Team-Based Surgical Scheduling for Improved Patient Access in a High-Volume, Tertiary Head and Neck Cancer Center.

BACKGROUND: Delays in care can lead to inferior survival outcomes in head and neck cancer and other cancers. In the case of malignancies for which surgery is the preferred primary treatment modality, challenges in surgical scheduling can present a major hurdle to initiating definitive therapy in a timely fashion. It is critical to maintain efficient use of operating room resources. Traditionally, surgery is scheduled with the surgeon who initially saw the patient in consultation, and timing of surgery is tightly linked to the availability and operating room block time of the individual surgeon. METHODS: Scheduling of oncologic head and neck surgery was transitioned from a surgeon-specific method to a team-based approach wherein a patient in need of oncologic head and neck surgery is scheduled with the next-available surgeon with appropriate expertise. RESULTS: Despite substantial growth of our practice, transition to a team-based scheduling approach allowed us to maintain high utilization of operating room block time. Patient and surgeon satisfaction remain high with this new system. CONCLUSIONS: A team-based surgical scheduling approach can help optimize operating room utilization and minimize delays in cancer care, potentially leading to improved oncologic outcomes.

TORS elective lingual tonsillectomy has less acute morbidity than therapeutic base of tongue TORS.

OBJECTIVE: To determine the impact of diagnostic TORS lingual tonsillectomy (DTLT) on objective swallowing measures for carcinoma of unknown primary (CUP). METHODS: Between 10/2016-1/2020, 27 patients with p16+ squamous cell carcinoma (SCC) level 2a nodal disease underwent DTLT and ipsilateral neck dissection for CUP. No patient had a history of cutaneous SCC. Patients participated in Modified Barium Swallow (MBS) three weeks post-TORS, which were then compared to those from a contemporaneous cohort of 40 patients with clinically-identified p16+ base of tongue (BOT) primary tumors. DIGEST scores were retrospectively calculated. Univariate and multivariate analysis performed, stratified by BOT glossectomy (n = 40) versus lingual tonsillectomy for CUP (n = 27). Radiation to the resected primary or potential primary sources was omitted if margins were ≥3 mm or if no primary identified. RESULTS: Twenty-seven consecutive patients with clinical stage cT0N1 HPV-associated OPSCC had a BOT primary pathologically identified in 18/27 (67%). Univariate analysis of functional swallow assessment on MBSImP correlated with improved post-TORS DIGEST scores for CUP. On multivariate analysis (MVA) DIGEST safety scores were improved for CUP than cT1 BOT glossectomy [Odds Ratio (OR) 0.28, p = 0.038]. MVA on matched pT1 CUP (n = 27) vs. pT1 BOT (n = 19), OR of moderate/severe dysphagia for CUP was 0.54 [0.12-2.38, p = 0.417] for DIGEST safety scores and 0.27 [0.06-1.18, p = 0.082] for DIGEST efficiency scores. Moderate/severe dysphagia as determined by DIGEST overall scores for CUP compared to cT1 and pT1 yielded an OR of 0.39 (p = 0.081) and 0.42 (p = 0.195), respectively. Twenty-six total patients received adjuvant RT, and 18 (11 with ≥3 mm margins, 9 with negative specimens) were spared intentional RT to the oropharynx. Median follow-up was 22.6 months with 100% PFS. CONCLUSIONS: Patients undergoing DTLT for CUP demonstrated acute swallow defecits in the post-operative setting. A comparison of long-term functional results between DTLT and elective irradiation of the primary site should be studied. LEVEL OF EVIDENCE: Level III.

Socioeconomic Factors Influence the Impact of Tumor HPV Status on Outcome of Patients With Oropharyngeal Squamous Cell Carcinoma.

