Background: Tricuspid regurgitation velocity (TRV), measured by echocardiography, is a surrogate marker for pulmonary hypertension. Limited pediatric studies have considered the association between TRV and surrogate markers of end-organ disease. Methods: Therefore, we conducted a cross-sectional study that evaluated the prevalence of elevated TRV ≥ 2.5 m/s and its associations with renal and cerebrovascular outcomes in children with SCD 1-21 years of age in two large sickle cell cohorts, the University of Alabama at Birmingham (UAB) sickle cell cohort, and the Sickle Cell Clinical and Research Intervention Program (SCCRIP) cohort at St. Jude Children’s Research hospital. We hypothesized that patients with sickle cell disease with elevated TRV would have higher odds of having either albuminuria or cerebrovascular disease. Results: We identified 166 children from the UAB cohort (mean age: 13.49 ± 4.47 years) and 325 children from the SCCRIP cohort (mean age: 13.41 ± 3.99 years) with echocardiography. The prevalence of an elevated TRV was 21% in both UAB and SCCRIP cohorts. Elevated TRV was significantly associated with cerebrovascular disease (OR 1.88 (95% CI: 1.12- 3.15)) and persistent albuminuria (OR: 1.81 (95% CI: 1.07– 3.06)) after adjusting for age, sex, treatment, and site. Conclusion: This cross-sectional, multicenter study identifies associations between surrogate markers of pulmonary hypertension with kidney disease and cerebrovascular disease. A prospective study should be performed to evaluate the longitudinal outcomes for patients with multiple surrogate markers of end-organ disease.

Objectives：We aimed to investigated whether artificial light at night (ALN) are associated with Nasopharyngeal carcinoma (NPC) risk in Fujian province of China. Design：We use spatial epidemiology to understand the spatiotemporal distribution characteristics of nasopharyngeal carcinoma hospitalization rates, and use least squares and geographic detection models to understand the impact of nighttime light intensity on nasopharyngeal carcinoma hospitalization rates. Participants：Inpatients with NPC in 2019 were determined according to ICD-10 code and the hospitalization records of Fujian province were obtained from basic medical insurance for urban and rural residents in Fujian Province, which was provided by Fujian Medical Security Center. Variables: The main variable calculated in this study is the crude hospitalization rate Results：The NPC hospitalization rate are spatially positively correlated . The results of Ordinary Least Square (OLS) model analysis showed that ALN was positively correlated with the hospitalization rate of NPC. The R2 in the geographic weighted regression model（GWR）is greater than the OLS model, which indicates that the explanation degree of the GWR model variables on the hospitalization rate of NPC is significantly better than OLS model. Conclusions：ALN level was positively correlated with the hospitalization rate of nasopharyngeal carcinoma, which provide valuable information for the prevention and treatment strategy of NPC in Fujian province.

Objective: We aimed to investigate the relationship between gene polymorphisms and the occurrence of adverse clinical events following dual antiplatelet therapy in Patients with Symptomatic Intracranial Atherosclerotic Stenosis. Methods: A total of 195 patients were enrolled, categorized into 32 cases (those with clinical adverse events) and 163 controls (without events). Genotyping of 20 SNPs from 17 genes was executed. Statistical analyses (Fisher’s exact test, logistic regression) were applied to determine associations. Results: The ITGA2 rs1126643 (C807T) and rs1062535 (G873A) polymorphisms were significantly correlated with adverse clinical events. Specifically, the mutant frequency of allele C (ITGA2 rs1126643) and allele G (ITGA2 rs1062535) was significantly higher in cases compared to controls (OR = 2.97, 95%CI = 1.702-5.172, P = 0.0001; OR = 3.27, 95%CI = 1.762-6.066, P = 0.0002, respectively). Other genotypes showed no significant differences between the groups. Conclusion: The ITGA2 C807T and G873A polymorphisms may elevate the risk of vascular events in Chinese patients. Detecting these polymorphisms may be valuable in identifying patients at risk of recurrent ischemic events.

