Discretion in Capital Sentencing Instructions: Guided or Misguided?

Symposium: The Capital Jury Projec

Endoscopic repair of high-flow cranial base defects using a bilayer button.

OBJECTIVES/HYPOTHESIS: Repair of the skull base still begins with a direct repair of the dural defect. We present a new button closure for primary repair of the dura for high flow defects. STUDY DESIGN: Retrospective review. METHODS: We reviewed our 20 cases of primary button grafts and compared the results to the previous 20 high-flow open-cistern cerebrospinal fluid (CSF) cases. Subjects were excluded if they had no violation of the arachnoid space or potential for low-flow CSF leak. The button is constructed so that the inlay portion is at least 25% larger than the dural defect, and the onlay portion is just large enough to cover the dural defect. The two grafts are sutured together using two 4-0 Neurolon sutures and placed with the inlay portion intradurally and the onlay portion extradurally. RESULTS: The button graft repair of open-cisternal defects had a drop in CSF leak complications to 10% (2/20), and these two leaks were repaired with the button technique as the salvage surgery. This is a significant improvement over the 45% leak rate in the prebutton graft group (P \u3c .03). In our button graft group we used nasoseptal flaps on 16/20 repairs, and 1/2 repairs that leaked in the button group did not have a nasoseptal flap. Lumbar drains were used in approximately 38% in both groups (P = .83). CONCLUSIONS: The button graft can be used in conjunction with the nasal septal flap or as a stand-alone repair with good results reducing the postoperative leak rate to 10% for high-flow CSF repairs

Single institution implementation of permanent 131Cs interstitial brachytherapy for previously irradiated patients with resectable recurrent head and neck carcinoma

Purpose: Permanent interstitial brachytherapy is an appealing treatment modality for patients with locoregional recurrent, resectable head and neck carcinoma (HNC), having previously received radiation. Cesium-131 (131Cs) is a permanent implant brachytherapy isotope, with a low average photon energy of 30 keV and a short half-life of 9.7 days. Exposure to medical staff and family members is low; patient isolation and patient room shielding are not required. This work presents a single institution’s implementation process of utilizing an intraoperative, permanent 131Cs implant for patients with completely resected recurrent HNC. Materials & Methods: Fifteen patients receiving 131Cs permanent seed brachytherapy were included in this analysis. The process of pre-planning, selecting the dose prescription, seed ordering, intraoperative procedures, post-implant planning, and radiation safety protocols are described. Results: Tumor volumes were contoured on the available preoperative PET/CT scans and a pre-implant treatment plan was created using uniform source strength and uniform 1 cm seed spacing. Implants were performed intraoperatively, following tumor resection. In five of the fifteen cases, intraoperative findings necessitated a change from the planned number of seeds and recalculation of the pre-implant plan. The average prescription dose was 56.1 ±6.6 Gy (range, 40-60 Gy). The average seed strength used was 2.2 ±0.2 U (3.5 ±0.3 mCi). Patients returned to a recovery room on a standard surgical floor and remained inpatients, without radiation safety restrictions, based on standard surgical recovery protocols. A post-implant treatment plan was generated based on immediate post-operative CT imaging to verify the seed distribution and confirm delivery of the prescription dose. Patients were provided educational information regarding radiation safety recommendations. Conclusions: Cesium-131 interstitial brachytherapy is feasible and does not pose major radiation safety concerns; it should be considered as a treatment option for previously irradiated patients with recurrent, resectable HNC

Avoidance of Maxillary Swing for Nasopharyngectomy via Combined Open Lateral and Endoscopic Approach

Objectives: Nasopharyngectomy performed via a solely endoscopic approach has limitations in access and feasibility, particularly regarding management of the carotid artery. To address these limitations, we report three cases with one cadaver dissection where nasopharyngectomy was performed via a combined open lateral an endoscopic approach. We highlight the benefits and technical considerations for this operative technique. Study Design: Case Series Methods: Patients diagnosed with recurrent nasopharyngeal carcinoma (NPC) that underwent combined open lateral and endoscopic nasopharyngectomy from 2016-2020 were analyzed. A cadaver dissection was also performed. Results: We present the details of the approach and follow-up in three patients with recurrent nasopharyngeal carcinoma. Briefly, a preauricular incision is extended down to the neck. The zygoma and mandibular ramus can be removed and replaced if required. V3, the pterygoid plates and the eustachian tube can be resected or mobilized. The carotid artery may be identified proximally in the neck and traced to the skull base, where the carotid canal may be drilled to the level of the foramen lacerum and protected with a pledget. Then, tumor mucosal cuts are made via an endoscopic endonasal approach and connected to the lateral exposure. No carotid artery injuries occurred. Conclusion: The combined open lateral approach and endoscopic nasopharyngectomy technique is a useful technique in salvage patients. It provides excellent control of major vessels, adequate access to the carotid canal, V3, and remainder of the skull base, and cervical protection.https://jdc.jefferson.edu/otoposters/1009/thumbnail.jp

Free Tissue Transfer for Central Skull Base Defect Reconstruction: Case Series and Surgical Technique

