Team-Based Surgical Approach to Head and Neck Microvascular Free Flap Reconstruction.

Importance: Because microvascular free flap reconstruction is increasingly used to restore function in patients with head and neck cancer, there is a growing need for evidence-based perioperative care. Objective: To assess the association of different team-based surgical approaches with intraoperative and postoperative outcomes for patients undergoing head and neck free flap reconstruction. Design, Setting, and Participants: This retrospective cohort study of 733 patients was conducted at an academic tertiary care medical center. Head and neck oncologic procedures involving microvascular free flap reconstruction with available intraoperative data collected from January 1, 2000, to December 31, 2021, were included. Main Outcomes and Measures: Patient characteristics including demographic characteristics and comorbid conditions, operative variables, length of stay, and postoperative outcomes were measured. Descriptive statistics and effect size measures were performed to compare the 3 intraoperative surgical team approaches, specifically single surgeon, separate 2-team approach, and integrated 2-team approach; 1:1 nearest neighbor matching without caliper was performed to compare single- vs 2-team and separate and integrated 2-team approaches. Effect size measures including Cramer V for dichotomous variables, the Kendall W coefficient of concordance for ordinal variables, and η2 for continuous variables were reported with 95% CIs to describe precision. Results: Among 733 cases, there were no clinically significant differences in patient demographic characteristics, clinicopathologic characteristics, and choice of free flap reconstruction based on intraoperative surgical team approach. The mean (SD) age was 58.7 (12.4) years, and 514 were male (70.1%). In terms of operative and postoperative variables, there was a difference in operative times and intraoperative fluid requirements among the 3 different techniques, with the integrated 2-team approach demonstrating a mean reduction in operative time of approximately 2 hours (η2 = 0.871; 95% CI, 0.852-0.887; mean [SD] operative time = 541 [191] minutes for the single-surgeon approach, 399 [175] minutes for the integrated 2-team approach, and 537 [200] minutes for the separate 2-team approach) and lower fluid requirements of greater than 1 L (η2 = 0.790; 95% CI, 0.762-0.817). In both unadjusted analyses and propensity score matching, there were no clinically significant differences in terms of ischemia time, use of pressors, postoperative complications (including free flap failure, number of return trips to the operating room, length of stay, or 30-day readmission) based on intraoperative team approach. Conclusions and Relevance: Findings suggest that the integrated 2-team surgical approach for complex head and neck microvascular reconstruction can be used to safely decrease operative time, with no difference in postoperative outcomes.

Sinonasal Neuroendocrine Carcinoma: 15 Years of Experience at a Single Institution.

Objectives Sinonasal neuroendocrine carcinomas (SNECs) are among the rarest paranasal sinus cancers. Consensus guidelines for therapy are difficult to develop due to limited data regarding the natural history and successful treatment of these tumors. This study presents 15 years of experience treating SNEC at a single institution and a review of the literature. Design Retrospective review. Setting Academic medical center in the United States. Participants Patients diagnosed with primary SNEC. Main Outcome Measures Overall survival. Results Thirteen patients were identified and included. Overall estimated survival was 74.6% at 5 years. Ten of 13 (76.9%) patients were diagnosed with high-grade neuroendocrine carcinoma and three (23.1%) with intermediate or low grade. All three patients with low- or intermediate-grade cancer survived more than 10 years from their initial diagnosis (median survival: 11.6 years) and are currently alive. The four patients who died had high-grade carcinoma, and estimated overall 5-year survival for all patients with high-grade carcinomas was 65.6%. Five patients, all with high-grade carcinoma, of seven who completed primary chemoradiation therapy (CRT) required salvage resection, and 60% are alive without disease. Conclusion This cohort has a higher overall rate of survival than many recent case series and reviews. There is consensus that multimodal therapy is preferred over monotherapy, but approaches to treatment vary widely. Our approach of surgical resection as primary therapy for low-grade tumors and primary CRT for high-grade SNEC has been successful, and could indicate hope for improved survival among these patients.

Translation of Legislation: Effect Analysis of Michigan Opioid Law on Clinical Practice.

BACKGROUND: To combat almost 450,000 Americans dying of opioid overdose between 1999 and 2018, the Michigan Opioid Laws were implemented on July 1, 2018, to reduce overprescription of opioids. This retrospective study evaluated the effect of this legislation on prescribing patterns after thoracic operations at an academic, tertiary care center. METHOD: Charts of 776 patients undergoing lobectomy, paraesophageal hiatal hernia repair, Nissen fundoplication, or esophagectomy between July 1, 2017, and July 1, 2019, were reviewed. Populations were identified before and after the July 1, 2018 implementation of the Michigan Opioid Laws. Procedure type, analgesic type, total pills, morphine equivalents, and refills and their pill number were independent variables. Patients using opioids for >30 days before operations were excluded. RESULTS: Overall, 629 patients were included in the analysis (324 pre-legislation patients, 305 post-legislation patients). The average number of opioids prescribed to patients at discharge before the legislation was 28.0 pills vs 21.4 pills after (P < .01). Before implementation of the Michigan Opioid Laws, 14.5% of patients received refills, whereas only 5.9% received refills after implementation, reducing the average number of refills per patient from 0.19 to 0.07 (P < .001). Average morphine equivalents and percentage of patients receiving opioids showed no statistical difference. CONCLUSIONS: The implementation of the Michigan Opioid Laws correlated with a change in clinical practice, potentially by reducing the number of pills and refills prescribed per patient, and did not deter providers from prescribing opioids acutely. This suggests that the Michigan Opioid Laws allow prescribing freedom while giving legislative structure encouraging time-conscious tapering. The Michigan Opioid Laws may serve as a model for other states to emulate.