Objectives: We aimed to report the surgical outcomes of phosphaturic mesenchymal tumors causing tumor-induced osteomalacia in the head and neck. Design: A retrospective cohort study Setting: A tertiary care academic hospital Methods: This study analyzed nine patients who underwent surgical excision of phosphaturic mesenchymal tumors in the head and neck region. The primary sites were two in the maxilla and ethmoid sinus, and one in the intracranial, skull, parotid gland, maxillary sinus, and nasal cavity in each patient. Outcomes were compared with those in the extremities and trunk (n = 32). Results: Five of nine patients (56%) developed residual disease/local recurrence associated with low serum phosphate level after initial surgical excision. At the last follow-up, the biochemical parameters were normalized in four of the five patients after re-excision without any medication. The local recurrence/residual disease risk was significantly higher for the head and neck compared with the extremities and trunk (56% vs. 25%, p = 0.048). The rate of remission (normalized serum phosphate without medication) at final follow-up was similar in both groups after re-excision (head and neck vs. extremities and trunk, 86% vs. 73%, p = 0.827). Conclusions: Phosphaturic mesenchymal tumor resection in the head and neck region was challenging because of its complex anatomy and proximity to the brain or other crucial organs, which was associated with high local recurrence/residual disease rate. However, biological remission was achieved in the majority of the patients after re-excision.

Objective: This study aimed to test the inter-rater reliability, construct validity, and feasibility of the modified “Which Health Approaches and Treatments Are You Using?” (WHAT) questionnaires in pediatric oncology. Methods: A sample of parent-child dyads was invited to complete self- and proxy-report modified WHAT, Pediatric Quality of Life Inventory, demographics, a diary of child recent use of CHA, and a questionnaire assessing aspects of feasibility. Parents were also asked to complete a satisfaction of children’s use of CHA survey. Results: Twenty-four dyads completed the study. The mean weighted kappa showed strong inter-rater reliability (k=0.77, SE=0.056); and strong agreements between the modified WHAT and the diary (self-report [k=0.806, SE=0.046], proxy-report [k=0.894, SE=0.057]). Significant relationships were found only between recent and non-recent CHA users in relation to easy access to CHA (self-report [p=0.02], proxy-report [p<0.001]). The mean scores of the feasibility scale (out of 7.0) for the self- and proxy-report were 5.64 (SD=0.23) and 5.81 (SD=0.22), respectively, indicating the feasibility of the modified WHAT. Conclusions: The findings of this study provide initial evidence of the reliability and validity of the modified WHAT questionnaires and their feasibility in assessing child CHA use and initiating clinical discussions about CHA with children and their parents. Further research is needed to test the theoretical relationships and to further explore the validity and reliability of the modified WHAT.

Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome is a drug hypersensitivity reaction characterized by rash, multiple systemic symptoms, and eosinophilia. DRESS syndrome develops following exposure to inciting medications, typically antibiotics and antiepileptics. Anticoagulants are not classically associated with this syndrome, though cases exist in association with vitamin K antagonists and oral anticoagulants. There are two known cases of enoxaparin-induced DRESS syndrome in adults, but no reports in the literature in the pediatric setting. In this report, we present the case of a pediatric patient who developed classic symptoms and lab findings of DRESS syndrome secondary to enoxaparin therapy.

There still is inadequate literature regarding the surgical indications and postoperative outcomes of cochlear implantation (CI) in patients with Branchio-oto-renal syndrome; therefore, the aim of this study was to investigate whether CI surgery improved the hearing and speech performance of children with BOR syndrome-related severe hearing loss. Clinical manifestations, genetic results,audiological features, intraoperative findings and post-CI outcomes of four children were ascertained and analysed. All patients had bilateral profound HI before CI). The surgery of one patient with aural atresia and complex ear deformity was rather challenging, but the outcome after CI was satisfactory. However,auditory and speech performance of other three patients wasn’t good enough, which was probably related to cochlear nerve deficiency.

Cost effectiveness of support with out-of-pockets costs to prevent treatment abandonment in Malawi and sub-Saharan Africa; lessons learnt and the way forward – a report from CANCaRe Africa Junious Sichali1, Avi Denburg2, Harriet Khofi3, Cecilia Mdoka1, Deborah Nyirenda4, Yamikani Chimalizeni3, George Chagaluka3, Elizabeth Molyneux3, Marc Y. R. Henrion4,5, Sumit Gupta2, Trijn Israels11 Collaborative African Network for Childhood Cancer Care and Research (CANCaRe Africa), 2Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Canada,3 Kamuzu University of Health Sciences (KUHeS), Blantyre, Malawi, 4 Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi, 5Liverpool School of Tropical Medicine, Liverpool, UKCorresponding author:Dr Trijn Israels, CANCaRe Africa, Department of Paediatrics, Kamuzu University of Health Sciences (KuHES), Blantyre, Malawi. Email: cancareafrica@gmail.comWord count: 1189 wordsNumber of Tables: 0Number of Figures: 0Short running title: Cost-effectiveness of treatment abandonment preventionKey words: childhood cancer, treatment abandonment, cost-effectiveness,LMIC Low- and middle-income countryGICC Global Initiative for Childhood CancerCANCaRe Africa Collaborative African Network for Childhood Cancer Care and ResearchALL Acute lymphoblastic leukaemiaGDP Gross Domestic ProductDALY Disability Adjusted Life Year

