Multidisciplinary Management of Total Anterior Skull Base Osteoradionecrosis.

Cases of delayed osteoradionecrosis (ORN) of the anterior skull base have unique management considerations. A 59-year-old woman with a history of basaloid squamous cell carcinoma of the sinonasal cavity with intracranial extension through the anterior skull base developed delayed radiation sequelae of anterior skull base ORN. She underwent an initial endoscopic resection in 2011 with persistent disease that required an anterior craniofacial resection with left medial maxillectomy in 2012. She had a radiologic gross total resection with microscopic residual disease at the histologic margins prompting adjuvant chemoradiotherapy to target volume doses of 66 to 70 Gy with concurrent cisplatin chemotherapy. She subsequently developed an intracranial abscess in 2021 along the anterior skull base that required a craniotomy and endoscopic debridement. Despite aggressive surgical and medical therapy, she had persistent intracranial infections and evidence of skull base ORN. She ultimately underwent a combined open bifrontal craniotomy and endoscopic resection of the necrotic frontal bone and dura followed by an anterolateral thigh free flap reconstruction with titanium mesh cranioplasty. The patient recovered well from a microvascular free-tissue reconstruction without concern for cerebrospinal fluid leak. Anterior skull base reconstruction with free tissue transfer is a commonly utilized method for oncologic resections. Here, an anterolateral free flap was effectively used to treat an anterior skull base defect secondary to a rare indication of skull base ORN.

Three-dimensional fluid-structure interaction simulation of the Wheatley aortic valve.

Valvular heart diseases (such as stenosis and regurgitation) are recognized as a rapidly growing cause of global deaths and major contributors to disability. The most effective treatment for these pathologies is the replacement of the natural valve with a prosthetic one. Our work considers an innovative design for prosthetic aortic valves that combines the reliability and durability of artificial valves with the flexibility of tissue valves. It consists of a rigid support and three polymer leaflets which can be cut from an extruded flat sheet, and is referred to hereafter as the Wheatley aortic valve (WAV). As a first step towards the understanding of the mechanical behavior of the WAV, we report here on the implementation of a numerical model built with the ICFD multi-physics solver of the LS-DYNA software. The model is calibrated and validated using data from a basic pulsatile-flow experiment in a water-filled straight tube. Sensitivity to model parameters (contact parameters, mesh size, etc.) and to design parameters (height, material constants) is studied. The numerical data allow us to describe the leaflet motion and the liquid flow in great detail, and to investigate the possible failure modes in cases of unfavorable operational conditions (in particular, if the leaflet height is inadequate). In future work the numerical model developed here will be used to assess the thrombogenic properties of the valve under physiological conditions.

The impact of the pandemic on the presentation and treatment of head and neck squamous cell carcinoma at a county hospital.

INTRODUCTION: In March 2020, the World Health Organization declared COVID-19 a pandemic, initiating stay-at-home orders which delayed cancer care and screening. The impact on head and neck cancer care in populations at risk has yet to be elucidated. The objective of this investigation is to evaluate how the presentation, diagnosis, and treatment of head and neck squamous cell carcinoma cancer patients at a county hospital were affected by the pandemic. METHODS: A retrospective review of patients with head and neck squamous cell carcinoma that were diagnosed at a county hospital 365 days before and after stay-at-home orders were initiated. The primary outcomes were duration between diagnosis from imaging and initiation of treatment. Secondary outcomes included mortality, stage, nodal status, and distant metastasis at presentation. RESULTS: There was a total of 105 diagnoses. Sixty-five (62 %) head and neck squamous cell carcinoma diagnoses were diagnosed before the stay-at-home orders were initiated, and 40 (38 %) after. Eighty percent (32/40) of diagnoses presenting after had stage IV disease compared to 58 % (38/65) in those before (p < 0.05). A higher percentage of patients who presented later had a >30-day delay to biopsy (43 % v. 20 %, OR: 3.0, p < 0.05). This difference was exacerbated by those with laryngeal, oral cavity, or oropharyngeal cancer (45 % v. 15 %, OR: 4.5, p < 0.05). There was a larger delay from diagnosis to treatment after the orders were initiated (68 v. 53, p < 0.05) however there was no difference in one-year mortality (25 % v. 23 %, p > 0.05). This investigation found a 14 % loss to follow-up. CONCLUSIONS AND RELEVANCE: In this cohort of head and neck squamous cell carcinoma diagnoses at a county hospital, those diagnosed after the stay-at-home orders were initiated presented with more advanced disease. They also had more delays in diagnosis and initiation of treatment. There was no difference in one-year mortality rates between the two groups however there was a significant loss to follow-up, limiting prognostication. These findings serve to better prepare healthcare providers to implement optimized care during future shutdowns related to public health crises. LEVEL OF EVIDENCE: III.