PURPOSE: Human papilloma virus (HPV) association remains one of the most important predictors of clinical outcome in oropharyngeal squamous cell carcinoma (OPSCC). We aimed to determine whether the relationship between HPV status and overall survival was influenced by socioeconomic factors. MATERIALS AND METHODS: Using the National Cancer Database, we examined the relationship between socioeconomic status and overall survival, controlling for demographics and socioeconomic variables (age at diagnosis, race, sex, clinical stage, facility type, facility location, insurance status, median-income quartiles, percent of no high-school education quartiles, rural-urban dwelling, Charlson-Deyo score, primary site, and treatment type). RESULTS: HPV-positive patients with private insurance have improved overall survival compared with HPV-positive patients who are uninsured (hazard ratio [HR], 0.51, 95% CI, 0.41 to 0.63, P < .001). HPV-negative patients with private insurance have improved overall survival compared with HPV-negative patients who were uninsured (HR, 0.62, 95% CI, 0.53 to 0.73, P < .001). HPV-positive patients living in the south had improved overall survival compared with HPV-positive patients living in the west (HR, 0.83, 95% CI, 0.72 to 0.96, P = .013). As assessed through interaction, relationships between survival and insurance (P = .004), rural-urban status (P = .009), and facility location (P = .021) statistically differed between HPV-positive and HPV-negative patients. CONCLUSION: HPV status impact on overall survival for patients with OPSCC is influenced by socioeconomic factors including insurance status and treatment facility. A deeper understanding of these interactions is needed to improve equity of care for patients with OPSCC.

Estimation of the Share of Net Expenditures on Insulin Captured by US Manufacturers, Wholesalers, Pharmacy Benefit Managers, Pharmacies, and Health Plans From 2014 to 2018.

Importance: Recent US media and policy attention on insulin affordability has focused on the role of manufacturers in setting prices; however, the role of other drug distribution intermediaries in determining prices has received less attention. Objective: To estimate the share of net expenditures on insulin captured by manufacturers, wholesalers, pharmacy benefit managers, pharmacies, and health plans from 2014 to 2018. Design Setting and Participants: This cross-sectional study of the US insulin market was conducted in 2020 using 2014-2018 data from multiple sources, including list and estimated net prices from SSR Health for 32 insulin products, mean use weights from a commercial pharmacy claims database, mean acquisition costs and reimbursements from the Centers for Medicare & Medicaid Services, mean spread and share of rebates retained by pharmacy benefit managers from state Medicaid and drug transparency reports, and profit margins from the public filings of distribution system participant companies. Participants were insulin manufacturers, drug wholesalers, pharmacies, pharmacy benefit managers, and health plans. Main Outcomes and Measures: Mean list and net insulin prices, mean net expenditures on insulin, share of expenditures retained by each distribution system participant. Results: Between 2014 and 2018, mean list prices of 32 insulin products increased by 40.1% (from $19.60 to $27.45), while mean net prices received by manufacturers decreased by 30.8% (from $10.53 to $7.29). Net expenditures per 100 units of insulin increased by 3.2% (from $15.11 to $15.59) while the share of a hypothetical $100 insulin expenditure accruing to manufacturers decreased by 33.0% (from $69.71 to $46.73) and the share accruing to health plans decreased by 24.7% (from $13.82 to $10.40). The share of insulin expenditures retained by pharmacy benefit managers increased by 154.6% (from $5.64 to $14.36), the share retained by pharmacies increased by 228.8% (from $6.21 to $20.42), and the share retained by wholesalers increased by 74.7% (from $4.63 to $8.09). Conclusions and Relevance: Results of this cross-sectional study of the distribution of insulin expenditures suggest that policies to control insulin costs should consider all entities throughout the insulin distribution system. Manufacturers represented a decreasing share of insulin expenditures, and pharmacies, pharmacy benefit managers, and wholesalers accounted for a growing share; all entities play a role in increasing insulin costs.

Aqueous Chlorhexidine Compared with Povidone-Iodine as Ocular Antisepsis before Intravitreal Injection: A Randomized Clinical Trial.

