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Objectives To determine whether altered mental status (AMS) as a presenting symptom in older adults with COVID-19 is independently associated with adverse outcomes. Methods A retrospective single center observational study of admitted patients (n = 421) age greater than 60 and a positive COVID-19 test. Outcomes included mortality, intubation, acute respiratory distress syndrome, acute kidney injury, and acute cardiac injury. Multivariate regression analysis was used to determine if presenting with AMS was associated with adverse outcomes. Results There was an increased risk of mortality (RR 1.29, 95% CI 1.05–1.57), intubation (RR 1.52, 95% CI 1.09–2.12) and AKI (RR 1.42, 95% CI 1.13–1.78) in patients that presented with AMS. Conclusions During a global pandemic, prognostic indicators are vital to help guide the clinical course of patients, reduce healthcare cost, and preserve life. Our study suggests that AMS can play a major role in diagnostic algorithms in older adults with COVID-19.

Purpose The American College of Surgeons Oncology Group trial Z0011 demonstrated that axillary node dissection (ALND) can be omitted in patients managed with breast conserving surgery and 1 to 2 positive sentinel lymph nodes (SLNs) without adverse effects on locoregional recurrence or disease-free survival (DFS). We investigated patients with breast cancer for whom clinicopathologic features were underrepresented in the Z0011 trial and analyzed radiation therapy treatment patterns and clinical outcomes. Methods and materials We retrospectively reviewed records of patients who underwent a lumpectomy and SLN biopsy with positive SLNs but not an ALND and completed adjuvant radiation therapy. Eligible patients had T3 tumors, >2 positive SLNs, invasive lobular carcinoma, estrogen receptor negative status, extranodal extension, Nottingham Grade 3, or were age Results We identified 105 women treated between July 2011 and July 2016 with a median follow-up time of 48.5 months (Range, 11-83 months). There were 40 women with an extranodal extension (38.9%) and 42 women with grade 3 disease (40.0%). Nineteen patients received whole breast irradiation alone (18.1%) and 86 patients were treated with modified tangent fields including the superior axilla level I/II (81.9%). Thirty-three patients (31.4%) also received a 3rd supraclavicular, nodal-directed field. Among the 86 patients who received axillary nodal irradiation, nodal volume contouring was performed in 77 patients (89.5%). Fifty-one patients (48.6%) also received adjuvant chemotherapy. The overall rates of 4-year DFS and locoregional control (LRC) were 94.3% and 98.1%, respectively. Off all patients, 1 patient experienced an internal mammary nodal recurrence, another patient a contralateral breast tumor, and two patients distant metastases. There were no axillary or ipsilateral breast tumor recurrences. Conclusions This retrospective analysis of women who were underrepresented or excluded from the Z11 trial and underwent a lumpectomy and SLN biopsy with positive SLNs demonstrated comparable rates of LRC and DFS. The high rates of LRC and DFS suggest that completion ALND may be safely omitted in this patient population but larger data sets and longer follow-up times are needed to confirm this finding.

Background Studies demonstrate safety of omitting axillary nodal dissection for early-stage breast cancer with positive sentinel lymph node (+SLN) biopsy, although trial designs differed in radiation therapy (RT) fields. Regional nodal irradiation was separately shown to improve outcomes in high-risk patients. This led to lack of consensus in RT volumes. Clinical pathways (CPs) standardize care where practice varies unnecessarily. We evaluated the impact of changes to a CP guiding postoperative RT in women with +SLNs on practice patterns throughout a network. Methods and materials We implemented a CP for management of breast cancer with postoperative RT designed to promote uniform nodal treatment. The CP recommended modified tangents (MTs) including level I/II nodes for women with micrometastases (pN1mi). For women with macrometastases (pN1a), CPs recommended including level I/II LN in MT and a third supraclavicular node (SCN) LN ± internal mammary nodes for women with adverse factors present. Results RT fields of 233 women undergoing breast-conserving surgery with +SLN but not axillary nodal dissection were retrospectively reviewed: 25% had pN1mi disease and 75% pN1a. Of 127 women treated before CP changes, 35% with pN1mi and 22% with pN1a were treated with whole-breast irradiation alone. Following CP changes, 106 women were treated: 5% with whole-breast irradiation alone, 58% with MT, and 38% with MT + SCN field. Utilization of MT was associated with CP changes. Utilization of a third SCN field was associated with CP changes, pN stage, extracapsular extension, and total number of adverse factors. Conclusions CPs translate published data and institutional experience into management plans that promote evidence-based care and eliminate unnecessary practice variations. Recognizing that postoperative RT treatment volumes were heterogeneous, we modified the CP based upon the latest evidence for regional nodal irradiation, after which we found increased compliance and consistency with quality guidelines, which will also aid in tracking outcomes in future investigations.

