Influenza : Antiviral Chemoprophylaxis

 in Community Settings

X. Who should be considered for antiviral chemoprophylaxis to prevent influenza in the absence of exposure or an institutional outbreak (preexposure chemoprophylaxis)?

Antiviral drugs should not be used for routine or widespread chemoprophylaxis outside of institutional outbreaks; antiviral chemoprophylaxis can be considered in certain situations:

32. Clinicians can consider antiviral chemoprophylaxis for the duration of the influenza season for adults and children aged ≥3 months who are at very high risk of developing complications from influenza and for whom influenza vaccination is contraindicated, unavailable, or expected to have low effectiveness (eg, persons who are severely immunocompromised) (C-II).
33. Clinicians can consider antiviral chemoprophylaxis for the duration of the influenza season for adults and children aged ≥3 months who have the highest risk of influenza-associated complications, such as recipients of hematopoietic stem cell transplant in the first 6–12 months posttransplant and lung transplant recipients (B-II).
34. Clinicians can consider short-term antiviral chemoprophylaxis in conjunction with prompt administration of inactivated influenza vaccine for unvaccinated adults and children aged ≥3 months who are at high risk of developing complications from influenza in whom influenza vaccination is expected to be effective (but not yet administered) when influenza activity has been detected in the community (C-II).
35. Clinicians can consider short-term antiviral chemoprophylaxis for unvaccinated adults, including healthcare personnel, and for children aged ≥3 months who are in close contact with persons at high risk of developing influenza complications during periods of influenza activity when influenza vaccination is contraindicated or unavailable and these high-risk persons are unable to take antiviral chemoprophylaxis (C-III).
36. Clinicians can consider educating patients and parents of patients to arrange for early empiric initiation of antiviral treatment as an alternative to antiviral chemoprophylaxis (C-III).

XI. Which antiviral drugs should be used for preexposure chemoprophylaxis for influenza?

37. Clinicians should use an NAI (oral oseltamivir or inhaled zanamivir) if preexposure chemoprophylaxis for influenza is administered rather than an adamantane antiviral (A-II).

XII. What is the duration of preexposure antiviral chemoprophylaxis to prevent influenza?

38. Clinicians should administer preexposure antiviral chemoprophylaxis for adults and children aged ≥3 months who are at very high risk of developing complications from influenza (eg, severely immunocompromised persons such as hematopoietic stem cell transplant recipients) for whom influenza vaccination is contraindicated, unavailable, or expected to have low effectiveness, as soon as influenza activity is detected in the community and continued for the duration of community influenza activity (A-II).
39. Clinicians should test for influenza and switch to antiviral treatment dosing in persons receiving preexposure antiviral chemoprophylaxis who become symptomatic, preferably with an antiviral drug with a different resistance profile if not contraindicated (A-II).

XIII. Which asymptomatic persons exposed to influenza should be considered for postexposure antiviral chemoprophylaxis in a noninstitutional setting?

40. Clinicians can consider postexposure antiviral chemoprophylaxis for asymptomatic adults and children aged ≥3 months who are at very high risk of developing complications from influenza (eg, severely immunocompromised persons) and for whom influenza vaccination is contraindicated, unavailable, or expected to have low effectiveness, after household exposure to influenza (C-II).
41. Clinicians can consider postexposure antiviral chemoprophylaxis (in conjunction with influenza vaccination) for adults and children aged ≥3 months who are unvaccinated and are household contacts of a person at very high risk of complications from influenza (eg, severely immunocompromised persons), after exposure to influenza (C-II).
42. Clinicians can consider educating patients and arranging for early empiric initiation of antiviral treatment as an alternative to postexposure antiviral chemoprophylaxis (C-III).

XIV. When should postexposure antiviral chemoprophylaxis be started?

43. If chemoprophylaxis is given, clinicians should administer postexposure antiviral chemoprophylaxis as soon as possible after exposure, ideally no later than 48 hours after exposure (A-III).
44. Clinicians should not administer once-daily postexposure antiviral chemoprophylaxis if >48 hours has elapsed since exposure. Full-dose empiric antiviral treatment should be initiated as soon as symptoms occur, if treatment is indicated (A-III).

XV. How long should postexposure antiviral chemoprophylaxis be given?

45. Clinicians should administer postexposure antiviral chemoprophylaxis in a nonoutbreak setting for 7 days after the most recent exposure to a close contact with influenza (A-III).
46. Clinicians should test for influenza and switch to antiviral treatment dosing in persons receiving postexposure antiviral chemoprophylaxis who become symptomatic, preferably with an antiviral drug with a different resistance profile if not contraindicated (A-III).

