a self-administered questionnaire from survivors diagnosed with the top 6 cancers in Singapore seen at the National Cancer Centre Singapore (NCCS). Cancer survivorship stages were categorized as newly diagnosed and on treatment (NT), completed treatment or cancer-free ≥ 5 years (CT) and had recurrence or second cancer (RS). Out of the 998 cancer survivors, 676 (68%) had searched for cancer information since their diagnosis. About 57% of the searchers did their most recent search in the past 6 months prior to the survey, with most of these survivors from the NT and RS groups. Around half of the searchers (55%) obtained cancer information from the internet. The most preferred source for cancer information was the internet (38%), followed by healthcare professionals (HCPs) (23%). About half (49%) obtained cancer information from their preferred source. Some information searchers (24%) did not do so, out of which about half used the internet to obtain information that they would have preferred to obtain from HCPs. The top 3 most commonly sought information was related to treatment, cancer and diet/nutrition. Half of the searchers were concerned with the quality of the information that they found. These information seeking behaviours and experiences were similar across cancer survivorship stages. Our study reveals that information seeking is prevalent across all survivorship stages. Patterns of information-seeking revealed a discrepancy between preferred and actual source.

Surgeons urgently need guidance on how to deliver surgical services safely and effectively during the COVID-19 pandemic. The aim was to identify the key domains that should be considered when developing pandemic preparedness plans for surgical services.A scoping search was conducted to identify published articles relating to management of surgical patients during pandemics. Key informant interviews were conducted with surgeons and anaesthetists with direct experience of working during infectious disease outbreaks, in order to identify key challenges and solutions to delivering effective surgical services during the COVID-19 pandemic.Thirteen articles were identified from the scoping search, and surgeons and anaesthetists representing 11 territories were interviewed. To mount an effective response to COVID-19, a pandemic response plan for surgical services should be developed in advance. Key domains that should be included are: provision of staff training (such as patient transfers, donning and doffing personal protection equipment, recognizing and managing COVID-19 infection); support for the overall hospital response to COVID-19 (reduction in non-urgent activities such as clinics, endoscopy, non-urgent elective surgery); establishment of a team-based approach for running emergency services; and recognition and management of COVID-19 infection in patients treated as an emergency and those who have had surgery. A backlog of procedures after the end of the COVID-19 pandemic is inevitable, and hospitals should plan how to address this effectively to ensure that patients having elective treatment have the best possible outcomes.Hospitals should prepare detailed context-specific pandemic preparedness plans addressing the identified domains. Specific guidance should be updated continuously to reflect emerging evidence during the COVID-19 pandemic.Los cirujanos necesitan urgentemente disponer de guías de cómo pueden realizar su trabajo con seguridad y de forma efectiva durante la pandemia de COVID-19. Nuestro objetivo fue identificar los puntos clave que deberían tener en cuenta los servicios quirúrgicos en el momento de desarrollar un protocolo ante la pandemia. MÉTODOS: Se realizó una búsqueda del tema para identificar los artículos publicados relacionados con el manejo de pacientes quirúrgicos durante pandemias. Además, se realizaron entrevistas a cirujanos y anestesistas con experiencia directa durante brotes de enfermedades infecciosas para obtener información e identificar los retos clave y las soluciones para proporcionar servicios quirúrgicos efectivos durante la pandemia de COVID-19.Se identificaron 13 artículos y se entrevistó a cirujanos y anestesistas de 11 territorios. Con el fin de organizar una respuesta efectiva a la COVID-19, se debe disponer de antemano de un plan de respuesta para los servicios quirúrgicos ante una pandemia. Los puntos clave que debe incluirse en este plan son: proporcionar formación al personal (por ejemplo, traslado de pacientes, colocación y retirada de equipos de protección personal; reconocer y tratar la infección por COVID-19); medidas de soporte de todo el hospital ante la COVID-19 (reducción de actividades clínicas, endoscópicas o de cirugía electiva no urgente); establecimiento de equipos mixtos de atención en urgencias; reconocimiento y tratamiento la infección por COVID-19 en pacientes de urgencias y en pacientes postoperados. Al final de la pandemia de COVID-19 es inevitable la acumulación de procedimientos retrasados y los hospitales deben planificar cómo abordar esta situación de forma efectiva para garantizar que los pacientes electivos tengan los mejores resultados posibles. CONCLUSIÓN: Los hospitales deberían preparar planes detallados ante una pandemia que aborden los puntos clave señalados. Estos planes deben actualizarse continuamente ante las nuevas evidencias que surjan durante la pandemia de COVID-19.

