The Patient Experience of Adolescents With Traumatic Injuries: Recommendations for Improvement.

GOAL: Positive patient experience is associated with less healthcare utilization, better treatment adherence, increased likelihood of returning to the same hospital, and fewer complaints. However, hospitals have been able to collect few insights into the experiences of pediatric patients due to age limitations. As an exception to that reality, adolescents (aged 12-20 years) are able to share their experiences and recommend improvements, yet little is known about their hospital experiences with traumatic injuries. We examined the patient experience of adolescents with traumatic injuries and collected their recommendations for improving care. METHODS: We conducted 28 semistructured interviews with English-speaking adolescents hospitalized at two trauma Level 1 hospitals (pediatric and adult) for physical injuries from July 2018 to June 2021. Interviews were transcribed and analyzed using modified thematic analysis. PRINCIPAL FINDINGS: The patients expressed three basic desires: (1) autonomy and active involvement in their care, (2) human connections with their clinicians, and (3) minimal discomfort. Study participants provided actionable recommendations for improving the patient experience for adolescents with traumatic injuries. PRACTICAL APPLICATIONS: Hospital administrators and clinicians can improve the patient experience for adolescents in their care by sharing information, expectations, and goals with them. Hospital administrators can also empower the clinical staff to connect with adolescents with traumatic injuries on a personal level.

Using prescription opioids throughout a traumatic injury recovery: A qualitative exploratory study of adolescents in a Midwestern state.

BACKGROUND: Injury is one of the most common reasons adolescents are prescribed opioids. Little is known about adolescent experiences who used prescription opioids throughout their recovery from traumatic injury. METHODS: We used a qualitative exploratory study design nested within a longitudinal cohort study conducted at two trauma hospitals in the United States. We conducted semi-structured telephone interviews with adolescents (n = 28) aged from 12 to 20 years at the time of their hospital admission for injury. We used purposive sampling to gather a broad range of experiences from the longitudinal patient cohort. We conducted a modified thematic analysis of transcribed interviews. RESULTS: Adolescents reported a wide range of efficacy with which prescription opioids controlled their pain during the injury recovery and numerous opioid-related side effects. A desire for relief from acute pain caused by the injury was the most common driver for using opioids in the hospital. At home, adolescents' decisions to use opioids were influenced by family history of addiction, awareness of harms associated with opioids, and desire to challenge themselves. Adolescents reported closely adhering to a prescribed regimen or using fewer opioids than prescribed while recovering at home. Finally, adolescents reported considerable variability in parental involvement in prescription opioid use, ranging from giving adolescents unrestricted access to prescription opioids to complete parental discretion and administration upon request. CONCLUSIONS: Adolescents had diverse experiences with prescription opioids during recovery from traumatic injury. Educational interventions that focus on the appropriate use of opioids to address pain care needs among adolescents with traumatic injuries are urgently needed.

An Appraisal of Printed Online Education Materials on Spasmodic Dysphonia.

OBJECTIVE: The use of the Internet for seeking health-related information has increased exponentially. We aimed to comprehensively appraise the readability, understandability, actionability, and quality of printed online education materials (POEMs) pertaining to Spasmodic Dysphonia (SD). STUDY DESIGN: Descriptive, correlational study. METHODS: POEMs were identified using the Google search engine with the phrase "spasmodic dysphonia." The first 50 websites meeting criteria were included. Accreditation of POEMs was evaluated using Health on the Net Foundation Code of Conduct (HONcode) toolbar. Readability of the content was analyzed using the Flesch-Kincaid Grade Level (FKGL) and Flesch Reading Ease (FRE) tests. Understandability and actionability was evaluated using the Patient Education Material Assessment Tool for Printed Materials. Overall quality of POEMs was appraised using the DISCERN instrument. RESULTS: The overall mean [SD] FKGL and mean [SD] FRE score was 11.5 [2.5] and 42.1 [12.8], respectively. The mean understandability score was 65% [14], while the mean [SD] actionability score was only 17% [12]. The overall mean [SD] quality score for all websites was 43.5 [13]. Only four websites (8%) were HONcode certified. A moderately positive correlation was discovered between understandability and overall quality of POEMs (r = 0.38, P 0.01) CONCLUSIONS: POEMs pertaining to SD are written above recommended reading levels with subsequent poor understandability and actionability. We recommend that authors assess POEMs prior to publication to ensure alignment with the needs of the target audience.