Solute transport with Michaelis-Menten kinetics for in vitro cell culture.

A traditional method of in vitro cell culture involves a monolayer of cells at the base of a petri dish filled with culture medium. While the primary role of the culture medium is to supply nutrients to the cells, drug or other solutes may be added, depending on the purpose of the experiment. Metabolism by cells of oxygen, nutrients and drug is typically governed by Michaelis-Menten (M-M) kinetics. In this paper, a mathematical model of solute transport with M-M kinetics is developed. Upon non-dimensionalization, the reaction/diffusion system is re-characterized in terms of Volterra integral equations, where a parameter $\beta $, the ratio of the initial solute concentration to the M-M constant, proves important: $\beta \ll 1$ is relevant to drug metabolism for the liver, whereas $\beta \gg 1$ is more appropriate in the case of oxygen metabolism. Regular perturbation expansions for both cases are obtained. A small-time expansion and steady-state solution are also presented. All results are compared against the numerical solution of the Volterra integral equations, and excellent agreement is found. The utility of the model and analytical solutions are discussed in the context of assisting experimental researchers to better understand the environment within in vitro cell culture experiments.

Levofloxacin versus clarithromycin for Helicobacter pylori eradication: are 14 day regimens better than 10 day regimens?

BACKGROUND: Helicobacter pylori eradication by the conventional clarithromycin therapy has largely dropped in the recent years possibly due to antimicrobial resistance. Hence, levofloxacin-based regimen has been used as salvage therapy. However, data regarding its effectiveness on eradication are controversial. This study aimed to compare the eradication rate of levofloxacin-based regiment to that of the conventional first-line clarithromycin regimen. METHODS: Patients diagnosed with H. pylori infection and treated with levofloxacin triple therapy or clarithromycin-based regimen for 10 or 14 days were included. Patients were excluded if they used antibiotics or proton pump inhibitors within 4 or 2 weeks, respectively, of the H. pylori eradication confirmation test. H. pylori eradication rate was assessed, as well as the impact of diabetes and esophagogastroduodenoscopy (EGD) findings. RESULTS: Of 245 patients, 145 were in the levofloxacin group and 100 in the clarithromycin group. Most patients in either group received therapy for 14 days vs. 10 days (P = 0.002). Levofloxacin-based treatment was associated with a higher eradication rate compared with clarithromycin-based treatment (74.5 vs. 62%, respectively; P = 0.04). The 14 day levofloxacin-based regimen resulted in the highest eradication rate, followed by the 14 day regimen of clarithromycin (80.9 vs. 66.3%; P = 0.03). The 10 day regimens exhibited 62.7 and 41.2% eradication rates, respectively (P = 0.12). H. pylori eradication was not affected by diabetes or EGD findings (P = 0.98 and 0.3, respectively). CONCLUSIONS: Results from this study support the use of a levofloxacin-based regimen as a first-line therapy in the treatment of H. pylori infection for 14 days regardless of diabetes and EGD findings.

Impact of COVID-19 on nationwide pediatric otolaryngology: Otitis media and myringotomy tube trends.