Otolaryngology Curriculum During Residency Preparation Course Improves Preparedness for Internship.

OBJECTIVES/HYPOTHESIS: Residency preparation courses (RPCs) have become a widely adopted practice to ease the transition of medical students into residency, but these courses often lack training in skills expected of subspecialty interns. To fill this gap, a simulation-based curriculum in otolaryngology (ORL) was implemented at the University of Michigan Medical School. The curriculum aimed to improve confidence and perceived ability to perform common ORL skills for graduating students prior to internship. STUDY DESIGN: Cross-sectional study. METHODS: Six basic simulations (tracheostomy, flexible laryngoscopy, otomicroscopy, myringotomy and tube insertion, epistaxis and peritonsillar abscess management) were included in the first course in 2019. The course was expanded in 2020 with the addition of three advanced simulations (ear foreign body extraction, tracheostomy complications, and "cannot intubate, cannot ventilate" situations). Pre- and postsession surveys were collected to assess individual simulations and the course overall. RESULTS: A total of 32 students participated in the ORL simulation curriculum in Spring 2019 and 2020. Paired t-tests showed significant improvement in self-perception of ability on every simulation. Qualitative feedback revealed that students particularly valued the opportunity for hands-on learning. Non-ORL students rated their baseline abilities significantly lower than ORL students on five stations, but they achieved statistically equivalent postsession ratings on all but the otomicroscopy station. CONCLUSIONS: An ORL-specific curriculum is a valuable addition to procedural RPCs. The curriculum resulted in increased confidence and perceived ability in skill performance for both students pursuing ORL residencies, as well as those pursuing other procedural specialties. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E2143-E2148, 2021.

Coping with COVID-19: medical students as strong and responsible stewards of their education.

BACKGROUND: Due to the COVID-19 pandemic, clinical rotations at the University of Michigan Medical School (UMMS) were suspended on March 17, 2020, per the Association of American Medical Colleges' recommendations. No alternative curriculum existed to fill the educational void for clinical students. The traditional approach to curriculum development was not feasible during the pandemic as faculty were redeployed to clinical care, and the immediate need for continued learning necessitated a new model. APPROACH: One student developed an outline for an online course on pandemics based on peer-to-peer conversations regarding learners' interests and needs, and she proposed that students author the content given the immediate need for a curriculum. Fifteen student volunteers developed content to fill knowledge gaps, and expert faculty reviewers confirmed that the student authors had successfully curated a comprehensive curriculum. EVALUATION: The crowdsourced student content coalesced into a 40-hour curriculum required for all 371 clinical-level students at UMMS. This student-driven effort took just 17 days from outline to implementation, and the final product is a full course comprising five modules, multiple choice questions, discussion boards, and assignments. Learners were surveyed to gauge success, and 93% rated this content as relevant to all medical students. REFLECTION: The successful implementation of this model for curriculum development, grounded in the Master Adaptive Learner framework, suggests that medical students can be entrusted as stewards of their own education. As we return to a post-pandemic "normal," this approach could be applied to the maintenance and de novo development of future curricula.

Development of a novel mandibular distraction osteogenesis simulator using Computer Aided Design and 3D printing.

INTRODUCTION: Micrognathia, a component of Robin Sequence, can cause glossoptosis, failure of palatal fusion, and critical obstruction of the airway. Mandibular distraction osteogenesis (MDO) is at times offered to anteriorly translate the mandible and tongue, relieving airway obstruction. MDO is an intricate reconstructive procedure that may be ideal for teaching using a high-fidelity educational simulator, allowing early hands-on experience in a zero-risk environment. OBJECTIVES: To design a novel, low-cost, high-fidelity neonatal MDO simulator that can be used for trainee education and refinement of surgical technique. METHODS: A novel MDO simulator was developed using additive manufacturing techniques. Three experts in MDO surgery completed a 20-item survey, rating the simulator's physical attributes, the realism of experience, the simulator's value, its relevance to practice and the surgeon's ability to perform tasks on a 4-point Likert scale. RESULTS: Computer Aided Design (CAD) and 3D printing allowed for the production of a realistic surgical simulator that emulates important aspects of MDO surgery. This preliminary evaluation indicated adequate means across the five domains relevant to the simulator's fidelity and usability (M = 3.33 to 3.75) out of a maximum of 4 points. Lowest rated items were consistent with expert comments allowing future refinement on subsequent iterations. Consumable material costs per model were $9.39 USD. CONCLUSIONS: The MDO model demonstrated adequate fidelity and holds promise as a skill-development tool for surgeons in training. Further studies are planned to determine its utility as a training and assessment tool.