Urothelial carcinoma in situ response to cisplatin-based neoadjuvant chemotherapy, or lack thereof: Impact on patient selection for organ preservation in muscle-invasive disease?

INTRODUCTION: Neoadjuvant cisplatin-based chemotherapy (NACT) followed by radical cystectomy improves urothelial bladder cancer survival [1]. Complete pathological response on cystectomy pathology (pT0N0) is associated with the best survival outcomes [2]. Rates of complete response have increased with improved adoption of NACT calling into question the need for radical cystectomy or perhaps use of organ preservation protocols. In patients with papillary bladder tumors, carcinoma in situ (CIS) has been shown to influence progression and develop into invasive urothelial carcinoma [3]. Furthermore, in patients with invasive urothelial carcinoma, concurrent CIS has been reported in roughly 45% to 65% of cases [4]. Thus, we sought to determine the response rate of CIS to NACT to determine if the presence of CIS should factor into excluding patients from organ preservation. METHODS: A review of our prospectively maintained bladder cancer database was performed among patients undergoing preoperative cisplatin-based chemotherapy followed by cystectomy between 2007 and 2017. Presence of CIS before and after radical cystectomy was assessed. Random bladder biopsies or transurethral resection (TUR) with enhanced imaging for CIS (Cysview) were not routinely utilized in the preoperative setting. RESULTS: One-hundred eighty-three patients were identified that underwent preoperative cisplatin chemotherapy. A total of 96 (52.4%) unique patients had documented CIS in the entire cohort. Forty-eight (50%) patients were noted to have CIS on TUR. Of these 48 patients, 26 (54.1%) were noted to have residual CIS on final pathology. An additional 48 patients were found to have CIS on final pathology that was not diagnosed on TUR, making a total of 74 (77.1%) patients with CIS refractory to NACT on cystectomy pathology. CONCLUSIONS: CIS seems to respond poorly to cisplatin-based neoadjuvant chemotherapy. If organ preservation protocols are considered, a thorough assessment for CIS with enhanced photodynamic detection cystoscopy or random bladder biopsies should be considered. Residual cisplatin-refractory disease, even if noninvasive CIS, may lead to poor outcomes. Future molecular classifiers may assist in disease signatures to help guide treatment protocols.

Readability of Printed Online Education Materials on Pituitary Tumors: Untangling a Web of Complexity.

BACKGROUND: Patients are increasingly turning to the internet for health education. Due to the complex pathophysiology, clinic-diagnostic profile, and management spectrum of pituitary tumors, an evaluation of the readability of printed online education materials (POEMs) regarding this entity is warranted. OBJECTIVE: (1) To apply established readability assessment tools to internet search results on the topic of pituitary tumors. (2) To identify sources of complexity in order to guide the creation POEMs that are in line with the reading level of the target audience.Methodology: After independent, neutral internet search for the phrase "pituitary tumor," the first 100 results were subjected to inclusion criteria matching. Analysis was performed using 5 readability assessment tools including Flesch Reading Ease (FRE), Flesch-Kincaid Grade Level (FKGL), Gunning-Fog Score (GFS), Coleman-Liau Index (CLI), and Simple Measure of Gobbledygook (SMOG). RESULTS: A total of 82 websites met inclusion criteria. All websites were found to be at a higher reading level (P < .01) than the United States Department of Health and Human Services (USDHHS) recommended sixth-grade level. Mean readability scores were as follows: FRE, 38.79; FKGL, 11.27; GFS, 12.83; CLI, 17.31; SMOG, 12.12. Intergroup comparison between FKGL, GFS, CLI, and SMOG yielded that CLI was significantly higher (P < .03). No significant differences in readability were noted between academic and other websites. CONCLUSION: There is a significant misalignment between the reading level of patients and the readability of pituitary tumor POEMs. This may lead patients to misconceive their diagnoses, management options, and prognosis.

Evaluation of the Quality of Printed Online Education Materials in Cosmetic Facial Plastic Surgery.

