Speech Pathology Services Are Integral, but Underutilized in Tracheostomy Rehabilitation.

STUDY DESIGN: Retrospective case series. OBJECTIVE: Speech language pathology (SLP) is an underutilized but important component in rehabilitation after tracheostomy. The purpose of this study was to determine rates of SLP utilization and to streamline tracheostomy decannulation to be more efficient and safer through increased utilization of SLP. METHODS: Adult patients who underwent tracheostomy from April 2016 to December 2018 were evaluated. The primary outcome was completion of any SLP evaluation after tracheostomy, and secondary outcomes were duration from surgery to evaluation, speaking valve and swallow study utilization, downsize and decannulation rates, mean duration of cannulation, and complications. RESULTS: A total of 255 subjects were included, where 197 (77.3%) underwent SLP evaluation. A minority received a speaking valve (33.7%), while approximately half underwent a swallow study (52.9%). There was a delay in SLP evaluation, with mean duration from surgery to SLP evaluation of 5.9 ± 8.0 days. There was consistent improvement in downsize and decannulation rates in all cohorts that utilized SLP services. Tracheostomy indication of head and neck cancer, trauma, completing a successful swallow study conferred increased odds of eventual decannulation, while obesity and tracheostomy history conferred lower odds. An interdisciplinary decannulation pathway was created, based on literature review and results, to assist in decision-making while progressing toward decannulation. CONCLUSION: Speech language pathologists are underutilized for rehabilitation of tracheostomy patients, where they are able to offer many skills to diagnose, treat, manage, and troubleshoot, as patients advance through the decannulation process.

Evidence-Based Protocol for Ophthalmology Consult for Orbital Fractures.

PURPOSE: Previous retrospective studies demonstrate that urgent evaluation by an ophthalmologist for orbital fractures is not required in visually asymptomatic patients, although a consult is often seen as a necessity in many hospital institutions. To determine when an ophthalmology consult is indicated for a surgical patient, the oral and maxillofacial and ophthalmology departments at 1 institution collaborated for an evidence-based approach utilizing retrospective and prospective data. PATIENTS AND METHODS: The retrospective arm looked at patients from 2012 to 2017, who had an isolated, surgically repaired orbital fracture without preoperative ophthalmology consultation. A prospective arm was then created from August 2019 to July 2020 with a designed protocol that determined which patients required an ophthalmology consult preoperatively. Extra-ocular movements, visual acuity, and diplopia were examined in the preoperative and postoperative setting to determine if the lack of an ophthalmology consult adversely affected patient outcome. RESULTS: Of the retrospective patients who met criteria, 82 of the 84 (98%) patients had a normal postoperative examination: baseline visual acuity, intact extra-ocular movement, and no diplopia. The 2 of the 84 (2%) patients had postoperative diplopia consistent with preop examination. In the prospective group, 10 of the 39 patients required a preop ophthalmology consult while 29 of 39 did not require one. A normal postoperative examination was present in 26 of the 29 patients (90%). Of those 3 remaining patients, 2 patients (7%) had postoperative diplopia consistent with preoperative while 1 patient (3%) had postoperative diplopia without preoperative diplopia. CONCLUSIONS: The authors conclude that a routine ophthalmology consult is not warranted in visually asymptomatic patients with orbital fractures requiring surgical repair.

Obese Tracheostomy: A Challenging Path From Surgery to Decannulation.

PURPOSE: Well-defined or standardized tracheostomy decannulation guidelines are not available, and the long-term data on the outcomes in the obese are limited. The purpose of the present study was to determine the outcomes associated with tracheostomy for obese patients from surgery to decannulation. The specific aims were to measure 1) the rate of successful tracheostomy downsize; 2) the rate of successful tracheostomy decannulation; and 3) the associated pre-, intra-, and postoperative subject variables with tracheostomy downsizing and decannulation success. PATIENTS AND METHODS: A retrospective cohort study was implemented to determine the outcomes associated with downsizing and decannulation after obese tracheostomy. The predictive value of the independent variables from the subjects' pre-, intra-, and postoperative periods were evaluated as they related to successful downsizing and decannulation. The included subjects had undergone tracheostomy from April 2016 to December 2018. The primary outcomes were successful downsizing and successful decannulation. A downsize checklist was created with the following yes/no criteria that should reasonably be met before downsizing a tracheostomy in an obese subject. The secondary analysis was the association between the checklist criteria and successful downsize and decannulation. The data were analyzed using the χ2 test, analysis of variance, t test, likelihood ratio, Kaplan-Meier analysis with Cox regression, and logistic binary regression, with statistical significance set at P < .05. RESULTS: The study sample included 82 obese subjects (body mass index [BMI] >30 kg/m2), with a mean age of 55.7 ± 15.0 years; 56% were men. Only 62 of the subjects could be downsized (75.6%) and 39 (47.6%) could be decannulated. The general trend showed that an increased BMI resulted in an increased time to decannulation, long-term tracheostomy dependence, and less successful downsize and decannulation. For patients with a BMI of 30 kg/m2 or more, the downsize success rate was 93.5% and the decannulation success rate was 89.7%. CONCLUSIONS: Obese patients have a greater likelihood of complications and an increased risk of remaining tracheostomy dependent. Consideration of the patient's BMI is crucial when initiating the decannulation progression.

Modified GoPro Hero 6 and 7 for Intraoperative Surgical Recording-Transformation Into a Surgeon-Perspective Professional Quality Recording System.