PURPOSE: The pandemic related to the novel coronavirus (COVID-19) has led to a decrease in communicable diseases due to social distancing and mask-wearing. How have the prevalence of otitis media (OM) and its associated procedures changed during the pandemic? STUDY DESIGN: Retrospective Cohort Study. METHODS: This is a retrospective cohort study using the Pediatric Health Information System® (PHIS) database, which consists of 48 children's hospitals. Regions were defined according to PHIS rules. We compared proportion of OM to total diagnoses codes, and collected mastoiditis, and MT placements from all encounters through January 1, 2019-June 31, 2021. RESULTS: In April 2020, there was a decrease in mean proportion of OM cases per 100 hospital visits (7 v. 2, p < 0.0001) and this was sustained through 2020 and until June 2021 (6-7 v. 2-4, p < 0.05; p < 0.05). Compared to 2020, the months of April and June 2021 showed an increase in mean proportion of OM cases (6-7 v. 3-4, p < 0.05) while May did not. This relative increase in OM cases through April-June were primarily driven by the South, the Midwest, and the Northeast in April and the South and the Midwest in June. MT procedures followed similar trends. In 2020, there was no difference in mastoiditis as a proportion of OM cases compared to 2019 however there was a statistically higher rate of mastoiditis in 2020 compared to 2021. CONCLUSIONS: The COVID-19 pandemic led to declines in OM and MT case volumes that have started to increase. A geographic relationship may exist, and this connection could be influenced by mask mandates and social distancing.

The role of fungus in the pathogenesis of chronic rhinosinusitis.

PURPOSE OF REVIEW: The etiologic role of fungi in chronic rhinosinusitis remains controversial. The purpose of this review is to further our understanding of molecular immunologic pathways activated by fungi and clinical trials of antifungals in severe subtypes of asthma and allergic fungal rhinosinusitis. RECENT FINDINGS: Various fungal components such as protease and chitin are capable of eliciting a type 2 innate and adaptive immune response. However, definitive studies on the etiologic role of fungi in chronic rhinosinusitis (CRS) is dependent on the development of a fungi-induced murine model of CRS. Short of this model, extrapolations of observations and results from clinical trials in fungi-induced asthma subtypes support a key role of fungi in the pathophysiology of allergic fungal rhinosinusitis and possibly other CRS endotypes. SUMMARY: Fungi plays a key role in the pathophysiology of several subtypes of chronic inflammatory respiratory diseases. However, a fungi-induced murine model of CRS is needed to explicitly investigate the molecular pathways and potential therapeutic targets.

Traumatic xylophagia leading to foreign body removal and tracheostomy in the setting of postpartum psychosis.

Postpartum psychosis (PPP) is a severe mood disorder following childbirth that rarely leads to injurious or suicidal behavior. This report illustrates otolaryngologic intervention for pharyngeal laceration and airway instability following traumatic foreign body ingestion in the setting of PPP. A 25-year-old woman with PPP presented with hemoptysis after attempting suicide by traumatically forcing tree branches into her oropharynx. Imaging revealed pneumomediastinum, and flexible laryngoscopy and esophagoscopy showed a large foreign body (tree branch) extending from the hypopharynx to the gastroesophageal junction. She was taken to the operating room for direct microlaryngoscopy, bronchoscopy and esophagoscopy with removal of the 25-cm tree branch. Panendoscopy revealed a mucosal laceration at the cricopharyngeus with supraglottic and hypopharyngeal edema but no injury to the larynx. Due to airway concerns, a cuffed tracheostomy was placed along with a gastrostomy tube for feeding access. She tolerated her postoperative course with successful decannulation and oral feeding prior to discharge.

Long Term Olfactory Outcomes Following Frontal Sinus Surgery in Chronic Rhinosinusitis.