Importance: In the modern-day health care environment, it is expected that a large proportion of patients will utilize the Internet to gather health care-related information. However, online sources are often not subjected to adequate quality control measures. Objective: To evaluate the quality of printed online education materials (POEMs) pertaining to elective facial cosmetic surgery. Design, Setting, and Participants: This is a descriptive correlational study. Independent Internet searches for the terms "rhinoplasty," "rhytidectomy," "blepharoplasty," and "browlift" were carried out using the Google search engine. The top 20 web resources for each term were analyzed. Main Outcomes and Measures: All web resources were analyzed for HONcode certification. The DISCERN instrument was then used to determine reliability and specificity of information, whereas readability was assessed using the Flesch Reading Ease (FRE) score and the Flesch-Kincaid Grade Level (FKGL). Results: Of the resulting 80 web resources, 30% (n = 24) were HONcode certified. None of the surgical society web resources (n = 12) were HONcode certified, and only 42% (n = 8) of web resources associated with academic institutions were HONcode certified. Out of a maximum DISCERN score of 80, the mean (standard deviation [SD]) scores were 48 (11) for rhinoplasty, 50 (11) for rhytidectomy, 47 (11) for blepharoplasty, and 45 (10) for browlift. The mean DISCERN scores of the HONcode-certified web resources did not differ significantly from scores of uncertified web resources (p = 0.069). There was no significant difference in overall mean DISCERN scores for the different web resource categories. The mean (SD) FRE score was 45.7 (11.9), whereas the mean FKGL score was 10.7 (1.9). HONcode-certified web resources had significantly higher FRE scores (p = 0.028) and significantly lower FKGL scores (p = 0.0003). Conclusions and Relevance: A significant proportion of POEMs regarding elective cosmetic facial plastic surgery remains uncertified and of inadequate quality. This can negatively impact the informed decision-making process and increase the risk of poor outcomes and lower satisfaction rates.

Low Misrepresentation Rates of Scholarly Work in Otolaryngology-Head and Neck Surgery Residency Applications.

Objectives To evaluate research trends, including rates of misrepresentation of scholarly work, in otolaryngology residency applications received by a single institution during the 2018-2019 residency application cycle. Methods After obtaining Institutional Review Board approval, all residency applications to the Department of Otolaryngology-Head and Neck Surgery at Indiana University School of Medicine, Indianapolis, IN for the 2018-2019 cycle were de-identified and analyzed. Demographic and research information including the number of listed peer-reviewed articles/abstracts, types of research projects, and misrepresentations were retrospectively evaluated. Results Our institution received 321 applications, which represented 69.5% of the entire 2018-2019 otolaryngology applicant pool. The average United States Medical Licensing Examination (USMLE) Step 1 score was 246 ±12.4. There were 203 (62.2%) applicants who reported 591 published citations with 20 (6.2%) applicants misrepresenting 26 items (4.4%). Applicants who misrepresented research output had lower average Step 1 scores (237.4 vs 246.4, p: <0.05). Self-promotion to higher authorship status was the most common form of misrepresentation (61.5%). Conclusions The role of scholarly work in stratifying applicants continues to expand. Although a competitive application climate motivates a minority of applicants to misrepresent scholarly work, rates of misrepresentation in otolaryngology applications are low and continue to decline. The level of evidence assigned to this study is III.

Facing Facts: Facial Injuries from Stand-up Electric Scooters.

Background Stand-up electric scooters (SES) are a popular public transportation method. Numerous safety concerns have arisen since their recent introduction. Methods A retrospective chart review was performed to identify patients presenting to the emergency departments in Indianapolis, who sustained SES-related injuries. Results A total of 89 patients were included in our study. The average patient age was 29 ± 12.9 years in a predominantly male cohort (65.2%). No patient was documented as wearing a helmet during the event of injury. Alcohol intoxication was noted in 14.6% of accidents. Falling constituted the leading trauma mechanism (46.1%). Injuries were most common on Saturday (24.7%) from 14h00 to 21h59 (55.1%). Injury types included: abrasions/contusions (33.7%), fractures (31.5%), lacerations (27.0%), or joint injuries (18.0%). The head and neck region (H&N) was the most frequently affected site (42.7%). Operative management under general anesthesia was necessary for 13.5% of injuries. Nonoperative management primarily included conservative orthopedic care (34.8%), pain management with nonsteroidal anti-inflammatory drugs (NSAIDs) (34.8%) and/or opioids (4.5%), bedside laceration repairs (27.0%), and wound dressing (10.1%). Individuals sustaining head and neck injuries were more likely to be older (33.8 vs. 25.7 years, p=0.003), intoxicated by alcohol (29.0% vs. 3.9%, p=0.002), and requiring CT imaging (60.5% vs. 9.8%, p <0.001). Conclusion Although SESs provide a convenient transportation modality, unregulated use raises significant safety concerns. More data need to be collected to guide future safety regulations.