Background In orthopedic and sports medicine literature there is minimal information regarding accurate diagnosis and the treatment options for tenosynovitis of the distal semimembranosus tendon. After reviewing the literature, the authors question both the etiology and treatment of this condition. Previous descriptions have associated the condition primarily with the endurance athlete but we have noted multiple cases in which this is a condition common to the ‘sprinter' as well. There has been very little mention of this condition in recent literature but the most recent complete description of operative treatment for this condition recommends both tendon transfer and concomitant arthroscopy. We propose this condition is akin to De Quervain's tenosynovitis of the knee, with sensitive and specific signs on physical examination. Methods We describe a case series of six cases (five patients), that underwent open surgical release for semimembranosus tenosynovitis. The anatomy and the treatment options for the condition are also discussed. Results At a follow-up period of 18–64months, all cases showed improvement in the Tegner activity score following surgical release. Conclusion Diagnostic confusion can be decreased with more modern diagnostic imaging modalities than those described in the literature. The authors outline an alternative operative approach significantly decreasing surgical complexity and therefore post-operative morbidity. What is known about this subject: This is a rare condition and the surgical treatment is seldom performed. What this study adds to existing knowledge: We describe the technique for surgical decompression and reveal positive results at medium term follow-up.

Natural rubber latex (NRL) is present within many dental products including local anaesthetic (LA) cartridges. Patients with NRL sensitivity are at risk of developing type I and type IV allergic reactions from exposure to these products. Evidence from current literature is inconclusive yet highly suggestive that NRL contamination may occur in medicines stored within vials containing natural rubber components. It would therefore be prudent to avoid using such products in patients with a known NRL allergy. For dental practitioners this applies to LA cartridges and is easily achievable, as manufacturers now produce products not made with NRL. This article aims to provide guidance for dental health professionals regarding the use of LA in patients with a known NRL hypersensitivity. CPD/Clinical Relevance: NRL allergies are a rising concern amongst medical professions and these reactions should be avoided wherever possible.

Objectives: Long-term quality-of-life data following stereotactic body radiation therapy (SBRT) for recurrent head and neck cancer (rHNC) is underreported. We report patient-reported quality-of-life (PR-QOL) after at least 1 year post-treatment.Methods and Materials: A retrospective review was performed on 64 patients receiving SBRT for previously-irradiated rHNC. PR-QOL was prospectively evaluated using the University of Washington Quality of Life Questionnaire. The mixed effects proportional odds model was used to assess post-treatment overall PR-QOL changes, as well as the effects of late toxicities, tumor volume > 25 cc, local failure, nodal recurrence, distant failure, prior neck dissection, performance status other than ECOG 0 or Karnofsky 100, sex, age >65, squamous vs. non-squamous primary histology, and specific organ recurrence.Results: SBRT had no significant effect on overall PR-QOL at days 1-90 post-treatment (SBRT effect 0.035, p = 0.93) and days 91–365 (SBRT effect −0.30, p = 0.45). Beyond day 365, overall PR-QOL was significantly worse than baseline (SBRT effect −0.77, p =.03). Grade ≥3 late toxicities (p = 0.0072) and tumor volume > 25 cc (p = 0.032) predicted significantly worse overall PR-QOL. Oral cavity recurrence predicted significant decrements in chewing (p = 0.0006), swallowing (p = 0.0301), and taste PR-QOL (p = 0.02). Nasal recurrence predicted significant decrements in taste PR-QOL (p = 0.030). Grade ≥3 late dysphagia predicted significant decline in chewing (p = 0.039) and swallowing (p = 0.0004). Grade ≥3 late osteonecrosis predicted significant differences in pain PR-QOL (p = 0.0026).Conclusion: PR-QOL across several domains declines immediately after SBRT for previously-irradiated rHNC before returning to baseline levels at 1 year. Long-term PR-QOL declines thereafter. Patients with grade ≥3 late toxicities or tumor volume >25 cc report reduced long-term overall PR-QOL, likely representing late disease progression. Specific organ recurrence and grade ≥3 late toxicities predict decrements in specific PR-QOL domains.