OBJECTIVES/HYPOTHESIS: No studies have evaluated the impact of the types of frontal sinus surgery (FSS) on objective olfaction scores. This study evaluated olfactory function and quality of life (QOL) in chronic rhinosinusitis (CRS) patients before and after total ethmoidectomy with frontal sinusotomy (FS). STUDY DESIGN: Prospective cohort study. METHODS: A prospective study of adult CRS patients undergoing FSS (Draf 2 or Draf 3 procedures) was conducted at a tertiary care center. Primary outcomes included brief smell identification test (BSIT) and sinonasal outcome test-22 (SNOT-22), which were assessed during preoperative evaluation, 6 to 9 weeks postoperatively, and 12 to 24 weeks postoperatively. Normosmia was defined as BSIT ≥9. Statistical significance was determined using the Wilcoxon signed-rank test with α = .05. RESULTS: Thirty-eight patients followed up 12 to 24 weeks after FSS. The differences between baseline and long-term outcomes for BSIT (6.11 vs. 8.24, P = .00034) and SNOT-22 (55.49 vs. 24.32, P < .00001) scores were found to be statistically significant. Although both subgroups had clinically significant olfactory improvements, only the Draf 2 cohort experienced a statistically significant improvement in olfaction at long-term follow-up. There was no statistically significant change in data from 6 to 9 weeks to 12 to 24 weeks postoperatively. CONCLUSIONS: Patients undergoing total ethmoidectomy with FS demonstrated statistically significant increases in olfaction and QOL at long-term postoperative follow-up. This study demonstrated that FS does not negatively impact the olfactory improvement seen in sinus surgery. The lack of statistically significant changes in these olfactory metrics from short to long-term follow-up suggests that there is no additional negative effect of FSS in the long term. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:2173-2178, 2021.

Incorporating Virtual Reality to Improve Otolaryngology Resident Wellness: One Institution's Experience.

OBJECTIVE: Burnout is defined as work-related emotional exhaustion, depersonalization, and decreased sense of accomplishment. Virtual reality (VR) has emerged as an effective treatment modality for various conditions related to anxiety, however, few studies have assessed its role for stress management in residents. We hypothesize that VR-based mindfulness meditation can reduce resident burnout in real-world settings. STUDY DESIGN: Prospective randomized crossover trial. METHODS: Resident participants completed the validated Maslach Burnout Inventory (MBI). One group used a VR-based meditation app; the second group received no intervention. After a 2-month rotation, all subjects completed an MBI and crossed over to the other arm. Wilcoxon rank-sum tests were used to compare MBI scores before and after intervention, and to compare results by gender and postgraduate year. Mann-Whitney U tests were used to assess qualitative differences between participants. RESULTS: Eighteen residents completed the study. Five participants were female and 13 were male. Weekly use of VR-guided meditation and paced breathing was associated with a significant decrease in emotional exhaustion (P = .009), and on subgroup analysis, male gender specifically was associated with a decrease in emotional exhaustion (P = .027). In the post-intervention survey, 42.9% subjects reported that VR encouraged them to employ paced breathing techniques, 71.4% reported that they would use the technology if regularly available, and 21.4% reported they would use paced breathing in the future. CONCLUSION: VR-based therapy may serve as a successful tool in stress management and reduce the rate of burnout among otolaryngology residents. LEVEL OF EVIDENCE: NA Laryngoscope, 131:1972-1976, 2021.

Virtual Reality as Distraction Analgesia for Office-Based Procedures: A Randomized Crossover-Controlled Trial.

OBJECTIVE: The purpose of this study was to explore the use of immersive and interactive virtual reality (VR) for analgesia, anxiety reduction, and overall satisfaction in patients undergoing outpatient postoperative debridements. STUDY DESIGN: Randomized crossover-controlled trial. SETTING: Academic outpatient clinic. SUBJECTS AND METHODS: Adult patients who had functional endoscopic sinus surgery and skull base surgery and were undergoing office-based postoperative nasal endoscopy and debridement were recruited and followed for 2 consecutive office visits. Participants were randomized to receive either the control or experimental analgesia for the first postoperative visit (PO1) and crossed over into the opposite treatment arm during the second postoperative visit (PO2). Outcomes included procedural pain, anxiety and satisfaction scores, procedural time, and reflexive head movements per minute (RHM). RESULTS: Eighty-two participants were recruited. At PO1, 39 received standard analgesia, and 43 received an immersive VR experience. At PO1, the VR group experienced significantly less anxiety (P = .043) and fewer RHM (P = .00016) than the control group. At PO2, the VR group experienced significantly fewer RHM (P = .0002). At PO2, patients who received the experimental treatment after initially receiving the control treatment had significantly decreased pain, anxiety, and RHM. This effect was not seen in the second group. Overall, 69.51% of patients felt that the VR treatment was better; 19.51% thought that it was the same; and 9.76% found it to be worse. CONCLUSION: VR technology holds promise as a nonpharmacologic analgesic and anxiolytic intervention for otolaryngology office-based procedures. Further study of VR use in other procedures is warranted. LEVEL OF EVIDENCE: 1, randomized controlled trial.