Consulting "Dr. YouTube": an objective evaluation of hypospadias videos on a popular video-sharing website.

INTRODUCTION: Parents who make decisions about hypospadias repair for their child may seek information from online platforms such as YouTube. OBJECTIVE: The purpose of this study is to evaluate the health literacy demand of hypospadias videos on YouTube using the Patient Education Materials Assessment Tool for Audiovisual Materials (PEMAT-A/V). STUDY DESIGN: We performed a YouTube search using the term "hypospadias," limiting results to the first 100 videos. We excluded videos that were <1 min or >20 min and videos that were not in English or did not include subtitles. Two evaluators independently examined videos and determined PEMAT-A/V scores for understandability and actionability (i.e., ability to identify actions the viewer can take). Videos with scores >70% are understandable or actionable. The inter-rater reliability (kappa) and intraclass correlation coefficient (ICC) of PEMAT scores were calculated. Bivariate and multivariable linear regression models assessed the association of video characteristics with respective scores. RESULTS: Of the 100 videos that were identified on YouTube, 47 (47%) were excluded leaving 53 for analysis: 14 were >20 min, 14 were <1 min, 9 had no audio or subtitles, 7 were not in English, 1 was a duplicate, 1 was unrelated to hypospadias, and 1 was deleted at the time of data analysis. Three (5.6%) were understandable (mean score 54.5%, standard deviation (SD) 14.9) and eight (15.1%) were actionable (mean score 21.8%, SD 16.6) (Extended Summary Figure). Kappa values ranged from 0.4 to 1. The ICC's were 0.55 and 0.33 for understandability and actionability, respectively. In the bivariate analysis, mean understandability scores were significantly higher for English language videos (p = 0.04), videos with animation (p = 0.002), and those produced by industry (p = 0.02). In the multivariable analysis, mean understandability scores were significantly higher for "expert testimonial" or "other" video types after adjusting for graphics type and overall tone (p = 0.04). Mean understandability scores were also significantly higher for videos with animation after adjusting for video type and overall tone (p = 0.01). Mean actionability scores were significantly higher for videos with a negative tone (p = 0.01). DISCUSSION: The vast majority of hypospadias-related YouTube content is not appropriate for users with low health literacy although certain types of videos, such those with animation and expert testimonials, scored higher on understandability than other types. CONCLUSION: Due to the lack of sufficient online informational content regarding hypospadias, we plan to engage parents of sons with hypospadias in the development of high-quality patient educational materials about hypospadias.

Understandability and actionability of audiovisual patient education materials on sinusitis.

BACKGROUND: Acute and chronic rhinosinusitis are debilitating diseases that affect from 5% to 16% of the population. YouTube is the second most commonly used search engine and is often utilized by patients to garner health information regarding various disease processes and their respective management options. An evaluation of these information resources for quality and reliability is warranted, especially in an era in which patients are increasingly turning to audiovisual (A/V) media to educate themselves regarding their ailments. METHODS: The YouTube video database was searched using the term "sinusitis" from its inception through to November 2018. The first 50 videos populated under the relevance-based ranking option were collected and parsed by time and language. Of the 50 videos, 10 were eliminated either for length (≤1 minute or ≥20 minutes), language (any language other than English), and/or for later being removed by YouTube for copyright violations. The videos were then assessed using the Patient Education Materials Assessment Tool-Audio/Visual (PEMAT-A/V) by 2 independent reviewers for understandability and actionability. RESULTS: A total of 40 videos were examined using the PEMAT-A/V tool. The average understandability score was 57.7%, whereas the average actionability score was 46.3%. Eleven videos (28%) had actionability scores of 0%. Videos most commonly addressed disease management options (38%). The second largest category was case presentations regarding surgical techniques (30%). There were only 6 videos focused primarily on education about the definition and common traits of sinusitis (15%). CONCLUSION: Our results show a paucity of high-quality online A/V educational material pertaining to sinusitis, with a majority of videos being neither understandable nor actionable. As patients increasingly turn to internet video databases like YouTube for medical information, it is critical that physicians and institutions create A/V material that is accurate, understandable, and actionable.