ObjectivesTo qualitatively interpret the information and supportive care needs perceived by cancer patients undergoing treatment in order to get a deeper appreciation of patients’ needs and concerns. The intended outcome is to provide baseline knowledge for improving patient-centred strategies to better meet the information and supportive needs of patients.DesignA qualitative research approach, based on conventional content analysis, was used throughout the research process. The three open-ended questions obtained from a previous quantitative study guided the researchers to explore the information and supportive care needs of patients. Data from patients’ responses were analysed and coded in themes.Participants and settingPatients attending the Ambulatory Treatment Unit of the National Cancer Centre Singapore were invited to participate in the study. We determined from these subjects the type of information that cancer patients need, and to measure the extent to which these information needs are met by measuring patients’ level of satisfaction. Included in the quantitative study were three open-ended questions designed to gain a deeper understanding of their needs and concerns. All subjects were aged 21 years and above and able to understand and communicate in English/Mandarin. They were also aware of their diagnosis, they were not cognitively impaired and were not at the end-of-life situation.ResultsA variety of information and supportive care needs were identified, and three specific areas of concerns were identified: (1) psychosocial and supportive care needs, (2) information needs and (3) information delivery by professionals.ConclusionThe information and supportive care needs expressed were consistent with issues of cancer patients undergoing treatment. The strategies to improve patients’ coping abilities through patient-centred care are discussed. Further studies assessing the barriers of information provision by healthcare professionals should provide more detailed knowledge about unmet information needs.

There are no well-defined treatment recommendations for elderly patients with advanced head and neck squamous cell carcinoma. This study aimed to investigate whether aggressive treatment among the elderly translated into better survival outcomes.Retrospective cohort study.Single tertiary institution.Elderly patients (≥60 years) with advanced-stage head and neck squamous cell carcinoma (stage III and IV) treated between January 1991 and May 2014 were reviewed. According to current National Comprehensive Cancer Network guidelines, they were classified to have received standard or substandard treatment. Overall survival (OS), locoregional recurrence-free survival, and distant recurrence-free survival were evaluated.A total of 355 patients were treated curatively: 194 with up-front surgery and 161 with radiotherapy or concurrent chemotherapy and radiotherapy. Median OS was higher among patients who received standard treatment (42.0 vs 16.0 months, P.001). On multivariate analysis, standard treatment showed superior OS ( P.001). Use of substandard treatment showed a hazard ratio of 2.09 (95% CI, 1.59-2.74) for poorer OS.Aggressive standard treatment protocols should be advocated for elderly patients, where comorbidities permit, as they confer better outcomes.

Objective Orocutaneous and pharyngocutaneous fistula (OPCF) is a debilitating complication of head and neck surgery for squamous cell carcinoma (SCC), resulting in delayed adjuvant treatment and prolonged hospitalization. As yet, there is no established test that can help in prompt and accurate diagnosis of OPCF. This study aims to determine the accuracy of bedside blue dye testing and its role as part of an algorithm for early diagnosis. We also analyze the risk factors predisposing to OPCF. Study design Retrospective cohort study from 2012 to 2014 Methods Patients with head and neck SCC who underwent major resection and reconstruction, at risk of OPCF, were included. Results of blue-dye and video-fluoroscopic swallow-studies (VFSS) testing for OPCF were recorded. For the patients that were noted to develop OPCF, the length of time to diagnosis of fistula and subsequent mode of management were examined. Results Of the 93 patients in this study, 25 (26.9%) developed OPCF. Advanced T-classification (T3/T4) was the only significant predisposing risk factor (p = 0.013). The sensitivity and specificity of the bedside blue dye testing was found to be 36.4% and 100%, respectively. The test positive patients were diagnosed with OPCF at a median of postoperative day (POD) 9.5 as compared to POD 13 for the test negative patients (p = 0.001). Early diagnosis was associated with faster fistula resolution with treatment. Conclusion Blue dye testing is a simple bedside test that can assist in the early diagnosis of OPCF in patients, allowing treatment to be instituted earlier with improved outcomes. Level of Evidence 3

Genomics-driven cancer therapeutics has gained prominence in personalized cancer treatment. However, its utility in indications lacking biomarker-driven treatment strategies remains limited. Here we present a “phenotype-driven precision-oncology” approach, based on the notion that biological response to perturbations, chemical or genetic, in ex vivo patient-individualized models can serve as predictive biomarkers for therapeutic response in the clinic. We generated a library of “screenable” patient-derived primary cultures (PDCs) for head and neck squamous cell carcinomas that reproducibly predicted treatment response in matched patient-derived-xenograft models. Importantly, PDCs could guide clinical practice and predict tumour progression in two n = 1 co-clinical trials. Comprehensive “-omics” interrogation of PDCs derived from one of these models revealed YAP1 as a putative biomarker for treatment response and survival in ~24% of oral squamous cell carcinoma. We envision that scaling of the proposed PDC approach could uncover biomarkers for therapeutic stratification and guide real-time therapeutic decisions in the future., Treatment response in patient-derived models may serve as a biomarker for response in the clinic. Here, the authors use paired patient-derived mouse xenografts and patient-derived primary culture models from head and neck squamous cell carcinomas, including metastasis, as models for high-throughput screening of anti-cancer drugs.