Mathematical modelling of fluid flow and solute transport to define operating parameters for in vitro perfusion cell culture systems.

In recent years, there has been a move away from the use of static in vitro two-dimensional cell culture models for testing the chemical safety and efficacy of drugs. Such models are increasingly being replaced by more physiologically relevant cell culture systems featuring dynamic flow and/or three-dimensional structures of cells. While it is acknowledged that such systems provide a more realistic environment within which to test drugs, progress is being hindered by a lack of understanding of the physical and chemical environment that the cells are exposed to. Mathematical and computational modelling may be exploited in this regard to unravel the dependency of the cell response on spatio-temporal differences in chemical and mechanical cues, thereby assisting with the understanding and design of these systems. In this paper, we present a mathematical modelling framework that characterizes the fluid flow and solute transport in perfusion bioreactors featuring an inlet and an outlet. To demonstrate the utility of our model, we simulated the fluid dynamics and solute concentration profiles for a variety of different flow rates, inlet solute concentrations and cell types within a specific commercial bioreactor chamber. Our subsequent analysis has elucidated the basic relationship between inlet flow rate and cell surface flow speed, shear stress and solute concentrations, allowing us to derive simple but useful relationships that enable prediction of the behaviour of the system under a variety of experimental conditions, prior to experimentation. We describe how the model may used by experimentalists to define operating parameters for their particular perfusion cell culture systems and highlight some operating conditions that should be avoided. Finally, we critically comment on the limitations of mathematical and computational modelling in this field, and the challenges associated with the adoption of such methods.

Hospital Charge Variability across New York State: Sociodemographic Factors in Pituitary Surgery.

Introduction Significant charge disparities exist across New York State (NYS). Race and income are associated with increased charges. To determine risk factor, we correlate hospital charges for pituitary surgery with socioeconomic factors. Additionally, we identify patients at risk for increased hospital charges and provide insight into cost-effective practices. Methods Retrospective cohort study of the Statewide Planning and Research Cooperative System (SPARCS) database from the NYS Department of Health was conducted. The SPARCS database was reviewed. Patients who underwent transsphenoidal pituitary surgery from 1995 to 2015 were identified. Income and urban status were referenced from U.S. census data. Linear regression was performed to analyze the effect of sociodemographic factors, comorbidities, and complications on hospital charges while controlling for length of stay. Results A total of 9,373 patients were identified. Black (10.8%, p < 0.001) and Asian (14.5%, p < 0.001) had higher hospital charges. Patients from nonurban cities (13.4%, p < 0.001), Medicaid (13.8%, p < 0.001), and those from the 0 to 25th (9.1%, p < 0.001) and 25 to 50th (11.7%, p < 0.001) income quartile had lower hospital charges. Patients with postoperative cerebrospinal fluid leak (24.0%, p < 0.001), diabetes insipidus (22.1%, p < 0.001), smoking history (11.8%, p < 0.001), hypertension (7.4%, p < 0.001), and hypothyroidism (6.9%, p < 0.001) had higher hospital charges. Conclusion Patients incurring higher chargers were more likely to have a smoking history, hypertension, hypothyroidism, and comorbidities. The determinants of this analysis may provide insight into barriers to patient access and cost improvement strategies. In addition, this emphasizes the need for future studies to create a risk stratification model, similar to those in other fields.

Association of Surgical and Hospital Volume and Patient Characteristics With 30-Day Readmission Rates.