Recent innovations in wearable action cameras with high-definition video recording enable surgeons to use cameras for their surgical procedures. In this study, the GoPro HERO 6 (and 7) Black edition camera was modified step by step to allow for a completely wireless surgeon-perspective recording with a battery life and memory capacity never previously obtained with such a high level of digital video quality. With this system, a surgeon can record for more than 14 hours 26 minutes in 1,080 pixels at 60 frames per second without breaking scrub and capture the operating surgeon's direct view of the field. By modifying the newest generation of devices, the authors successfully eliminated all shortcomings of the prior generation of GoPro cameras for surgical recording. The modified GoPro HERO6 camera produced professional recording quality for a total cost lower than US$850. This is critically important, because video-based surgical training will continue to be a primary area of development in the future and represents a novel and effective way for young generations of surgeons to attain technical excellence and knowledge in surgery.

Overutilization of Computed Tomography for Odontogenic Infections.

PURPOSE: There is clear overuse of computed tomography (CT) in the emergency setting, which is associated with a long-term potential for malignancy. This study aimed to determine the rate of overuse of CT for odontogenic infection workup and the correlation of history and physical examination (H&P) findings to diagnose moderate- to high-risk infections. MATERIALS AND METHODS: A retrospective cross-sectional study was implemented to determine the rate of overuse of CT for odontogenic infections. Included patients presented through the emergency department for evaluation of an odontogenic infection. CT was deemed unnecessary if patients presented without "red-flag" signs at physical examination, which included voice change, elevated floor of mouth, signs of inflammation of deep fascial spaces, periorbital edema, nonpalpable inferior border of the mandible, dyspnea, dysphagia or odynophagia, and trismus. Patients could have no evidence of involvement of a moderate- to high-risk space or airway change at CT. Infection severity was low, moderate, or high risk based on anatomic proximity to the airway and critical structures. Sensitivity, specificity, and positive predictive and negative predictive values of H&P findings to predict moderate- to high-risk infections were calculated and included 95% confidence intervals. RESULTS: For the 470 included patients, 389 CT scans were performed, with 220 (56.6%) deemed unnecessary. Unnecessary scans were most prevalent in patients with low-risk infections, in whom 284 CT scans were performed, with 222 (78.2%) deemed unnecessary. There was a strong correlation between red-flag signs and moderate- to high-risk infections. CONCLUSION: There is overuse of CT for odontogenic infections that is most prevalent in low-risk infections without indicative findings in the workup. H&P findings can help accurately diagnose a higher-risk infection before subjecting a patient to CT.

Improving Surgical Outreach in Palestine: Assessing Goals of Local and Visiting Surgeons.

BACKGROUND: Short-term surgical outreach is often criticized for lack of sustainability and partnership with local collaborators. As global surgical capability increases, there is increased focus on educating local providers. We sought to assess and compare the educational goals of local surgeons in the Palestinian territories with goals of visiting volunteer providers. METHODS: Electronic surveys were sent to Palestinian surgeons and compared with evaluation data collected from Palestine Children's Relief Fund volunteer providers. RESULTS: The response rate was 52% from Palestinian surgeons and 100% from volunteer providers, giving a combined response rate of 83%. Ninety-two percent of Palestinian surgeons desired protected time during each mission trip for formal didactic teaching and 92% learn new techniques best by performing skills on patients with expert surgeons observing and providing feedback. Most respondents requested the addition of case reviews or debriefing sessions after completion of surgical cases. Volunteer providers indicate that 86% of prior mission trips involved training of local surgeons and 100% plan to volunteer with the organization again in the future. CONCLUSIONS: Surgical education is a vital component of any successful outreach program. Adult learning theory emphasizes the necessity of understanding the specific educational needs of participants to foster the most successful learning environment. This survey highlights the value of tailoring surgical specialty outreach to the explicit needs of local providers and patient populations, while also clearly demonstrating the importance of collaboration, feedback, and protected educational didactics as a critical focus of future surgical humanitarian endeavors.

Immediate Reconstruction and Dental Rehabilitation of Segmental Mandibular Defects: Description of a Novel Technique.

The aim of this report is to present a new technique using current technologic advances for immediate reconstruction and dental rehabilitation of segmental mandibular defects with a screw-retained prosthesis. One case is reviewed and a detailed review of surgical and prosthetic techniques used is presented.

Improvement of metal and tissue adhesion on surface-modified parylene C.

A general method for chemical surface functionalization of parylene C [PC, (para-CH2-C6H3Cl-CH2-)n] films is reported. Friedel-Crafts acylation is used to activate the surface of the PC film, and the resulting carbonyl groups are then used to form a range of different organic functional groups to the surface of the parylene film, including alcohol, imine, thiol, phthalimide, amine, and maleimide. The presence of these functional groups on the parylene surface was confirmed by Fourier transform infrared spectroscopy. Static water drop contact angle measurements were also used to demonstrate the changes in hydrophilicity of the PC film surface, consistent with each of the surface modifications. Enhanced metal (gold) adhesion was achieved by anchoring a thiol group onto the acylated surface of PC film. Acylation of parylene with 2-chloropropionyl chloride gave a surface bound chloropropionyl group. Grafting of poly-N-isopropylacrylamide (pNIPAM) onto the chloropropionyl substituted PC film via atom transfer radical polymerization (ATRP) was carried out. The grafted pNIPAM on the parylene surface leads to temperature-dependent cellular tissue adhesion on the PC film.