Factors Impacting Provider Treatment Decision-Making in Early Glottic Cancer.

OBJECTIVES: Transoral laser microsurgery (TLMS) and radiotherapy (XRT) are mainstays of treatment for early glottic carcinoma (EGC). Here, we investigated case-dependent provider treatment preferences and identify factors which impact decision-making in EGC. METHODS: This cross-sectional survey of laryngologists, head-and-neck surgeons, and radiation oncologists presented five diagrammatic cases of progressively advanced EGC (T1/2, N0). Respondents indicated preference for TLMS or XRT and ranked factors which influenced their recommendation for each case. Analysis utilized descriptive statistics, Fischer's exact tests, and Kruskal-Wallis tests for nonparametric data. RESULTS: A total of 141 complete responses (69.5% laryngologists) were received. Most respondents practiced in academic settings (93.5%) and within multidisciplinary teams (94.0%). Anterior commissure involvement was the most important a priori tumor factor for case-independent treatment recommendation (Likert Scale: 4.22/5), followed by Laterality (Likert Scale: 4.02/5). Across all specialties, TLMS was recommended for unilateral T1a lesions. Laryngologists continued recommending TLMS in T2 lesions (41.0%) more than head-and-neck surgeons (5.0%) and radiation oncologists (0.0%). Across all cases, survival and voice outcomes were the most important clinical factors impacting treatment decisions. Radiation oncologists weighed voice more heavily than laryngologists in more complex presentations of EGC (rank: 1.6 vs. 2.7, Kruskall-Wallis: p < 0.05). CONCLUSIONS: In more complex clinical presentations of EGC, preference for TLMS compared to XRT differed across specialists, despite similar rankings of factors driving these treatment recommendations. This may be driven by differing experiences and viewpoints on case-dependent voice outcomes following TLMS versus XRT, suggesting a need for increased understanding of how tumor location and depth impact voice outcomes. LEVEL OF EVIDENCE: V Laryngoscope, 2024.

The Impact of Hypogonadism on Surgical Outcomes Following Primary Urethroplasty: Analysis of a Large Multi-institutional Database.

OBJECTIVE: To compare surgical outcomes among a cohort of eugonadal and hypogonadal patients undergoing primary urethroplasty (UP). METHODS: A retrospective cohort study was conducted using TriNetX between 2008-2023. Patients who were eugonadal and hypogonadal (symptoms plus testosterone <300 ng/dL) prior to UP were compared. A subgroup analysis of hypogonadal patients was performed to compare those with testosterone replacement therapy (TRT) vs TRT-naïve prior to UP. Propensity-score matching was used to adjust for differences in comorbidities. Outcomes were 5-year revision rates and revision-free survival for endoscopic revision and redo UP following primary UP. RESULTS: We identified 12,556 eugonadal and 488 hypogonadal patients (153 TRT+, 335 TRT-) undergoing UP. Median age at UP and follow-up was 55years and 5years, respectively. After propensity-score matching, we compared 477 eugonadal and 477 hypogonadal patients. Hypogonadal patients had a statistically significantly higher 5-year redo UP rate (11% vs 6%, relative risk [RR] 1.5 [95%CI, 1.2-2.2]; P = .01) when compared to eugonadal patients however there was no difference in 5-year rates of endoscopic revision (11% vs 11%, RR 1.0 [95%CI, 0.7-1.5]; P = 1.0). We observed no difference in 5-year revision-free survival time for endoscopic revision or redo UP between groups. Hypogonadal patients treated with TRT had a significantly higher 5-year redo UP rate (15% vs 7%, RR 1.8 [95%CI, 1.1-3.3]; P = .02) compared to hypogonadal patients that were TRT-naïve prior to UP. There was no difference in rates of endoscopic revision (14% vs 10%, RR 1.3 [95%CI, 0.7-2.4]; P = .2) between subgroups. CONCLUSION: Pre-existing hypogonadism may modestly adversely affect surgical outcomes following primary UP based on data from a large, retrospective cohort study.

Cochlear Implant Revisions Over Three Decades of Experience.