XVI. Which antiviral drugs should be used for postexposure chemoprophylaxis?

47. Clinicians should administer an NAI (inhaled zanamivir or oral oseltamivir) if postexposure chemoprophylaxis for influenza is given, rather than an adamantane antiviral (A-II).

https://www.idsociety.org/practice-guideline/influenza/

Depth of invasion alone as a prognostic factor in low‐risk early‐stage oral cavity carcinoma

Objectives

To evaluate the significance of increasing depth of invasion (DOI) as the sole risk factor for recurrence in patients with low‐risk early‐stage oral cavity squamous cell carcinoma (OCSCC).

Methods

We retrospectively reviewed 560 patients with OCSCC treated at our institution between 2003 and 2013. Patients were included if they had low‐risk early‐stage OCSCC treated with surgical resection ± neck dissection and no adjuvant therapy. Low risk was defined as absence of positive or close margins, lymphovascular invasion, perineural invasion, and positive lymph nodes. Patients with tumor (T)3‐T4 disease were excluded. Pathology specimens were independently re‐reviewed by two board‐certified pathologists to confirm proper measurement of DOI. Kaplan‐Meier and Cox proportional hazards regression analyses were performed to identify factors predictive for recurrence as well as progression‐free survival (PFS) and overall survival (OS).

Results

A total of 126 patients with low‐risk early‐stage T1‐2N0 OCSCC were included. Median follow‐up time was 42.5 months and median DOI was 4 mm. There was no significant difference in incidence of local (P = 0.95), regional (P = 0.81), or distant recurrence (P = 0.96) among patients with DOI < 4 mm versus ≥4 mm. On multivariable analysis, DOI was significant for both PFS (P = 0.03) and OS (P = 0.002).

Conclusion

In this study, we show that in the absence of other high‐risk pathologic features, DOI ≥ 4 mm does not portend for increased incidence of local, regional, or distant relapse in patients treated with surgery alone; however, increasing DOI is a marker for worse PFS and OS in patients with low‐risk, early‐stage OCSCC.

Level of Evidence

4. Laryngoscope, 2019

http://bit.ly/2F31KFR

Mandibular muscle attachments in genial advancement surgery for obstructive sleep apnea

Objectives/Hypothesis

Genioglossus advancement is performed in select patients with obstructive sleep apnea. Surgical techniques attempt to capture the genial tubercle of the mandible; however, measurements of the genioglossus, geniohyoid, and digastric muscles are poorly delineated. This investigation is the largest anatomic study exploring the muscles of genial advancement surgery and the first to quantitatively characterize muscular attachments relative to the tubercle, providing new insights from an anatomic perspective on optimizing muscular advancement.

Study Design

Cadaveric study.

Methods

Fifty‐three fresh cadaveric mandibles underwent dissection of the genial tubercle and genioglossus, geniohyoid, and digastric muscles.

Results

Genial tubercle, geniohyoid, and genioglossus mean height was 7.78 mm, 5.15 mm, and 6.11 mm, respectively. On average, the geniohyoid began 4.88 mm and ended 10.03 mm from the inferior border of the mandible; the genioglossus 11.91 mm and 18.01 mm, similarly. Intermuscular distance, if present, was 2.67 mm; the muscles overlapped in 28% of cadavers. The combined vertical height of the muscles at their mandibular attachment was 13.94 mm, significantly differing from the height of the genial tubercle. The left and right lateral insertion of the digastric muscles was 19.34 mm and 19.31 mm, respectively, from midline.

Conclusions

The variable range of muscle attachments suggests that genioglossal and geniohyoid attachments extend beyond the genial tubercle and may not originate concentrically from the tubercle, but overlap and lie in very close proximity. Mandibular anterior muscle attachments require anatomic accuracy and an effective operative evaluation of advancement before reproducible, clinically effective osteotomies can be recommended.

Level of Evidence

NA Laryngoscope, 2019

http://bit.ly/2F9pmYH

Comparing short‐term outcomes of surgery and voice therapy for patients with vocal fold polyps

Objectives/Hypothesis

Optimal treatment for patients with vocal fold polyps (VFPs) remains controversial. We compared the short‐term outcomes of treatment with voice therapy alone (VT), surgery alone (SUR)m or voice therapy and surgery (VTS).

Study Design

Retrospective case series.