Validity testing of a three-dimensionally printed endoscopic sinonasal surgery simulator.

OBJECTIVES/HYPOTHESIS: To assess the face, content, construct, and concurrent validity of the PHACON Sinonasal Surgery Simulator (SNSS). STUDY DESIGN: Prospective cohort study. METHODS: A total of 12 otolaryngology residents were recruited to perform sinonasal surgery on the simulator followed by cadaveric heads. Resident performances were recorded and de-identified. Face and content validities were evaluated based on 5-point Likert scale questionnaires. The recordings were evaluated by extramural expert rhinologists based on a validated Global Rating Scale (GRS). These results were analyzed and compared to assess construct and concurrent validity. RESULTS: The appearance of anatomic structures was rated as realistic by 75% of all participants, while only 30% and 41.7% rated the mucosal and bony tissues as realistic, respectively. A total of 91.7% of participants found the model useful for teaching anatomy, while 66.7% said it was useful for teaching operative technique. Construct validity was confirmed by showing significant differences in performance between the novice and experienced groups. Concurrent validity was confirmed by showing significant correlation between performance on the model and gold standard (i.e. cadaver head). CONCLUSIONS: This study demonstrates the face, content, concurrent, and construct validity of a 3D-printed SNSS. Although this model has the potential to be a valuable tool in endoscopic sinus surgery training for otolaryngology residents, improvements are required with respect to the quality of simulated mucosal tissue as well as the simulated anatomy of the fronto-ethmoid compartment Level of Evidence: NA Laryngoscope, 2019.

Percutaneous Nephrolithotomy in the 80 Years of Age and Older Population.

OBJECTIVE: To evaluate feasibility of percutaneous nephrolithotomy (PCNL) for complex nephrolithiasis in patients 80 years of age and older compared to younger individuals. METHODS: From an institutional IRB-approved database, 1,647 patients were identified who underwent PCNL from 1999 to 2019. Patients were stratified by age: group 1 (20-59), group 2 (60-79), and group 3 (>80). Statistics were performed using chi-square and ANOVA to compare outcomes. RESULTS: Of the 1,647 patients, median age was 46, 66, and 83, respectively (P <0.0001). Three patients within group 3 were 90 or older. Females made up 54%, 46%, 56% of patients (P = 0.02). Average stone size with SD was 2.6 ± 2.2, 2.5 ± 2.3, 2.2± 1.9 cm for each group (P = 0.06). Mean preoperative hemoglobin (Hgb) was significantly lower in the 80+ group (13.8, 13.4, 13.1 g/dL, P <.0001). Change in Hgb was not significantly different. There were more Clavien II-IV complications (10.4, 14.4, 28.8%; P = 0.02) and transfusions (2.3, 4.7, 10.2%; P <0.001) in the elderly. The most common complications in the 80+ group were bleeding related (10.1%). No difference in readmission rates or ICU admissions was noted. CONCLUSION: PCNL is feasible in the extremely elderly; however with a higher rate of complications and longer hospitalizations. No long-term sequelae or deaths in the 80 and older cohort were seen. This study allows us to appropriately counsel older patients on a realistic postoperative course and supports use of PCNL as the best means of long-term survival.

Audiologic Improvement Following MCF Approach for Spontaneous Cerebrospinal Fluid Leaks.