Objective The use of apixaban in the pediatric cardiac population is expanding. We describe our apixaban dosing and monitoring strategy in children and young adults awaiting heart transplantation, along with outcomes related to bleeding and thrombosis during wait-list and early post-transplant periods. Methods This study is a retrospective, single center analysis of all patients receiving apixaban while awaiting cardiac transplantation. Weight-based dosing was monitored with peak drug-specific anti-Xa chromogenic analysis. Significant post-operative bleeding defined by chest tube output or need for surgical intervention. Results From September 2020 through December 2022, 19 patients, median age 13.5 years (6.1, 15.8 years), weighing 48.9 kg (15.4, 67.6) received apixaban while awaiting transplant. Indication for apixaban was prophylaxis (n=18, 3 with ventricular assist devices) and treatment of thrombus (n=1). There were no clinically relevant non-major or major bleeding, nor thrombotic events while awaiting transplant. The median time from last apixaban dose to arrival in the operating room was 23.2 hours (15.6-33.8), with median random apixaban level of 37 ng/ml (28.3, 59), 6.3 hours (4.8, 8.4) prior to arrival in the operating room. 32% of patients had significant post-operative bleeding based on chest tube output post-transplant or need for intervention. No patients meeting criteria for significant postoperative bleeding were thought to be attributable to apixaban. Conclusion Careful use of apixaban can be safe and effective while awaiting heart transplant. There was no appreciable increase in perioperative bleeding. The use of apixaban is promising in providing safe, predictable and efficacious anticoagulation while avoiding additional patient stressors.

Background Sinonasal anatomical variations are common and its knowledge plays an integral part in the management of sinonasal disease. Although sinonasal anatomic variations have been postulated as a risk factor for sinus disease, its role in the pathogenesis of nasal polyp is still unclear. This study was done to determine the prevalence of sinonasal anatomical variations by CT imaging and examine its association with sinonasal polyposis. Methodology A descriptive cross sectional study was conducted from January, 2019 to January, 2020 at a tertiary care center in Nepal after receiving ethical approval from the Institutional Review Committee of the hospital. Patients above 17 years of age having sinonasal polyp and not responding to 3-4 weeks of medical treatment were included in the study. Convenience sampling was done. Data were collected and entered in Microsoft Excel and analyzed using Statistical Package for the Social Sciences version 24.0. Results Among 72 patients, the prevalence of anatomical variations of nose and paranasal sinuses was found to be in 62 patients (86.11%). Agger nasi (79.09%) and deviated nasal septum (72.5%) were the common variations noted. Single variation was found in 29% and multiple variations in 70.9% Conclusion Our study showed that the prevalence of sinonasal anatomical variations was higher in patients with sinonasal polyp and the severity of polyp increases with the presence of more than one variation in a patient. Key words Computed tomography scan, sinonasal anatomical variations, sinonasal polyp

Background Current shortage of operative space and anaesthetic staff led to 531907 ENT cases waiting to be performed as of June 2022; a trend expected to worsen. Awake surgery can provide a safe and effective alternative reducing the need for anaesthetic cover while utilising alternative operating spaces. Methodology Prospective cohort study of 86 patients undergoing ENT procedures under local anaesthetic with/without operator delivered sedation using midazolam; performed in the ambulatory Procedure Zone of an ENT tertiary centre in the UK by a single sedation trained rhinologist. Results N=54 inferior turbinate reduction (n=19 with radiofrequency ablation, n=25 with co-ablation, n=13 combined with a second procedure). Pre-operative mean SNOT23 score 59, mean NOSE score of 17.89, 3 month post-operative mean SNOT 23 score 36 and mean NOSE score 7.92 (P<0.05). N=18 balloon sinoplasty, n=4 endoscopic sinus procedures; pre-operative mean SNOT23 score 76, 3 month post-operative mean SNOT23 score 25 (P<0.05). N=12 nasal biopsies, n=8 septoplasties, n=6 adhesiolysis, n=1 grommet insertion, n=1 excision of pinna lesion, n=1 canal polypectomy. Visual analogue scale was used to assess patient comfort during the procedure; 4/10 mean score (IQR 2-8) for cases under local anaesthetic ranged, with addition on sedation comfort increased with mean score of 8/10 (IQR 1-10). Due to the low numbers of cases statistical significance was not calculated. Conclusion Awake surgery in ENT is a safe and effective alternative to general anaesthesia. It is a cost effective service, which shortens waiting and treatment times, and coupled with operator delivered sedation leads to high patient satisfaction rates.