// Chin-Ann J. Ong 1, 3, * , Nicholas B. Shannon 2, * , Stefan Mueller 3, 7, * , Sze Min Lek 2, * , Xuan Qiu 1 , Fui Teen Chong 4 , Ke Li 2 , Kelvin K.N. Koh 2 , Gerald C.A. Tay 1, 7 , Thakshayeni Skanthakumar 3 , Jacqueline S.G. Hwang 5 , Tony Kiat Hon Lim 5 , Mei Kim Ang 6 , Daniel S.W. Tan 6 , Ngian-Chye Tan 7 , Hiang Khoon Tan 7 , Khee Chee Soo 7 and N. Gopalakrishna Iyer 2, 4, 7 1 Department of General Surgery, Singapore General Hospital, S169856, Singapore 2 Cancer and Stem Cell Biology, Duke-NUS Graduate Medical School, S169857, Singapore 3 Division of Surgical Oncology, National Cancer Centre, S169610, Singapore 4 Cancer Therapeutics Research Laboratory, National Cancer Centre, S169610, Singapore 5 Department of Anatomical Pathology, Singapore General Hospital, S169856, Singapore 6 Department of Medical Oncology, National Cancer Centre, S169610, Singapore 7 Singhealth Duke-NUS Head and Neck Centre, Singhealth, S169856, Singapore * These authors contributed equally to this work Correspondence to: N. Gopalakrishna Iyer, email: gopaliyer@nccs.com.sg Keywords: head and neck squamous cell carcinoma, immunohistochemistry, genomics Received: February 21, 2017 Accepted: June 08, 2017 Published: June 19, 2017 ABSTRACT Background: Current management of head and neck squamous cell carcinoma (HNSCC) depends on tumor staging. Despite refinements in clinical staging algorithms, outcomes remain unchanged for the last two decades. In this study, we set out to identify a small, clinically applicable molecular panel to aid prognostication of patients with HNSCC. Materials and Methods: Data from The Cancer Genome Atlas (TCGA) was used to derive copy number aberrations and expression changes to identify putative prognostic genes. To account for cross entity relevance of the biomarkers, HNSCC ( n = 276), breast ( n = 808) and lung cancer ( n = 282) datasets were used to identify robust and reproducible markers with prognostic potential. Validation was performed using immunohistochemistry (IHC) on tissue microarrays of an independent cohort of HNSCC ( n = 333). Findings: Using GISTIC algorithm together with gene expression analysis, we identified six putative prognostic genes in at least two out of three cancers analyzed, of which four were successfully optimized for automated IHC. Of these, three were successfully validated; each molecular target being significantly prognostic on univariate analysis. Patients were differentially segregated into four prognostic groups based on the number of genes dysregulated ( p < 0.001). The IHC panel remained an independent predictor of survival after adjusting for known survival covariates including clinical staging criteria in a multivariate Cox regression model ( p < 0.001). Interpretation: We have identified and validated a clinically applicable IHC biomarker panel that is independently associated with overall survival. This panel is readily applicable, serving as a useful adjunct to current staging systems and provides novel targets for future therapeutic strategies.

Highlights • TORS for oropharyngeal tumour may predispose susceptible patients to invasive fungal infection and osteomyelitis. • Susceptible patients included those with prior history of radiation at surgical site. • Fungal infection can present as an exophytic mass at the surgical site., Introduction Transoral robotic surgery(TORS) for the excision of oropharyngeal tumour is increasingly considered for its lower rates of postoperative complications and better functional outcomes. However, we report a case of invasive candidiasis in an immunocompetent patient with previous radiation therapy years ago who underwent TORS recently. Case presentation A 55 year old Chinese female with previous radiation therapy for nasopharyngeal carcinoma diagnosed in 1986 underwent wide excision of a newly diagnosed oropharyngeal carcinoma with TORS. From 4 to 8 weeks post-op, an enlarging exophytic lesion at the surgical excision site was noted. Initial biopsy did not show malignancy or fungal organisms. A repeat biopsy under anaesthesia was done as CT imaging showed suspicion of either infective or tumour recurrence. The patient was treated with long term antifungals as final culture results showed invasive candidiasis. The surgical site showed no further lesions 6 months post-op. Discussion Previous radiation therapy to the oropharyngeal area predisposes a patient to colonization of fungal organisms. Despite TORS showing lower rates of infection, patients who have had previous radiotherapy may be more susceptible to infections as the dissection involves down to the pre-vertebral fascia. Hence, it is appropriate for such patients to have microbiological and fungal cultures performed for a lesion such as this and be treated according to the results of the culture. Conclusion This case serves as a reminder of the risk of invasive candidiasis requiring early investigation and treatment in an immunocompetent patient with prior history of both radiation therapy and recent TORS.