PURPOSE: Topical povidone-iodine (PI) is widely used as an ocular surface antiseptic for intravitreal injections (IVIs). Although PI is generally well tolerated, it can be associated with significant ocular irritation. Aqueous chlorhexidine (AqCHX) has been described as a possibly better tolerated antimicrobial for ophthalmic procedures. We compared patient pain scores, ocular surface characteristics, and antimicrobial efficacy between PI 5% and AqCHX 0.1% during IVIs. DESIGN: Prospective single-center, randomized clinical trial. PARTICIPANTS: Patients receiving same-day bilateral intravitreal anti-vascular endothelial growth factor (VEGF) injections. METHODS: Each patient had 1 eye randomized to PI or AqCHX, and the second eye received the other agent. Both eyes received topical proparacaine 0.5%. MAIN OUTCOME MEASURES: After IVIs, participants rated their pain (Wong-Baker, scale 0-10) for each eye 1 minute after PI or AqCHX instillation and 1 day after the procedure. Each eye was assessed using a standardized quantitative grading system of corneal epitheliopathy (ocular staining score). Microbial swab cultures of the conjunctiva both before instillation of topical antisepsis and 10 minutes after IVIs were given. RESULTS: A total of 100 eyes of 50 patients were included. The mean patient age was 68 years (range, 39-92), and 30 of 50 (60%) were male. Compared with AqCHX, eyes receiving PI had a greater mean pain score immediately after injection (1.44 vs. 0.44, P < 0.001) but not on postprocedure day 1 (1.04 vs. 0.48, P = 0.06). Eyes that received PI had a higher ocular staining score indicating worse corneal epitheliopathy (4.22 vs. 3.10, P < 0.001). There was no difference in rates of positive microbial cultures between groups. There was no difference in rates of adverse events between groups (P = 0.99), and no cases of endophthalmitis occurred. CONCLUSIONS: Povidone-iodine demonstrated greater ocular surface discomfort and corneal epitheliopathy compared with AqCHX during same-day bilateral IVIs. The 2 agents otherwise demonstrated no difference in positive microbial cultures or adverse events. Aqueous chlorhexidine may be a better tolerated alternative to PI for antimicrobial prophylaxis during IVIs for some patients.

Improved survival for individuals with common chronic conditions in the Medicare population.

It is well established that the United States lags behind peer nations in life expectancy, but it is less established that there is heterogeneity in life expectancy trends. We compared mortality trends from 2004 to 2014 for the United States with 17 high-income countries for persons under and over 65. The United States ranked last in survival gains for the young but ranked near the middle for persons over 65, the group with universal access to public insurance. To explore the over-65 mortality trend, we estimated Cox proportional hazards models for individuals soon after entering Medicare. These were estimated separately by race and sex, controlling for 26 chronic conditions and condition-specific time trends. The separate regressions enabled survival comparisons for the 2004 and 2014 cohorts by race and sex, conditional on baseline health. We predicted 5-year survival for all combinations of diabetes, hyperlipidemia, hypertension, and ischemic heart disease (IHD). All 16 combinations of these conditions showed survival gains, with diabetes as a key driver. Notably, survival improved and racial disparities narrowed for individuals with diabetes, hypertension, and IHD. White females, black females, white males, and black males gained 3.61, 3.90, 3.57, and 5.89 percentage points in 5-year survival, respectively.

Endogenous Bacterial Endophthalmitis: A Five-Year Retrospective Review at a Tertiary Care Academic Center.

PURPOSE: To better characterize the demographics and outcomes of endogenous bacterial endophthalmitis (EBE). METHODS: Retrospective observational case series of 49 eyes of 41 patients with EBE evaluated at a single academic center. RESULTS: Gram stain (p = .395), symptom duration prior to treatment (p = .483), and number of intravitreal antimicrobial injections (p = .421) did not correlate with mean change in VA. There was no significant difference between mean LogMAR VA at initial evaluation (1.7 ± 0.9) and last available follow up (1.4 ± 1.1, p = .15). Patients with bilateral EBE had 7.25 times greater odds of having cancer (95% CI 1.28, 41.14; p = .025). CONCLUSION: EBE in a North American population showed poor visual recovery despite treatment. It was most commonly due to gram-positive bacteria with the most common infectious source being endocarditis. Malignancy should be considered in patients with bilateral EBE.