This article describes spontaneous globe rupture as a rare but serious complication of retinoblastoma. This warrants acknowledgement and discussion, given the implications for metastatic spread should it not be managed appropriately.

Abstract Objective: At present, human bone marrow mesenchymal stem cells (hBMSCs) used as target vectors for hypopharyngeal cancer is a new therapeutic direction of great potential. However, hBMSCs would be transmitted into cancer-associated fibroblasts(CAFs) under the induction of hypopharyngeal cancer. Here, we aimed to determine whether microRNA-21(miR-21) in exosomes from FaDu cells would play a role in hypopharyngeal cancer induced transition of hBMSCs to CAFs. Methods: qRT-PCR and western blot were employed to investigate expression level of miR-21 in hypopharyngeal cancer patient samples and FaDu cells. The exosomes were collected from FaDu cells then isolated and identified. Cell morphological changes were observed by inverted phase contrast microscope. Expression level of CAF-related proteins, includingα-SMA and FAP, were assessed by qRT-PCR and western blot. Cell cycle of hBMSCs were determined by flow cytometry. Results: MiR-21 expression level was up-regulated in hypopharyngeal cancer tissue and FaDu cells. Exosomes from FaDu cells promoted CAFs-like features of hBMSCs, including up-regulation of α-SMA and FAP and cell morphological changes. Proportions of hMBSCs in G1 phase significantly decreased, while proportions of hMBSCs in G2 phase significantly decreased at the presence of exosomes from FaDu cells. What’s more, miR-21 knock-out in FaDu cells suppressed transition of bone marrow mesenchymal stem cells to cancer-associated fibroblasts and reversed the cell cycle change. Conclusions: Our data showed that miR-21 promotes hypopharyngeal cancer induced transition of bone marrow mesenchymal stem cells to cancer-associated fibroblasts. Keywords: Hypopharyngeal cancer, Bone marrow mesenchymal stem cells, Cancer-associated fibroblasts, MicroRNA-21, Exosomes

Severe autoimmune lymphoproliferative syndrome phenotype in a pediatric patient with a germline FAS gene variant Authors: Alexandra Dreyzin MD MS1; Jinjun Cheng MD PhD2, David Leitenberg MD PhD3, and Yaser Diab MBBS1Center for Cancer and Blood Disorders, Children’s National Hospital, Washington, DCDivision of Pathology and Laboratory Medicine, Children’s National Hospital, Washington, DCDepartment of Microbiology, Immunology and Tropical Medicine, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA.

TitleA quality improvement project evaluating haemostasis techniques during tonsillectomy

Objective To analyze frequency-specific hearing results surgery for chronic ear diseases, in relation to various surgical factors. Study design Retrospective cohort study. Setting Tertiary referral centre. Participants A total of 173 patients with chronic ear diseases who underwent surgical management at our hospital. Main outcome measures Air conduction threshold (AC), bone conduction threshold (BC), and air-bone gap (ABG) were tested at 250, 500, 1000, 2000, and 4000 Hz, respectively. Frequency-specific results were investigate in relation to various surgical factors. Results The radical mastoidectomy group and tympanoplasty group significantly improved in AC changes at every frequency. In the tympanoplasty group, ABG at all frequencies except 4,000 (P =.069) significantly improved. AC improved at low and mid frequencies when ossicular reconstruction was conducted. Different tympanic membrane repair materials showed significant improvement in AC at all frequencies. In all groups, BC data revealed significant improvements at 500, 1000 and 2000 Hz. Conclusions The hearing improved significantly postoperatively in AC and ABG test, mainly at low and mid frequencies. The BC improved significantly at 500-2000Hz.