OBJECTIVE: To determine the audiologic improvement after middle cranial fossa (MCF) approach to repair spontaneous cerebrospinal fluid (sCSF) leaks. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary referral center. PATIENTS: Twenty-four consecutive patients (27 ears) with temporal bone sCSF leak over a 4-year period. Patient age, sex, ethnicity, body mass index (BMI), location of CSF leak, recurrence of CSF leak, and presence of encephalocele(s) were recorded. INTERVENTION: Audiometric testing in patients undergoing MCF repair of temporal bone sCSF leak. MAIN OUTCOME MEASURES: Comparison of preoperative and postoperative pure-tone average (PTA), air-bone gap (ABG), and word recognition score (WRS) in the sCSF leak ear. RESULTS: Out of 27 ears, 55% had multiple tegmen defects and 82% had more than or equal to 1 encephaloceles. There were no recurrent CSF leaks at a median follow up of 4 months. The mean (SD) preoperative PTA and ABG were 40.58 [15.67] and 16.44 [6.93] dB, respectively. There was significant improvement in mean PTA (10.28 [8.01] dB; p < 0.001; Cohen d = 0.95) and ABG (9.31 [7.16] dB; p < 0.001; Cohen d = 0.88) after sCSF repair. Mean WRS improved (by 3.07 [6.11] %; p = 0.024; Cohen d = 0.46) from a mean preoperative WRS of 93.16 [9.34]% to a mean postoperative WRS of 96.26 [6.49]%. CONCLUSIONS: MCF approach for repair of sCSF leaks yields significant improvement in conductive hearing loss and is highly effective in management of the entire lateral skull base where multiple bony defects are often identified.

Clinicopathological characteristics of ypT0N0 urothelial carcinoma following neoadjuvant chemotherapy and cystectomy.

AIMS: To describe a large tertiary care academic centre's experience with patients who achieve a complete pathological response (ie, ypT0N0) following neoadjuvant chemotherapy (NAC) and radical cystectomy (RC) with emphasis on morphological features present in the RC and clinical outcome. METHODS: 41 patients with ypT0N0 disease following transurethral resection of bladder tumour (TURBT), NAC and RC with available clinical follow-up information were analysed. Slides from all RCs were reviewed to confirm pathological stage and assess for morphological parameters (eg, foreign body giant cell reaction, dystrophic calcification, scar and fat necrosis). RESULTS: With median follow-up of 32.8 months, the recurrence-free survival at 1 and 5 years was 97.4% and 93.5%, while the overall survival at 3 and 5 years was 94.2% and 88.6%, respectively. No patients died of urothelial carcinoma. Stage assigned at TURBT was 1 pTa (2%), 1 pT1 (2%), 38 pT2 (93%) and 1 pT3a (2%). 17 TURBTs demonstrated variant histology, with the majority of these being squamous (65%). The most common morphological features present at RC were scar (100%), foreign body giant cell reaction (80%), chronic inflammation within lamina propria (68%) and dystrophic calcifications (39%). Other morphological features were less common or absent. CONCLUSION: ypT0N0 disease at RC portends an excellent prognosis, regardless of stage or variant histology in the TURBT; scar, foreign body giant cell reaction, chronic inflammation and dystrophic calcifications are often present.

Plasmacytoid/diffuse urothelial carcinoma: a single-institution immunohistochemical and molecular study of 69 patients.

Accurate diagnosis of plasmacytoid urothelial carcinoma (PUC) is important given its poor prognosis and frequent presentation at high stage. We aim to assess the clinicopathological features, molecular aberrations, and follow-up data in a series of PUC cases from a single tertiary cancer center. Seventy-two urinary bladder, ureteral, and renal pelvic specimens with urothelial carcinoma with plasmacytoid differentiation were identified. Immunohistochemical stains were performed on 48 cases. Among urinary bladder origin markers, GATA3 was most sensitive (96%). Breast carcinoma markers (estrogen receptor, mammaglobin) were usually negative, but progesterone receptor stained 1 case (4%). Neuroendocrine markers CD56 and TTF-1 were each positive in 1 case (4% and 4%, respectively). Gastrointestinal adenocarcinoma marker CDX2 was positive in 4 cases (15%), but nuclear ß-catenin was negative in all cases. CD138 was positive in 83% and E-cadherin expression was lost in 57% of cases. Fluorescence in situ hybridization using the UroVysion Bladder Cancer Kit and FGFR3 mutational analysis using polymerase chain reaction were performed on 15 cases; deletion of chromosome 9p21 was common (60%), and FGFR3 mutations were detected in 60% of cases (5 cases had both deletion 9p21 and FGFR3 mutations). Cases were divided into 3 morphologic groups: classic (29%), desmoplastic (35%), and pleomorphic (36%). The 3 morphologic subtypes had distinct survival outcomes (P = .083), with median survival for all patients 18 being months versus 10 months for the desmoplastic group.