Background Multidisciplinary team (MDT) meetings or tumor boards (TBs) are fundamental components of cancer treatment. Although their primary function is improved outcomes, this aspect is often underreported. The main objective of this study was to analyze the outcomes of patients with head and neck squamous cell carcinoma (HNSCC) discussed at TBs, and to compare the effect of adherence and nonadherence to recommended treatment plans on outcomes. Methods Retrospective data analysis was conducted of HNSCC patients those who were adherent and nonadherent to TB therapy recommendations during 2008‐2009 at a comprehensive cancer center. Fisher's exact test and t test were used for group‐wise comparison, and Kaplan‐Meier and logistic regression models, for survival analysis and determination of the contributing factors to nonadherence. Results Comprehensive Treatment plans were recommended by TBs in 293 HNSCC patients with curative intent. Seventy‐two patients were excluded based on the selection criteria. Among the remaining 221 patients, 172 (77.9%) were adherent to TB recommendations, while 49 (22.1%) failed to comply. Patient (n = 36; 73.5%), clinician (n = 2; 4.1%), and disease‐related (n = 11; 22.4%) factors were significant contributors to nonadherence. Mean (±standard deviation (SD)) survival time was 55.6 ± 2.32 and 29.1 ± 4 months in the adherent and nonadherent groups, (P, Despite the pivotal role that MDT TBs play in oncology care, the implementation of this science remains nebulous and has scope to improve. The need for standardising TB data reporting will enable to better understand HNC trends globally/regionally. Last but not the least, outcomes in HNC patients discussed at TBs and adherence of HNC patients to TB treatment plan is underreported, and analysis of this key area will be an essential cog in HNC patient management.

Aims Patient-reported outcome measures are important in assessing the impact of dysphagia on quality of life. Our aim was to adapt and examine the cultural validity and reliability of a swallowing-related quality of life measure, the MD Anderson Dysphagia Inventory (MDADI), in English and Chinese, with head and neck cancer patients. Methods We adapted the MDADI to Chinese through formal forward-backward translation. Sixty-six head and neck cancer survivors completed the MDADI, Swallowing Quality of Life (SWAL-QOL) questionnaire and Hospital Anxiety and Depression Scale (HADS) in English or Chinese. Swallowing status was scored on the Functional Oral Intake Scale (FOIS). Seventy-four percent (n = 49) of participants completed a repeat administration of the MDADI for test-retest reliability analysis. Results The MDADI showed high internal consistency reliability (Cronbach's α , 0.82 ≤ α ≤ 0.94), and test-retest reliability in both English (intraclass correlation coefficient, ICC = 0.81) and Chinese (ICC = 0.72). Criterion validity was established through moderate to strong correlations with relevant SWAL-QOL domains. Convergent validity was determined by significant correlations to the HADS and FOIS. Divergent validity was determined by nonsignificant association to the SWAL-QOL Sleep domain. The MDADI also presented as hypothesised to most known-group theoretical constructs. Conclusions The MDADI showed good psychometric properties in English and Chinese. This avails a reliable and psychometrically valid MDADI for Chinese speakers.

Cancer impacts not only the patient but also the family members who share the distressing trajectory of the patient. The literature indicates that caregivers have many unmet information needs while providing care and support to the cancer patients, and caregivers have to resort to seeking information to supplement their information needs. This study aims to establish the prevalence of health-information-seeking behaviours among caregivers of cancer patients as a means of ascertaining if their information needs have been met and their information source and resource preference. Data were obtained via a self-reported questionnaire from caregivers of cancer patients at the National Cancer Centre Singapore between 10 September and 7 December 2018. A total of 986 caregivers responded of which 180 (18%) caregivers did not undertake information search and the common reasons were 'trust healthcare professionals' (HCPs) more than other sources (64%), and 'HCPs provide enough information' (59%). Among the 795 caregivers who have searched for cancer information, about half of these caregivers (54%) have searched information on the Internet and another 15% have obtained their information from HCPs in their most recent search. A total of 371 (47%) caregivers have used their preferred source of information to conduct their most recent information search. The top three most commonly sought information was treatment (35.6%), disease (35.6%) and side effects (26.5%). Almost half (46%) of these caregivers was concerned about the quality of information they have found on the Internet. Our study supports that information-seeking is prevalent amongst caregivers of cancer patients and reveals the prevalence of Internet use and the concerns associated with its use. Patterns of information-seeking revealed a discrepancy between preferred and actual source. The results also suggest that HCPs play a significant role in the information-seeking behaviours of caregivers of cancer patients.