Objective: This study aims to explore the prevalence of anosmia and dysgeusia and their impact on COVID-19 patients. Design: This is a cross-sectional study. Patients diagnosed with COVID-19 between 1st October 2020 and 30th June 2021 were randomly selected from a national COVID-19 registry. The Anosmia Reporting Tool and a brief version of the questionnaire on olfactory disorders were used to measure the outcomes via telephone interviews. Data were analyzed using SPSS 27 statistics software. Results: A total of 405 COVID-19 adults were included in this study, 220 (54.3%) were males and 185 (45.8%) were females. The mean±SD age of participants was 38.2 ± 11.3 years. Alterations in the sense of smell and taste were reported by 206 (50.9%), and 195 (48.1%) of the patients respectively. Sex and nationality of participants were significantly associated with anosmia and dysgeusia (p<0.001) and (p-value=0.001) respectively. Among patients who experienced anosmia and dysgeusia, alterations in eating habits (64.2%), impact on mental wellbeing (38.9%), concerns that the alterations were permanent (35.4%), and physical implications and difficulty performing activities of daily living (34% ) were reported. Conclusion: Anosmia and dysgeusia are prevalent symptoms of COVID-19 disease, especially among females. Neuropsychological implications of COVID-19 in the acute infection phase and prognosis of anosmia and dysgeusia in COVID-19 are areas for further exploration.

Introduction: There is an increased demand for well-validated PROMs in otology. This study will systematically assess the methodological quality of all published patient-reported outcome measures (PROMS) for patients with multiple ear complaints and to identify the best suitable PROM for use by clinicians treating patients with multiple ear complaints. Methods: An extensive systematic mapping review on all otology questionnaires was performed to identify questionnaires measuring multiple ear complaints. The ‘Consensus‐based standards for the selection of health measurement Instruments’ (COSMIN) checklists were used to evaluate the quality of the questionnaire by two researchers. The worst item score per aspect of the methodological assessment counted. Results: Twelve multiple complaint questionnaires were included in the study for quality assessment. Ten questionnaires were disease specific (COMQ-12, CES, ZCMEI-21, MD-POSI, PAN-QOL, ETDQ-7, MDOQ, GYSSCDQ, COMOT-15 and DEU-MDDS). Two questionnaires were ear domain specific (OQUA and COQOL). The majority of multiple complaint questionnaires lacked good design with concept elicitation and patient involvement. Conclusion: For the majority of questionnaires, the quality assessment was inadequate as only a few authors consulted with patients affected by the complaints in the development. Modifications of earlier versions of PROMS or combinations of multiple questionnaires lead to ongoing (cross-cultural) validation of these questionnaires albeit the mediocre design and validation. The two domain specific questionnaires are the COQOL and OQUA, both with adequate quality but different focus. COOQL to quantify the quality of life and OQUA to measure and evaluate severity and impact of ear complaints.

Background: There is an increasing importance to increasing the day-case rate for children undergoing adenotonsillectomy. The primary aim of this study was to evaluate the immediate post-operative complication (IPOC) rate of children undergoing adenotonsillectomy for the treatment of paediatric obstructive sleep apnoea (OSA), with a view to increasing the day-case rate. IPOC was defined as any adverse clinical events experienced if admitted, or as a re-presentation to the emergency department/ward if done as a day-case, within 24 hours of the surgery. The secondary aim was to evaluate the risk factors predictive of IPOC. Methods: A retrospective analysis of children undergoing adenotonsillectomy for OSA between 01/11/2019–31/03/2022. Results: 464 children were included. Children done as a day-case experienced 0% IPOC (n=260; 220 were planned day-case). Children done as an inpatient experienced 16.7% IPOC (n=34/204). Every child who experienced IPOC had one or more of the following four clinical features: age <3 years, <15 kg, >98th weight centile, significant medical comorbidities. 269 children had none of these four clinical features, and experienced 0.371% IPOC (n=1/269; primary post-tonsillectomy bleed). Children with pre-operative oximetry scores of McGill 3-4 experienced 0% IPOC if they had none of the four clinical features (n=20). The overall readmission rate was 2.80% (n=13/464). Conclusion: Our experience suggests children with none of the four clinical risk factors identified can have adenotonsillectomy performed as a day-case procedure, irrespective of the pre-operative oximetry results. Pre-operative oximetry does not appear to add any additional value in predicting adverse post-operative events.

We aimed to report the case of a Pakistani female who presented with MMD and hyperthyroidism, and the worldwide literature review of the case reports on MMD associated with hyperthyroidism. Methods: The study was carried out using PRISMA’s recommendations. An electronic search on PubMed, Cochrane Library, and Google Scholar was carried out. Articles explaining the association between Moyamoya disease and thyroid-related diseases were included. Results: A total of 31 studies were included in the review, with the preponderance of Japanese females. The review has systematically compiled in detail all the aspects of moyamoya syndrome and thyroid disorders- from detailed histories of the included patients to the treatment interventions used and their outcomes. Conclusion: The authors are with the suggestion that more cases of MMD and its association with other major factors should be presented in Pakistan as well as in all parts of the world.