Importance: Thirty-day readmission rates have been suggested as a marker for quality of care. By investigating the factors associated with readmissions in all otolaryngology subspecialties we provide data relevant for the development of risk stratification systems to improve outcomes. Objective: To establish the association of surgical and hospital volume and patient characteristics with 30-day readmission rates to guide the development of otolaryngology-specific risk stratification models. Design, Setting, and Participants: A retrospective cohort study including adult patients who underwent inpatient otolaryngology surgery in New York State between 1995 and 2015 was conducted using the Statewide Planning and Research Cooperative System (SPARCS). Regression techniques were used to describe relationships of patient-level factors, hospital, and surgeon volume to 30-day readmission rates in New York State. Main Outcomes and Measures: The main outcome measures were patient-, surgeon-, and hospital-level risk factors for readmission. Secondary outcome measures were rate of readmissions by subspecialty procedure and by diagnosis on readmission. Results: We identified 254 257 cases of otolaryngology surgery (147 065 women [58%], mean [SD] age 50 [17] years). The 30-day readmission rate was 6%. In a multivariable model, odds ratios (ORs) identified Medicaid insurance (OR, 1.46; 99% CI, 1.36-1.57), Medicare insurance (OR, 1.32; 99% CI, 1.24-1.42), bottom quartile income (OR, 1.08; 99% CI, 1.01-1.15), patient comorbidities measured by the Charlson Comorbidity Index (CCI) (CCI >1; OR, 2.31; 99% CI, 2.16-2.47), length of stay (LOS) (LOS >10 days; OR, 2.29; 99% CI, 2.00-2.45), rhinology (OR, 1.37; 99% CI, 1.24-1.51), laryngology (OR, 1.98; 99% CI, 1.62-2.43), and head and neck cancer (OR, 1.27; 99% CI, 1.17-1.37) procedures as readmission predictors. High-volume surgeons were protective of 30-day readmission (OR, 0.67; 99% CI, 0.635-0.708) relative to low volume. Hospital volume was not significantly associated to readmissions. The most common causes of readmission included wound- (2682 patients, 18%), respiratory- (1776 patients, 12%), cardiovascular- (1210 patients, 8%), and volume- (1089 patients, 7%) related disorders. Conclusions and Relevance: This study evaluated the combined effects of patient-, surgeon-, and hospital-level factors on 30-day readmission after otolaryngology surgery. Socioeconomic factors, patient comorbidities, surgeon volumes, and procedure were significantly associated with 30-day readmission. Though the cause of 30-day readmission is multifactorial, a large portion is driven by socioeconomic factors. Addressing these disparities at the system level is necessary to address the described readmission disparities. The development of risk-stratification models based on patient-, procedure-, and surgeon-level factors may help facilitate resource distribution.

Combining mathematical modelling with in vitro experiments to predict in vivo drug-eluting stent performance.

In this study, we developed a predictive model of in vivo stent based drug release and distribution that is capable of providing useful insights into performance. In a combined mathematical modelling and experimental approach, we created two novel sirolimus-eluting stent coatings with quite distinct doses and release kinetics. Using readily measurable in vitro data, we then generated parameterised mathematical models of drug release. These were then used to simulate in vivo drug uptake and retention. Finally, we validated our model predictions against data on drug kinetics and efficacy obtained in a small in vivo evaluation. In agreement with the in vivo experimental results, our mathematical model predicted consistently higher sirolimus content in tissue for the higher dose stents compared with the lower dose stents. High dose stents resulted in statistically significant improvements in three key efficacy measures, providing further evidence of a basic relationship between dose and efficacy within DES. However, our mathematical modelling suggests a more complex relationship is at play, with efficacy being dependent not only on delivering an initial dose of drug sufficient to achieve receptor saturation, but also on the consequent drug release rate being tuned to ensure prolonged saturation. In summary, we have demonstrated that our combined in vitro experimental and mathematical modelling framework may be used to predict in vivo DES performance, opening up the possibility of an in silico approach to optimising the drug release profile and ultimately the effectiveness of the device.

Implementation of a Cardiac Transitions of Care Pilot Program: A Prospective Study of Inpatient and Outpatient Clinical Pharmacy Services for Patients With Heart Failure Exacerbation or Acute Myocardial Infarction.