Medical technology (MedTech) is traditionally seen as enabling the delivery of health in a better, innovative fashion. For example, the Da Vinci robot enables robotic surgeries, and Ardian enables surgical treatment of refractory hypertension. More recently, there has been a profound shift in emphasis on technologies that can provide cost-saving values to the payers. To this end, value signposts are fundamental in identifying and addressing clinical needs on a global scale. These value signposts include the potential to keep patients out of the hospital, change location of care to less expensive venues, and diagnose a condition earlier to reduce complications and/or slow disease progression. These presentations will review the key value signposts for translating health science technology and apply them to two case studies. Case 1: Even with readily available Emergency Medical Service and well equipped tertiary medical centres dotted across Singapore, the rate of patients with ischemic stroke receiving thrombolysis is low at 6.3%. Patients missing the window for thrombolysis have worse clinical outcome and require expensive rehabilitation. Our Singapore Stanford Biodesign team developed an app to identify the three most common symptoms of stroke and automatically activate medical response. Case 2: Our team of physicians from Singapore and the United States identified a scarcity of nasoendoscope in Vietnam. Only 45% of central and regional hospitals have nasoendoscopes whereas no community or district hospitals have such capacity. The team developed an affordable, LED-based, cord-free, AAA-battery-powered nasoendoscope system with data acquisition and transmission circuitry. This device can potentially add significant value to the delivery of ENT care in Vietnam and beyond. The objective is to demonstrate how innovations with strong focus on reducing the costs to healthcare systems have global appeal.

Background:The Singapore COVID-19 multi-ministry taskforce commissioned community care facilities (CCFs) as a hospital-sparing strategy amidst rising coronavirus disease 2019 (COVID-19) cases. An exhibition centre was repurposed within ten days as an ad-hoc 3200-bed medical facility (CCF@EXPO) to isolate and treat infected patients amidst concerns of potential COVID-19 transmissions to healthcare staff. This paper deconstructs the implementation of the CCF@EXPO infection prevention and control (IPC) innovation and elicits critical factors which enabled zero transmission of COVID-19 to staff during 100 days of operation using an implementation science framework.Methods:This study employed retrospective analysis using the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework. The CCF@EXPO IPC innovation comprised five key elements: (a) physical environment, (b) work practices, (c) tools and technology, (d) staff training, and (e) audits. Contextual assessment was conducted for baseline and 100thday of CCF@EXPO operations. Actions taken to improve scores between these timepoints were mapped against the Expert Recommendations for Implementing Change (ERIC) tool to surface key implementation strategies.Results:Positive shifts were observed in all constructs of the i-PARIHS framework, between baseline and 100thday. The largest shifts were in work practices, tools and technology, and staff training. Key implementation strategies used included: rapid Plan-Do-Study-Act (PDSA) cycles, identifying champions, team building, creating a culture of collaborative learning, multi-disciplinary teamwork, transparency in communications and decision-making, and skillful facilitation.Conclusions:Rapid PDSA cycles anchored by principles to ensure staff safety, was the key approach used in implementation of the CCF@EXPO IPC innovation. Retrospective analysis using the i-PARIHS framework is useful to elicit success factors and to inform preparedness planning of future pandemics.

Background Nasopharyngectomy for excision of nasopharyngeal tumors is challenging, as access to the nasopharynx is difficult. Recently our institution embarked on two new approaches – robotic nasopharyngectomy and open nasopharyngectomy with operating microscope (NOM) via maxillary swing approach. This article proposes that the novel approach of NOM via maxillary swing aids visualization for resection of locally invasive nasopharyngeal tumors. Methods Over a thirteen-month period, eight patients required nasopharyngectomy in our single Asian institution. Four underwent robotic nasopharyngectomy and four underwent NOM via maxillary swing approach. The latter four were retrospectively reviewed, and their clinical characteristics and surgical outcomes reported. Tips and pearls for operative setup and patient selection were also discussed. Results All four patients who underwent NOM had negative intraoperative frozen sections with subsequent negative paraffin sections. All patients remained disease free post-salvage surgery. Conclusion NOM via maxillary swing allows better visualization and aids in augmentation of open nasopharyngectomy. This enables achievement of adequate resection margins and fewer surgical complications in locally invasive nasopharyngeal tumors.