Objective: This study aimed to investigate the effect of the disease on the middle ear resonance frequencies with wide-band tympanometry in the people with temporomandibular disorder (TMD). Methods: A total of 40 individuals (24 patients, 16 control groups), 18 years of age and older, 25 females and 15 males, were included in the study. For the patients who came to the Oral Diagnosis Department of XXXX University with the complaint of TMD, the patient’s history and detailed examination were taken by the specialist dentist. Pure tone audiometry (125-8000 Hz air-way, 250-4000 Hz bone conduction thresholds) and speech audiometry, acoustic immitance and middle ear resonance measurements, outer ear resonance test were applied. Results: TMD ipsilateral and contralateral middle ear resonance values for each individual of the study group and control group and statistical data were determined. No difference was observed in the mean values of the 3 groups for middle ear resonance. However, there was a significant difference between the middle ear resonance values of the TMD ipsilateral and control groups. Conclusion: In a patient population with TMD the increase in middle ear RF values in the ipsilateral ears of the lesion may provide evidence of an increase in the stiffness of the middle ear system, offering a new perspective on the pathophysiology of the disease. KEY POINTS 1) Middle ear canal resonance frequency can be determined with wideband tympanometry (WBT). 2) There was no difference in the mean values of the three groups for the ipsilateral of the temporamandibular disorder, the contralateral of the temporamandibular disorder and the middle ear resonance values of the control group. 3) It was observed that there was a significant difference between the ipsilateral resonance values of the TMD patient group and the middle ear resonance values of the control group. 4) This study aims to present additional findings and methods for differential diagnosis by showing the differences between clinical tests applied to individuals with TMD and middle ear findings of normal individuals. 5) This study will also provide the first findings of minor middle ear pathology in patients with TMJ disorders by WBT.

Abstract Objective: To evaluate the results of the excision and chemotherapy treatment methods for ALHs located on the arytenoids. Study design: retrospective study. Methods: Twenty-six ALH patients in 29 different cases were enrolled in the study. Some patients were treated more than once. Twenty-nine cases of ALHs treated with either chemotherapy or excision were studied to assess the efficacy of both treatments. Results: All the patients in the ALH excision group were cured, and the ALHs did not recur. The mean lumen constriction score for the chemotherapy group was 2.95. The score for the ALH excision group was higher than that for the chemotherapy group. Conclusion: Both chemotherapy and excision are safe and effective treatments for ALHs located on the arytenoids. On the condition that the ALH is well exposed and can be completely removed, ALH excision surgery is a better method to treat ALHs located on the arytenoids.

Key points:  Diagnosis of AIFRS should be alert in the immunocompromised patient presenting with new-onset, rapidly progressive sinusitis with facial-cranio-orbital spread.  Extended debridement should be considered on a case-by-case basis.  Antifungal agent contributed greatly to the outcome of AIFRS.  Prognosis mostly up to the balance of underlying disease and fungal invasion, more emphasizes should be focused on comprehensive treatment.  AIFRS with facial-cranio-orbital involved often had a disastrous end.

Introduction: Vaccine hesitancy has historically played a large role in the low rate of the human papillomavirus (HPV) vaccine coverage in the United States and has further surfaced to the forefront of public discourse since the start of the COVID-19 pandemic. This study aims to determine how HPV vaccination attitudes and trends among primary care physicians and patients have changed since the COVID-19 pandemic. Design: Physicians and patients (aged 9-45) participated in a voluntary survey regarding HPV vaccination. In patients under 18 years of age, the survey was completed by the patient’s parent or guardian. Results: Of the 27 healthcare providers surveyed, 22.2% agreed that there has been an increase in misinformation about the HPV vaccine since the COVID-19 pandemic and 7.4% of providers believed that patients were less willing to discuss or receive the HPV vaccine. A majority of patients surveyed (87.7%) were aware of the HPV vaccine but only about a third of those patients had received all three doses of the vaccine (28.1%). Conclusion: Recent trends in receiving the HPV vaccine may be associated with the polarizing climate during the COVID-19 pandemic. Understanding how trends in vaccine hesitancy have changed since the pandemic will allow further and more targeted efforts to increase HPV vaccine uptake.