The Association Between Preoperative Opioid Exposure and Prolonged Postoperative Use.

OBJECTIVE: To determine the effect of nonchronic, periodic preoperative opioid use on prolonged opioid fills after surgery. BACKGROUND: Nonchronic, periodic opioid use is common, but its effect on prolonged postoperative opioid fills is not well understood. We hypothesize greater periodic opioid use before surgery is correlated with persistent postoperative use. METHODS: We used a national private insurance claims database, Optum's de-identifed Clinformatics Data Mart Database, to identify adults undergoing general, gynecologic, and urologic surgical procedures between 2008 and 2015 (N = 191,043). We described patterns of opioid fills based on dose, recency, duration, and continuity to categorize preoperative opioid exposure. Patients with chronic use were excluded. Our primary outcome was persistent postoperative use, defined as filling an opioid prescription between 91- and 180-days post-discharge. The association between preoperative opioid use and persistent use was determined using multivariable logistic regression, controlling for clinical covariates. RESULTS: In the year before surgery, 41% of patients had nonchronic, periodic opioid fills. Compared with other risk factors, patterns of preoperative fills were most strongly correlated with persistent postoperative opioid use. Patients with recent intermittent use were significantly more likely to have prolonged fills after surgery compared with opioid-naïve patients [minimal use: odds ratio (OR): 2.0, 95% confidence interval (CI) 1.89-2.03; remote intermittent: OR 4.7, 95% CI 4.46-4.93; recent intermittent: OR 12.2, 95% CI 11.49-12.90]. CONCLUSIONS: Patients with nonchronic, periodic opioid use before surgery are vulnerable to persistent postoperative opioid use. Identifying opioid use before surgery is a critical opportunity to optimize care after surgery.

Ten Years Into the Integrated Residency Era: A Pilot Study Shows Many Cardiothoracic Surgery Faculty Still Favor the Traditional Pathway.

The first integrated cardiothoracic surgery residents (I-6) graduated in 2013. Predominantly, there is still the option to pursue a traditional training pathway via general surgery residency followed by 2-3 years of specialized cardiothoracic surgery training. Our aim was to understand the perspectives of academic cardiothoracic faculty on the various training models. An anonymous web-based survey was distributed to all academic cardiothoracic surgeons in the United States. Respondents were asked about their perceptions of the 2 training models (I-6 and traditional). Descriptive statistics and Fisher exact test were used to analyze the data. A total of 15.4% (111/719) of faculty completed responses. When comparing training models, 23.4% of faculty believe the I-6 is a superior structure, 31.5% believe they are about the same, and 45.0% believe the traditional model is better. Also, 51.4% of the faculty said they would still apply into a traditional fellowship, with 27.9% picking an I-6 program and 20.7% picking a 4 + 3 model. A total of 40.5% believe the I-6 is good for the specialty and 55.0% think the I-6 attracts higher achieving applicants, but 26.1% and 19.8% believe it is improving training or increasing the scholarly activity of residents, respectively. When asked about resident experience, 56.4% of I-6 faculty feel there is a bias against their residents on the general surgery service, which some believe leads to poor educational outcomes for I-6 residents. The integrated residency represents a major shift in cardiothoracic surgery training. Faculty opinions vary regarding the quality and effectiveness of this model with many preferring the traditional model.

Does Performance on Evidence-Based Medicine and Urgent Clinical Scenarios Assessments Deteriorate During the Fourth Year of Medical School? Findings From One Institution.

PURPOSE: The fourth year of medical school (M4) should prepare students for residency yet remains generally unstructured, with ill-defined goals. The primary aim of this study was to determine whether there were performance changes in evidence-based medicine (EBM) and urgent clinical scenarios (UCS) assessments before and after M4 year. METHOD: University of Michigan Medical School graduates who matched into internship at Michigan Medicine completed identical assessments on EBM and UCS at the beginning of M4 year and 13 months later during postgraduate year 1 (PGY1) orientation. Individual scores on these assessments were compared using paired t test analysis. The associations of academic performance, residency specialty classification, and initial performance on knowledge changes were analyzed. RESULTS: During academic years 2014 and 2015, 76 students matched into a Michigan Medicine internship; 52 completed identical EBM stations and 53 completed UCS stations. Learners' performance on the EBM assessment decreased from M4 to PGY1 (mean 93% [SD = 7%] vs. mean 80% [SD = 13%], P < .01), while performance on UCS remained stable (mean 80% [SD = 9%] vs. mean 82% [SD = 8%], P = .22). High M4 performers experienced a greater rate of decline in knowledge level compared with low M4 performers for EBM (-20% vs. -4%, P = .01). Residency specialty and academic performance did not affect performance. CONCLUSIONS: This study demonstrated degradation of performance in EBM during the fourth year and adds to the growing literature that highlights the need for curricular reform during this year.