Background Achieving a good seal for the application of the vacuum-assisted closure (VAC) system in complex head and neck wounds is difficult. Methods A case series of 4 patients who developed postoperative orocutaneous or pharyngocutaneous fistulas were studied. A sterile green glove was used as a sealant together with the VAC system. Results With utilization of a green glove, a good seal for the VAC system was obtained. This gave ample time to cleanse the wound and allow granulation tissue to form before proceeding on to the next stage of treatment. Conclusion A green glove technique allows for a good seal for the VAC system to work, especially when applied to complex head and neck wounds. © 2016 Wiley Periodicals, Inc. Head Neck 38: E2523–E2526, 2016

OBJECTIVES We have previously identified and validated a panel of molecular prognostic markers (ATP13A3, SSR3, and ANO1) for Head and Neck Squamous Cell Carcinoma (HNSCC). The aim of this study was to investigate the consequence of ATP13A3 dysregulation on signaling pathways, to aid in formulating a therapeutic strategy targeting ATP13A3-overexpressing HNSCC. MATERIALS AND METHODS Gene Set Enrichment Analysis (GSEA) was performed on HNSCC microarray expression data (Internal local dataset [n = 92], TCGA [n = 232], EMBL [n = 81]) to identify pathways associated with high expression of ATP13A3. Validation was performed using immunohistochemistry (IHC) on tissue microarrays (TMAs) of head and neck cancers (n = 333), staining for ATP13A3 and phosphorylated Aurora kinase A (phospho-T288). Short interfering RNA was used to knockdown ATP13A3 expression in patient derived HNSCC cell lines. Protein expression of ATP13A3 and Aurora kinase A was then assessed by immunoblotting. RESULTS GSEA identified Aurora kinase pathway to be associated with high expression of ATP13A3 (p = 0.026). The Aurora kinase pathway was also associated with a trend towards poor prognosis and tumor aggressiveness (p = 0.086, 0.094, respectively). Furthermore, the immunohistochemical staining results revealed a significant association between Aurora kinase activity and high ATP13A3 expression (p

BACKGROUND The efficacy of parathyroidectomy for primary and secondary hyperparathyroidism is well-established but evidence in tertiary hyperparathyroidism is lacking. We examined parathyroidectomy's effect in tertiary hyperparathyroidism. METHODS Patients with tertiary hyperparathyroidism who underwent parathyroidectomy were followed up for 12 months. A modification of the 13-item parathyroid symptoms list developed by Pasieka was administered at 0, 1, 3, 6, and 12 months post-surgery. We also examined if preoperative factors would predict symptom improvement post-surgery. RESULTS Ninety-one patients were included. Survey response rates at 1, 3, 6, and 12 months post-surgery were 97.8%, 90.1%, 82.4%, and 80.2%, respectively. Mean preoperative Pasieka parathyroid score (PSS) was 6.3 ± 2.7. At first month, PSS decreased to 2.9 ± 2.0 (P

The goal of this study is to determine the type of information cancer patients need and to measure the extent to which these information needs are met by measuring patients’ levels of satisfaction. A self-administered questionnaire developed through extensive literature reviews was pilot tested on 11 cancer patients using convenience sampling in a large ambulatory cancer centre in Singapore. All eligible patients attending the centre during a 5-month period were invited to complete the 76-item survey that had been designed to evaluate self-reported information needs and level of satisfaction with the information received while undergoing cancer treatment. The importance of information and the level of satisfaction with needs being met were assessed with the 5-point Likert scale. A total of 411 patients (50%) completed the survey. Almost all patients wanted information about the disease, tests and investigations, treatment, side-effects, sexuality, psychosocial support and financial matters, and most items listed in the questions in each selection were rated as important or very important. Responses indicate that patients were generally satisfied with the information provided especially on diagnosis and diagnostic tests, treatment and overall experience but there are information needs that need to be addressed more efficiently and effectively. The findings of this study support previous research which indicates that cancer patients who are receiving treatment have many information needs. Respondents were generally satisfied with the information provided, although some discrepancies were noted which reflect the complexities associated with cancer patient education.