Purpose Many patients with endometrial cancer cannot undergo surgery and instead receive definitive radiation therapy (RT). We investigate the correlation between MRI response to RT and clinical outcomes. Methods and Materials Women with inoperable, clinical Stage I endometrial cancer were treated with definitive brachytherapy (BT) with/without pelvic RT (PRT). Patients underwent MRI with functional diffusion-weighted imaging before and after RT. A radiologist retrospectively classified cases as complete, partial, or indeterminate response (CR, PR, or IR, respectively) vs. disease progression. Local control was clinicopathologically defined. Results From 2007 to 2017, 50 women underwent definitive RT. Thirty-five (70%) received BT alone (median dose 37.5 Gy). For combined therapy, the median PRT and BT doses were 45 and 25 Gy, respectively. Median gross tumor volume and high-risk clinical target volume were 7.1 cc and 90.0 cc, respectively. Median followup among living patients was 20 months. All patients underwent post-RT MRI with T1/T2 sequencing at a median of 3.2 months after RT; 40 patients (80%) underwent functional diffusion-weighted imaging sequences. On initial post-RT MRI, CR was documented in 42 patients (84%), IR in 1 patient (2%), and PR in seven patients (14%). At median followup of 16.3 months, no CR patients had uterine failure. Among eight patients with initial PR/IR, all were found to be clinicopathologically no evidence of disease at the uterus on further evaluation. Conclusions Definitive RT with BT or BT + PRT is associated with high response rates on MRI. Overall, initial CR predicted for excellent outcome with no infield failure.

Hepatoid adenocarcinoma (HAC) is a rare tumor that typically originates in gastrointestinal tissue, such as the stomach, but can also occasionally originate in the lung. The majority of HACs express α-fetoprotein (AFP) on tumor cells, and serum AFP can be used as a marker of response to treatment or disease progression. HAC has a poor prognosis, although early diagnosis and aggressive treatment can result in long-term survival. To the best of our knowledge, this is the first reported case of HAC metastasizing to the tonsil. Irradiation using intensity-modulated radiation therapy (IMRT) to 30 Gray (Gy) achieved a significant, and durable tumor response. IMRT can be considered for local control of HAC at other metastatic sites of disease.

Acid-terminated polyglycolide microparticles (PG-MP) were prepared as a versatile substrate that could be surface-modified for either immobilization of anti-cd3 and anti-cd28 mAb to activate T cells or sustained release of granulocyte-macrophage colony stimulating factor (GM-CSF) for dendritic cell (DC) recruitment and maturation. PG-MP were prepared with a volume-weighted mean diameter of 56 or 57 microm. Accessible carboxylic acid group concentration was determined by potentiometric titration to be 0.3 mmole/g and corresponded to a zeta potential of -21.87 mV. PG-MP immobilized with either anti-human CD3/CD28 or anti-mouse cd3/cd28 induced significant proliferation of T cells. Intracellular flow cytometry in activated mouse T cells was significant for IFN-gamma, but not IL-4. Microparticles surface-modified for GM-CSF release were prepared from either PG-MP or PG pre-treated with poly-L-lysine (PG-Lys) to manipulate surface charge. GM-CSF released from PG-Lys-MP was observed for up to 26 days. The biologic activity of released GM-CSF was confirmed by using a h-GM-CSF-dependent cell line. The efficacy of the alpha-cd3/cd28-MP and GMCSF-MP was studied in a syngeneic mouse tumor prevention and regression model. Co-injection of Meth A fibrosarcoma cells with alpha-cd3/cd28-MP and GMCSF-MP completely prevented tumor implantation (0/24). The regression model showed complete tumor regression in four of seven animals and stable disease in three of seven. In the latter study, a dramatic level of DC infiltration was observed compared to controls.

The pubic scars of pregnancy and parturition as reported in the anthropological literature are a variant of the recognized clinical entity, osteitis pubis. The os pubis from 86 pre-Columbian and colonial Peruvian mummies were examined for this entity. Osteitis pubis was found in 13 pre-Columbian females (72.3%) and 19 colonial Indians (57.6%). Four of the colonial women were buried with newborn children and one had a four-month-old fetus in utero. This type of study has application in paleopathology and forensic medicine to show possible frequency of pregnancy in a population, but must be refined and quantitated to achieve any more than this. This study is of further interest as it demonstrates that racial groups have apparently a wide difference in frequency of this particular lesion of the pubic symphysis, a matter for further investigation.