Methods

A retrospective study was performed for patients diagnosed with VFP (International Classification of Diseases, Ninth Revision code 478.4 and Tenth Revision code J38.1) between January 2010 and April 2016. Inclusion criteria were age greater than 18 years and charted evidence of treatment with voice therapy, surgery, or both. Exclusion criteria were history of laryngeal cancer or radiation above the clavicles. Outcomes measured included chart records of lesion absence, persistence or recurrence, and differences between pretreatment and post‐treatment Voice Handicap Index‐10 and GRBAS (G/grade, R/roughness, B/breathiness, A/asthenia, S/strain) scores.

Results

One hundred twenty patients with VFPs were identified (SUR = 23, 19.2%, VT = 29, 24.2%, VTS = 68, 56.7%). Mean follow‐up was 5.5 months. There were no recurrences in 115 patients (95.8%). There was significant improvement from pre‐ to post‐treatment VHI‐10 scores in the SUR (mean improvement = 12.5, standard deviation [SD] = 12.7) and VTS (mean improvement = 12.3, SD = 10.3) groups compared to the VT (mean improvement = 2.84, SD = 11.9) group (P = .009). Pre‐ and post‐treatment GRBAS scores did not significantly change in any group.

Conclusions

When using patient‐reported outcomes measures, patients with VFPs receive the greatest short‐term gains from treatment paradigms involving surgery or a combination of surgery and voice therapy. Voice therapy alone did not result in significant short‐term changes. Perceptual voice characteristics did not change significantly for any group. Further research on long‐term treatment outcomes for patients with VFPs is needed.

Level of Evidence

3 Laryngoscope, 2019

http://bit.ly/2F4c28w

A survey of anesthetic preference and preoperative anxiety in hip and knee arthroplasty patients: the utility of the outpatient preoperative anesthesia appointment

Abstract

Purpose

The general public's perceptions of anesthesia and the risks associated with it may be skewed. The outpatient preoperative appointment with an anesthesiologist allows for patient education regarding different anesthetic options and counseling regarding anxiety related to anesthesia and surgery. This study investigates whether the preoperative appointment for hip and knee arthroplasty alters patient preference for general or spinal anesthesia and reduces patient anxiety.

Methods

Sixty-two patients undergoing hip or knee arthroplasty were administered two verbal questionnaires at the preoperative clinic. The first questionnaire was completed prior to meeting the anesthesiologist and addressed patient anesthetic preferences, previous anesthetic experiences, and perioperative anxiety and need for information using the Amsterdam Preoperative Anxiety and Information Scale (APAIS). The second questionnaire was completed immediately following the appointment and addressed the patient's anesthetic preference, reasons for any preference changes, and anxiety levels and need for information using the APAIS. The clinic anesthesiologist was blinded to the nature of the study.

Results

Following the clinic appointment, a significant decrease in patients wanting general anesthesia (from 48 to 18%, P < 0.001) and a significant increase in patients wanting spinal anesthesia (from 39 to 76%, 95%, P < 0.01) was noted. A significant decrease in overall anxiety and anxiety related to the patients' upcoming surgeries and need for information was also noted.

Conclusions

The preoperative anesthesia meeting serves an important role in educating patients regarding anesthesia, and can influence patients' choice of anesthetic while also reducing overall patient anxiety.

http://bit.ly/2VsUuI3

Influenza : Treatment

IV. Which patients with suspected or confirmed influenza should be treated with antivirals?

18. Clinicians should start antiviral treatment as soon as possible for adults and children with documented or suspected influenza, irrespective of influenza vaccination history, who meet the following criteria:
    • Persons of any age who are hospitalized with influenza, regardless of illness duration prior to hospitalization (A-II).
    • Outpatients of any age with severe or progressive illness, regardless of illness duration (A-III).
    • Outpatients who are at high risk of complications from influenza, including those with chronic medical conditions and immunocompromised patients (A-II).
    • Children younger than 2 years and adults ≥65 years (A-III).
    • Pregnant women and those within 2 weeks postpartum (A-III).

19. Clinicians can consider antiviral treatment for adults and children who are not at high risk of influenza complications, with documented or suspected influenza, irrespective of influenza vaccination history, who are either:
    • Outpatients with illness onset ≤2 days before presentation (C-I).
    • Symptomatic outpatients who are household contacts of persons who are at high risk of developing complications from influenza, particularly those who are severely immunocompromised (C-III).
    • Symptomatic healthcare providers who care for patients who are at high risk of developing complications from influenza, particularly those who are severely immunocompromised (C-III)

V. For patients who are recommended to receive antiviral treatment for suspected or confirmed influenza, which antiviral should be prescribed, at what dosing, and for what duration?