Highlights • Adenoid Cystic Carcinoma is a malignant neoplasm originating in both major and minor salivary glands. • It is characterized by slow progression, local invasiveness and perineural invasion. • It may present as a hypoglossal nerve palsy. • When the diagnosis is in doubt, we suggest examination under anasthesia and deep biopsy., Introduction We describe a patient with an unusual presentation of an isolated hypoglossal nerve palsy as a result of perineural invasion (PI) from adenoid cystic carcinoma (ACC). We will also discuss the diagnostic pitfalls as well as present a short literature review of adenoid cystic carcinomas and suggest improvement to the current diagnostic algorithm for isolated hypoglossal nerve palsies. Presentation of case A 63 year old Malay female presented with progressive dysphagia and slurred speech for one year. Physical examination showed unilateral right tongue wasting, fasciculation and deviation to the right. An MRI showed atrophy of the tongue due to denervation and subsequently she was treated in a neurology clinic for 8 months. Due to lack of improvement, she was referred to our surgical unit and underwent examination under anaesthesia (EUA) and biopsy. Histology showed adenoid cystic carcinoma with perineural involvement, resulting in lower motor neuron signs. She underwent radiotherapy to the base of her tongue (70 Gy/35#). A PET-CT one month post treatment showed complete response. Discussion Adenoid cystic carcinoma (ACC) is a salivary gland neoplasm. It is characterized by local invasiveness with frequent recurrence and indolent growth. It affects major salivary glands more than minor salivary glands. In malignancies that have a propensity for PI such as ACC, patients may present atypically with nerve palsies. In infiltrative lesions, the primary tumour may not be evident on magnetic resonance imaging. Therefore, to achieve a diagnosis, a high index of suspicion is required. When the diagnosis is in question, deep biopsy and positron emission tomography may be useful.

Background Metastatic nasopharyngeal carcinoma (NPC) is commonly treated with palliative chemotherapy. The purpose of this study was to review the feasibility of metastasectomy for metachronous pulmonary and hepatic metastases from NPC. Methods We present 6 patients who developed metachronous metastases from NPC (4 patients with pulmonary metastases and 2 patients with hepatic metastases) and underwent curative resection. Results Four patients are still alive with no recurrence of NPC after metastasectomy. Two patients died with postoperative survival periods of 57 and 70 months and recurrence-free intervals of 14 and 39 months, respectively. Conclusion Metastasectomy is a feasible option for the treatment of metachronous and resectable oligometastatic NPC to the lung and liver. Application of appropriate selection criteria would be required. © 2015 Wiley Periodicals, Inc. Head Neck, 2015

Background The prognostic significance of lymph node density in oral squamous cell carcinoma (OSCC) has been well recognized. However, its use in a specific subsite of the tongue has not been evaluated. The purpose of this study was to determine the prognostic significance of lymph node density in tongue squamous cell carcinoma (SCC). Methods A retrospective analysis of 99 patients with tongue SCC who underwent primary curative resection and neck dissection was conducted. Overall survival (OS) and disease-specific survival (DSS) was used to evaluate the prognostic significance of lymph node density. Results Lymph node density (using a cutoff of 0.06) was shown to be an independent predictor of OS and DSS. The impact of lymph node density on OS and DSS remained significant on multivariate analysis, whereas conventional nodal staging was not. An alternative staging strategy incorporating depth of invasion and lymph node density performs better than conventional TNM staging in predicting survival. Conclusion Our data suggest that lymph node density is a reliable and applicable predictor of prognosis in patients with tongue SCC. © 2015 Wiley Periodicals, Inc. Head Neck, 2015

The aim of this study was to investigate the prevalence of Internet usage among cancer patients in seeking health-related information and the type of information sought. Sources of information received from, preferences for information sources and the perceived usefulness of information from these sources were also examined in this study. A self-administered questionnaire was used to evaluate the information needs of patients undergoing cancer treatment. The questionnaire also evaluated the current source and preferred source of information as well as their online information seeking behaviours. A total of 411 patients with cancer were recruited from an ambulatory cancer centre. The patients’ physicians and healthcare specialists comprised a large majority of the patients’ information sources; they were also the most preferred source of information. 59.1% of the respondents used the Internet to search for cancer-related information, namely diagnosis and treatment options, side effects of treatment and complementary and alternative therapy; demonstrating the importance of the above information. Physicians (60.3%) and healthcare specialists (26.5%) were the largest and most preferred sources of information for cancer patients in our study. It was not uncommon for cancer patients to use the Internet to search for additional information demonstrating the need to integrate this tool more effectively for knowledge transfer for those patients who want it. It is important for healthcare professionals to help cancer patients by directing them to sources of quality information (including websites). In addition, the provision of guidelines on how to evaluate health information on the Internet would be helpful to cancer patients.