BACKGROUND:: Pharmacists may assist with reducing 30-day readmission rates for patients with heart failure (HF) exacerbation or acute myocardial infarction (AMI) by promoting medication adherence. OBJECTIVE:: To determine the change in 30-day readmission rates for patients with HF exacerbation or AMI after implementation of a "high-touch" standard of care. METHODS:: Patients admitted with HF exacerbation, non-ST-segment elevation AMI, or ST-segment elevation AMI from August 1, 2013, to June 30, 2015, were included in this prospective study. Patients were educated while in the inpatient setting and followed up in the outpatient setting through telephone contact and scheduling a medication therapy management (MTM) appointment with a pharmacist. Data were collected by pharmacy personnel involved in the implementation of the intervention. RESULTS:: Within the HF and AMI arms, 100 and 93 patients, respectively, were included in the study. The 30-day readmission rates were 24% and 17.2% for HF and AMI, respectively, which were not statistically significant when compared to historical institutional readmission rates prior to study initiation (18.2% for HF, P = .238; 11.4% for AMI, P = .252). CONCLUSION:: A "high-touch" pharmacist-driven transitions of care program may affect 30-day readmission rates for patients with HF exacerbation or AMI; potential processes for initiating transitions of care programs are provided.

Double-blinded randomized controlled trial to evaluate a multimedia surgical care tour in improving patient satisfaction and knowledge after functional endoscopic sinus surgery.

BACKGROUND: Current delivery of patient education is done during the clinic visit, where physicians or clinic staff have limited time for each patient. One potential solution is to provide a multimedia surgical care tour delivered to patients throughout the perioperative period. The purpose of the study is to evaluate the effectiveness of this surgical care tour in enhancing patient knowledge and satisfaction after functional endoscopic sinus surgery (FESS). METHODS: A total of 121 patients were enrolled and a double-blinded randomized controlled trial was initiated. Patients in the experimental group received 4 educational videos and automated reminders to take medications. The control group received a sham platform. Patients were randomized by MEDUMO software, and physicians, clinic staff, and patients were blinded. Patient satisfaction was measured by Consumer Assessment of Healthcare Providers and Systems (CAHPS) Surgical Care Survey Version 2.0. Patient knowledge was graded by the blinded surgeon and clinic staff. Fischer's exact test and 2-tailed independent samples Student t test were used to compare the satisfaction and patient knowledge outcomes, respectively. RESULTS: Patients in the experimental group were more likely to answer "Yes, definitely" to "Did these pictures drawings models or videos help you better understand your condition and its treatment?" (95.7% vs 74.1%, p = 0.011). The mean ± standard deviation clinic staff assessment of patient knowledge was 3.04 ± 1.05 in the control group and 3.68 ± 1.41 in the experimental group (p = 0.043). CONCLUSION: A multimedia surgical care tour was developed and has promising effects on patient satisfaction and knowledge after FESS.

Percutaneous versus surgical tracheostomy: timing, outcomes, and charges.

OBJECTIVES/HYPOTHESIS: The purpose of this study was to compare timing of procedure, patient characteristics, outcomes, and charges for patients who underwent percutaneous versus surgical tracheostomy. STUDY DESIGN: Retrospective cohort study. METHODS: A retrospective analysis was performed for all patients who underwent tracheostomy in 2015 to 2016 in New York State. Patients were identified using International Classification of Diseases, 10th Revision, Clinical Modification codes and stratified to the type of tracheostomy performed. The primary outcome of interest was mortality at index stay. Secondary outcomes of interest included length of stay and total hospitalization charges. RESULTS: Of the 8,682 patients, 2,488 (28.7%) underwent percutaneous and 6,194 (71.3%) underwent surgical tracheostomy. At hospitals where both procedures were performed, percutaneous tracheostomy patients were older, had more comorbidities, and had lower income (P < .05). Timing of the tracheostomy relative to admission did not affect the type of tracheostomy performed. While controlling for patient characteristics and complications during the visit, percutaneous tracheostomy was associated with increased mortality (odds ratio [OR]: 1.17, 95% confidence interval [CI]: 1.03-1.33, P = .0153) and increased hospital charges (OR: + 7.76%, 95% CI: 5.4-10.11, P < .0001). Length of stay was not affected by procedure type. CONCLUSIONS: Surgical tracheostomies are more commonly performed than percutaneous tracheostomies across New York State. Older, lower-income, and sicker patients have a higher chance of receiving percutaneous tracheostomies. Percutaneous approaches were associated with statistically significant increased mortality and higher charges despite no difference in length of stay. Further studies are needed to determine if these differences in outcomes are clinically significant. LEVEL OF EVIDENCE: NA Laryngoscope, 128:2844-2851, 2018.