20. Clinicians should start antiviral treatment as soon as possible with a single neuraminidase inhibitor (NAI) (either oral oseltamivir, inhaled zanamivir, or intravenous peramivir) and not use a combination of NAIs (A-I).
21. Clinicians should not routinely use higher doses of US Food and Drug Administration–approved NAI drugs for the treatment of seasonal influenza (A-II).
22. Clinicians should treat uncomplicated influenza in otherwise healthy ambulatory patients for 5 days with oral oseltamivir or inhaled zanamivir, or a single dose of intravenous peramivir (A-I).
23. Clinicians can consider longer duration of antiviral treatment for patients with a documented or suspected immunocompromising condition or patients requiring hospitalization for severe lower respiratory tract disease (especially pneumonia or acute respiratory distress syndrome [ARDS]), as influenza viral replication is often protracted (C-III).

VI. In a patient with suspected or confirmed influenza, when should bacterial coinfectoin of the upper or lower respiratory tract be considered, investigated, and treated?

24. Clinicians should investigate and empirically treat bacterial coinfection in patients with suspected or laboratory-confirmed influenza who present initially with severe disease (extensive pneumonia, respiratory failure, hypotension, and fever), in addition to antiviral treatment for influenza (A-II).
25. Clinicians should investigate and empirically treat bacterial coinfection in patients who deteriorate after initial improvement, particularly in those treated with antivirals (A-III).
26. Clinicians can consider investigating bacterial coinfection in patients who fail to improve after 3–5 days of antiviral treatment (C-III).

VII. If a patient with influenza does not demonstrate clinical improvement with antiviral treatment or demonstrates clinical deterioration during or after treatment, what additional testing and therapy should be considered?

27. Clinicians should investigate other causes besides influenza virus infection in influenza patients who fail to improve or deteriorate despite antiviral treatment (A-III).

VIII. When should testing be done for infection with an antiviral-resistant influenza virus?

28. Influenza NAI resistance testing can be considered for:
    • Patients who develop laboratory-confirmed influenza while on or immediately after NAI chemoprophylaxis (C-III).
    • Patients with an immunocompromising condition and evidence of persistent influenza viral replication (eg, after 7–10 days, demonstrated by persistently positive RT-PCR or viral culture results) and remain ill during or after NAI treatment (B-III).
    • Patients with laboratory-confirmed influenza who inadvertently received subtherapeutic NAI dosing (C-III).
    • Patients with severe influenza who do not improve with NAI treatment and have evidence of persistent influenza viral replication (eg, after 7–10 days) (C-II).

29. Clinicians should remain informed on current CDC and World Health Organization surveillance data on the frequency and geographic distribution of NAI-resistant influenza viruses during influenza season, and with the latest CDC antiviral treatment recommendations (A-III).

IX. Should adjunctive therapy be administered to patients with suspected or confirmed influenza?

30. Clinicians should not administer corticosteroid adjunctive therapy for the treatment of adults or children with suspected or confirmed seasonal influenza, influenza-associated pneumonia, respiratory failure, or ARDS, unless clinically indicated for other reasons (A-III).
31. Clinicians should not routinely administer immunomodulation using immunoglobulin preparations such as intravenous immunoglobulin for treatment of adults or children with suspected or confirmed seasonal influenza (A-III).

https://www.idsociety.org/practice-guideline/influenza/

Influenza : For patients who are recommended to receive antiviral treatment for suspected or confirmed influenza, which antiviral should be prescribed, at what dosing, and for what duration?

Clinicians should start antiviral treatment as soon as possible with a single neuraminidase inhibitor (NAI) (either oral oseltamivir, inhaled zanamivir, or intravenous peramivir) and not use a combination of NAIs (A-I).
Clinicians should not routinely use higher doses of US Food and Drug Administration–approved NAI drugs for the treatment of seasonal influenza (A-II).
Clinicians should treat uncomplicated influenza in otherwise healthy ambulatory patients for 5 days with oral oseltamivir or inhaled zanamivir, or a single dose of intravenous peramivir (A-I).
Clinicians can consider longer duration of antiviral treatment for patients with a documented or suspected immunocompromising condition or patients requiring hospitalization for severe lower respiratory tract disease (especially pneumonia or acute respiratory distress syndrome [ARDS]), as influenza viral replication is often protracted (C-III).
https://www.idsociety.org/practice-guideline/influenza/