BACKGROUND The current study was performed to report the long-term results of a trial comparing concurrent chemotherapy and radiotherapy (CCRT) with surgery and adjuvant radiotherapy (RT) in patients with stage III/IV nonmetastatic head and neck squamous cell carcinoma. METHODS Patients with stage III/IV resectable head and neck squamous cell carcinoma were randomized to surgery followed by RT or CCRT. The trial was halted prematurely due to poor accrual. Human papillomavirus status was tested on archival material using polymerase chain reaction sequencing. RESULTS Of the total of 119 patients, 60 patients were randomized to primary surgery (S arm) and 59 patients were randomized to CCRT (C arm). Human papillomavirus status was tested in 75 patients, and only 3 were found to be positive. The median follow-up for surviving patients was 13 years. Analysis of the entire cohort demonstrated no statistically significant difference in overall survival and disease-specific survival (DSS): 5-year rates were 45% versus 35% for overall survival (P = .262) and 56% versus 46% for DSS (P = .637) for the S arm and C arm, respectively. Analysis by subsites indicated that this difference favoring the S arm was mainly driven by survival data among patients with cancers of the oral cavity and maxillary sinus. For patients with oral cavity cancer, survival was significantly better in those who underwent primary surgery compared with CCRT; the 5-year DSS rate was 68% versus 12% for the S arm and C arm, respectively (P = .038). For patients with cancers of the maxillary sinus, the 5-year DSS rate was 71% for patients on the S arm and 0% for patients on the C arm (P = .05). CONCLUSIONS These long-term results demonstrate a significant advantage for primary surgery in patients with cancers of the oral cavity or maxillary sinus, providing strong support for primary surgery as the main modality of treatment for these subsites. In other subsites, CCRT and surgery with adjuvant RT were found to demonstrate similar efficacy for survival in patients with advanced resectable tumors. Cancer 2015;121:1599–1607. © 2015 American Cancer Society.

Background Nasopharyngeal carcinoma (NPC) has a high propensity for metastasis. The purpose of this study was for us to determine whether serglycin expression can be used to predict distant metastases. Methods Serglycin expression of tumor tissue of 112 patients with NPC was assessed based on percentage of tumor cells expressing serglycin, staining intensity, percentage of tumor-infiltrated lymphocyte (TIL) expressing serglycin and TIL-staining intensity. Results Risk factors for distant metastases include sex, smoking status, tumor intensity, and TIL percentage for serglycin. The odds of distant metastases was 4.13 and 0.18 in patients with strong tumor intensity and >50% TIL percentage, respectively. Based on a nomogram incorporating predictors, patients were stratified into 2 prognostic groups. The proportion of distant metastases in the high-risk group (strong tumor intensity and ≤50% TIL percentage) was 78% versus 19% in the low risk group (p

Ameloblastoma is a locally aggressive and disfiguring oral cavity tumour and surgical management is the mainstay of treatment. The ideal management of ameloblastoma should minimise recurrence, restore function and appearance and present minimal donor site morbidity. Conservative management is associated with minimal downtime but high recurrence rates. By contrast, segmental mandibulectomy with appropriate margins have much lower recurrence rates but presents the challenge of reconstruction. Osseointegrated (OI) implants and permanent dental prosthesis, while ideal, are not always available. We conducted a retrospective review on 30 consecutive patients at our centre with unicystic and multicystic ameloblastoma who were treated with segmental mandibular resection and free fibula flap reconstruction. Only three patients underwent OI implant insertion, with 40% of the patients not receiving any form of dental rehabilitation. We performed a functional and aesthetic outcome survey to determine patient satisfaction with this form of treatment. At an average follow-up of 5 years, there were no recurrences of tumour in our population. Of the 26 patients who responded to the survey, 96% of the patients reported that they were satisfied with their appearance, 88% reported an absolutely normal diet and 93% of the patients reported no problems with donor site function. Overall, we found that low uptake of dental rehabilitation did not adversely affect patient satisfaction and outcomes.

Objective: The objective of the study was to review 1) patient demographics, 2) hard tissue defect, 3) surgical information and outcomes, 4) early and late complications and 5) dental rehabilitation. Study Design: A retrospective review was carried out on 44 cases of mandibular ameloblastoma that were treated by resection and mandibular reconstruction using fibula grafts from October 1994 to October 2011 in local institutions. Results: The patients were predominantly Chinese (67.4%) with ages ranging from 11 to 57 years. Defect and surgical data were reviewed and there was only one failure of graft (2.3%). Early complications were observed in 10 patients (23.3%) while late complications were observed in six patients (14%). Dental rehabilitations were in the form of removable dentures (41.9%) and implant supported prostheses (4.7%). Conclusion: The fibula flap has been shown to be a reliable flap with low morbidity and also suitable for future dental rehabilitation.