Sex work-related stigma: Experiential, symbolic and structural forms in the health systems of Delhi, India.

Sex work-related stigma is prevalent in urban India. While HIV-stigma is often discussed in urban Indian health contexts, rarely is sex work-related stigma investigated as it shapes sex workers' health experiences. This paper discusses the findings of an ethnographic study with women who practice sex work (WPSW), healthcare providers, and NGO workers in Delhi, India over seven months in 2017. We apply a tri-tiered model of stigma as constituted of experiential, symbolic, and structural forms, to better understand how WPSW experience sex work-related stigma as it relates to their health. Identifying and understanding manifestations and experiences of stigma is crucial to supporting WPSW health. We conclude that in the face of criminalized legal contexts, both non-governmental and governmental interventions to improve WPSW's health must contend with their own tendencies to reinforce prevailing stereotypes and symbols that stigmatize sex work and the people who engage in it.

Secondary Vitreoretinal Lymphoma Masquerading as Acute Retinal Necrosis.

Intraocular lymphoma is considered a uveitis masquerade syndrome and may rarely present with features resembling a necrotizing viral retinitis. The authors report a secondary vitreoretinal lymphoma presenting in this fashion, which was treated with a unique combination of intravitreal methotrexate and rituximab.

Comparison Among Methods of Retinopathy Assessment (CAMRA) Study: Smartphone, Nonmydriatic, and Mydriatic Photography.

PURPOSE: We compared smartphone fundus photography, nonmydriatic fundus photography, and 7-field mydriatic fundus photography for their abilities to detect and grade diabetic retinopathy (DR). DESIGN: This was a prospective, comparative study of 3 photography modalities. PARTICIPANTS: Diabetic patients (n = 300) were recruited at the ophthalmology clinic of a tertiary diabetes care center in Chennai, India. METHODS: Patients underwent photography by all 3 modalities, and photographs were evaluated by 2 retina specialists. MAIN OUTCOME MEASURES: The sensitivity and specificity in the detection of DR for both smartphone and nonmydriatic photography were determined by comparison with the standard method, 7-field mydriatic fundus photography. RESULTS: The sensitivity and specificity of smartphone fundus photography, compared with 7-field mydriatic fundus photography, for the detection of any DR were 50% (95% confidence interval [CI], 43-56) and 94% (95% CI, 92-97), respectively, and of nonmydriatic fundus photography were 81% (95% CI, 75-86) and 94% (95% CI, 92-96%), respectively. The sensitivity and specificity of smartphone fundus photography for the detection of vision-threatening DR were 59% (95% CI, 46-72) and 100% (95% CI, 99-100), respectively, and of nonmydriatic fundus photography were 54% (95% CI, 40-67) and 99% (95% CI, 98-100), respectively. CONCLUSIONS: Smartphone and nonmydriatic fundus photography are each able to detect DR and sight-threatening disease. However, the nonmydriatic camera is more sensitive at detecting DR than the smartphone. At this time, the benefits of the smartphone (connectivity, portability, and reduced cost) are not offset by the lack of sufficient sensitivity for detection of DR in most clinical circumstances.

Cost-effectiveness of Different Diabetic Retinopathy Screening Modalities.

Current screening strategies aimed at detection of diabetic retinopathy (DR) historically have poor compliance, but advancements in technology can enable improved access to care. Nearly 80% of all persons with diabetes live in low- and middle-income countries (LMICs), highlighting the importance of a cost effective screening program. Establishing mechanisms to reach populations with geographic and financial barriers to access is essential to prevent visual disability. Teleretinal programs leverage technology to improve access and reduce cost. The quality of currently employed screening modalities depends on many variables including the instrument used, use of pupillary mydriasis, number of photographic fields, and the qualifications of the photographer and image interpreter. Recent telemedicine and newer technological approaches have been introduced, but data for these technologies is yet limited. We present results of a systematic review of studies evaluating cost-effectiveness of DR screening, and discuss potential relevance for LMICs.