Intracranial Meningioma Surgery: Value-Based Care Determinants in New York State, 1995-2015.

OBJECTIVE: Intracranial meningiomas are the most commonly diagnosed brain tumor in the United States. With increasing incidence, efficient allocation of limited health care resources is a critical component of emerging value-based models of care. The purpose of this study was to evaluate the effect of patient and hospital variables on metrics of value-based care. METHODS: The Statewide Planning and Research Cooperative System database was queried for records of patients undergoing intracranial meningioma surgery in New York State from 1995 to 2015. Multivariate logistic regression was used to investigate the effect of hospital volume and patient demographics on 30-day readmissions, 30-day mortality, prolonged length of stay (pLOS), and excess hospital charges. RESULTS: Among the 14,239 patients included, 10,252 (72%) cases were performed at high-volume centers (HVC) (>75th percentile). HVC were associated with lower rates of readmissions, mortality, and pLOS, but higher hospital charges. In the multivariate analysis, HVC had reduced odds of pLOS (odds ratio, 0.56; P < 0.0001) and 30-day mortality (odds ratio, 0.39; P < 0.0001). Patient variables associated with adverse outcomes in the multivariate model included advanced age, male gender, higher Charlson Comorbidity Index, lower socioeconomic status (low income, Medicaid, and Medicare insurance), black race, and Hispanic ethnicity. These populations were more likely to undergo treatment at lower-volume centers. CONCLUSIONS: This statewide population analysis of readmissions, mortality, length of stay, and hospital charges after intracranial meningioma surgery identified patient predictors of adverse outcomes. These determinants may be used by hospitals to develop improved systems of care in at-risk populations.

The socioeconomic determinants for transsphenoidal pituitary surgery: a review of New York State from 1995 to 2015.

BACKGROUND: Prolonged length of stay (pLOS), disease-related complications, and 30-day readmissions are important quality metrics under the Affordable Care Act. The purpose of our study was to investigate the effect of patient-level and hospital-level factors on these outcomes for patients admitted for transsphenoidal pituitary surgery. METHODS: The Statewide Planning and Research Cooperative System (SPARCS) database was queried to investigate 30-day readmissions and pLOS for transsphenoidal pituitary surgery in New York from 1995 to 2015. Multivariate logistic regression, adjusting for patient and hospital characteristics, was performed to assess the effect of these variables on the outcomes of interest. RESULTS: A total of 9950 patients underwent transsphenoidal pituitary surgery; 7122 (72%), 2394 (24%), and 434 (4%) patients were treated at high-volume, medium-volume, and low-volume centers, respectively. Patient factors associated with treatment at high-volume centers (HVCs) included: top income quartile, private insurance, urban residence, and white or Asian race (p < 0.05). Patient variables associated with treatment at low-volume centers (LVCs) included: age >65 years, elevated Charlson comorbidity index (CCI) scores, bottom income quartile, Medicaid and Medicare insurance, rural residence, black race, and Hispanic ethnicity (p < 0.05). Variables predictive of prolonged hospitalizations in our multivariable model included black race, Hispanic ethnicity, Medicaid insurance, low income, female gender, LVC, and comorbidities (panhypopituitarism, hypothyroidism, diabetes insipidus [DI], visual disturbances, CCI) while predictors of readmissions included Asian race, female gender, and comorbidities (Cushing syndrome, DI, CCI). CONCLUSION: Patients undergoing transsphenoidal pituitary surgery at HVCs have shorter hospitalizations, fewer postoperative electrolyte abnormalities, and lower charges; however, socioeconomic factors may influence access to quality care.