Objectives: Local reconstruction of central skull base defects may be inadequate for large defects or reoperative cases; free tissue transfer may be necessary. Inset of the flap and management of the pedicle can be challenging. We report our experience and approach. Methods: Retrospective review identifying seven patients with central skull base defects who underwent free flap reconstruction from 2016-2020. Results: Four patients with recurrent nasopharyngeal carcinoma, one with recurrent craniopharyngioma, one with clival-cervical chordoma, and one with meningioma of the middle cranial fossa were analyzed. Six defects were closed with an anterolateral thigh free flap and one with a radial forearm free flap. In two patients, the flap was secured in an onlay fashion to the defect via a Caldwell-Luc transmaxillary approach. In one patient, the flap was passed transorally, and the pedicle was delivered into the neck via Penrose drain. In two patients, a parapharyngeal technique and in two others, a retropharyngeal was used for nasopharyngeal inset with endoscopic assistance. There were no flap failures, with an average follow-up time of 20.1 (range 3.2 - 47.1) months. One patient required flap repositioning on postoperative day three due to midline shift and intracranial contents compression. The transoral inset flap necessitated flap repositioning on postoperative day 13 to improve the nasopharyngeal airway. Conclusion: Free flap reconstruction of the central skull base is challenging, but transmaxillary, transoral, parapharyngeal, and retropharyngeal approaches can be used with endoscopic assistance to ensure secure inset flap and avoid airway obstruction

The Effect of Passively Viewing a Consent Campaign Video on Attitudes Toward Rape

© Copyright © 2020 Rowe and Hills. Around 90% of rape victims know their perpetrator, making acquaintance rape the most common form of rape, contradicting societal beliefs. There is ambiguity about the meaning and use of consent in sexual scenarios (Beres, 2007). This study used a mixed methods approach to test the effectiveness of a campaign video aimed at increasing understanding of consent. We assessed whether the video affected rape judgments in vignettes depicting consensual or non-consensual sexual scenarios. We also manipulated whether making consent the primary or secondary question influenced attitudes. Text responses were also obtained to gain an insight into participant reasoning. The campaign showed no increase in rape judgments. Making consent primary in question order did lead to greater accuracy in rape judgment. A content analysis of the free-text responses indicated that the presence of the campaign actually reduced people’s use of consent in explaining why a scenario may represent rape: Instead they focused on the attractiveness of the attacker. These results are discussed in relation to the effectiveness of passively viewing campaign material

Astrometry and Photometry for Cool Dwarfs and Brown Dwarfs

Trigonometric parallax determinations are presented for 28 late type dwarfs and brown dwarfs, including eight M dwarfs with spectral types between M7 and M9.5, 17 L dwarfs with spectral types between L0 and L8, and three T dwarfs. Broadband photometry at CCD wavelengths (VRIz) and/or near-IR wavelengths (JHK) are presented for these objects and for 24 additional late-type dwarfs. Supplemented with astrometry and photometry from the literature, including ten L and two T dwarfs with parallaxes established by association with bright, usually HIPPARCOS primaries, this material forms the basis for studying various color-color and color-absolute magnitude relations. The I-J color is a good predictor of absolute magnitude for late-M and L dwarfs. M_J becomes monotonically fainter with I-J color and with spectral type through late-L dwarfs, then brightens for early-T dwarfs. The combination of zJK colors alone can be used to classify late-M, early-L, and T dwarfs accurately, and to predict their absolute magnitudes, but is less effective at untangling the scatter among mid- and late-L dwarfs. The mean tangential velocity of these objects is found to be slightly less than that for dM stars in the solar neighborhood, consistent with a sample with a mean age of several Gyr. Using colors to estimate bolometric corrections, and models to estimate stellar radii, effective temperatures are derived. The latest L dwarfs are found to have T_eff ~ 1360 K.Comment: 48 pages, including 7 figures and 6 tables. Accepted for A

Tadalafil Enhances Immune Signatures in Response to Neoadjuvant Nivolumab in Resectable Head and Neck Squamous Cell Carcinoma

Purpose: We hypothesize that the addition of the phosphodiesterase-5 inhibitor tadalafil to the PD-1 inhibitor nivolumab, is safe and will augment immune-mediated antitumor responses in previously untreated squamous cell carcinoma of the head and neck (HNSCC). Patients and methods: We conducted a two-arm multi-institutional neoadjuvant randomized trial in any-stage resectable HNSCC (NCT03238365). Patients were stratified at randomization by human papillomavirus (HPV) status. Patients in both arms received nivolumab 240 mg intravenously on days 1 and 15 followed by surgery on day 28. Those in the combination therapy arm also received tadalafil 10 mg orally once daily for 4 weeks. Imaging, blood, and tumor were obtained pretreatment and posttreatment for correlative analysis. Results: Neoadjuvant therapy was well-tolerated with no grade 3 to 5 adverse events and no surgical delays. Twenty-five of 46 (54%) evaluable patients had a pathologic treatment response of ≥20%, including three (7%) patients with a complete pathologic response. Regardless of HPV status, tumor proliferation rate was a negative predictor of response. A strong pretreatment T-cell signature in the HPV-negative cohort was a predictor of response. Tadalafil altered the immune microenvironment, as evidenced by transcriptome data identifying enriched B- and natural killer cell gene sets in the tumor and augmented effector T cells in the periphery. Conclusions: Preoperative nivolumab ± tadalafil is safe in HNSCC and results in more than 50% of the patients having a pathologic treatment response of at least 20% after 4 weeks of treatment. Pretreatment specimens identified HPV status-dependent signatures that predicted response to immunotherapy while posttreatment specimens showed augmentation of the immune microenvironment with the addition of tadalafil

Discretion in Capital Sentencing Instructions: Guided or Misguided?

Symposium: The Capital Jury Projec