IMPORTANCE: The indications, technology, and surgical technique for cochlear implantation have evolved over the last three decades. Understanding the risk of cochlear implant revision (CIR) is important for patient counseling. OBJECTIVE: The objective of this study was to analyze the rates, indications, and audiologic outcomes for CIR over three decades of experience at a single academic medical center. DESIGN: A retrospective chart review was performed at a single academic medical center for individuals who underwent cochlear implantation between 1985 and 2022. SETTING: Single academic medical center. PARTICIPANTS: Three thousand twenty-five individuals who underwent 3,934 cochlear implant operations from 1985 to 2022. EXPOSURE: Cochlear implantation. MAIN OUTCOMES AND MEASURES: Rates, indications, risk factors, and audiologic outcomes for CIR. RESULTS: There were 276 cases of CIR after primary implantation and an overall revision rate of 7.6% (95% confidence interval, 6.8-8.5%) over 37 years of follow-up with many cases of CIR secondary to Advanced Bionics vendor B and field action failure groups. CIR rates increased sharply through the early and mid-2000s and have since remained stable. Hard or soft device failure was the most common indication for CIR, accounting for 73% of cases. Pediatric patient status and previous CIR were associated with an increased risk of CIR. Audiologic outcomes after CIR were similar to those before device failure. CONCLUSIONS AND RELEVANCE: CIR remains a common procedure most often performed for device failure. Pediatric patients and those who have undergone previous CIR are at the highest risk for future CIR. Audiologic outcomes remain stable after CIR, and these data will help providers counsel patients at the risk of future CIR and understand the risk factors associated with CIR.

"Where You Feel Like a Family Instead of Co-workers": a Mixed Methods Study on Care Teams and Burnout.

BACKGROUND: Physicians and nurses face high levels of burnout. The role of care teams may be protective against burnout and provide a potential target for future interventions. OBJECTIVE: To explore levels of burnout among physicians and nurses and differences in burnout between physicians and nurses, to understand physician and nurse perspectives of their healthcare teams, and to explore the association of the role of care teams and burnout. DESIGN: A mixed methods study in two school of medicine affiliated teaching hospitals in an urban medical center in Baltimore, Maryland. PARTICIPANTS: Participants included 724 physicians and 971 nurses providing direct clinical care to patients. MAIN MEASURES AND APPROACH: Measures included survey participant characteristics, a single-item burnout measure, and survey questions on care teams and provision of clinical care. Thematic analysis was used to analyze qualitative survey responses from physicians and nurses. KEY RESULTS: Forty-three percent of physicians and nurses screened positive for burnout. Physicians reported more isolation at work than nurses (p<0.001), and nurses reported their care teams worked efficiently together more than physicians did (p<0.001). Team efficiency was associated with decreased likelihood of burnout (p<0.01), and isolation at work was associated with increased likelihood of burnout (p<0.001). Free-text responses revealed themes related to care teams, including emphasis on team functioning, team membership, and care coordination and follow-up. Respondents provided recommendations about optimizing care teams including creating consistent care teams, expanding interdisciplinary team members, and increasing clinical support staffing. CONCLUSIONS: More team efficiency and less isolation at work were associated with decreased likelihood of burnout. Free-text responses emphasized viewpoints on care teams, suggesting that better understanding care teams may provide insight into physician and nurse burnout.

Readability Analysis and Accessibility of Online Materials About Transgender Voice Care.

OBJECTIVE: To determine readability, understandability, and actionability of online health information related to transgender voice care. STUDY DESIGN: Review of online materials. SETTING: Academic medical center. METHODS: A Google search of "transgender voice care" was performed with the first 50 websites meeting inclusion criteria included. Readability was assessed using the Flesch Reading Ease Score (FRES), Flesch-Kincaid Grade Level (FKGL), and the Simple Measure of Gobbledygook (SMOG). Understandability and actionability were measured by 2 independent reviewers using the Patient Education Materials Assessment Tool for Printable Materials (PEMAT-P). Unpaired t tests were used to compare clinician- and patient-oriented sites, surgical and nonsurgical sites, and sites that discuss nonbinary indications for voice care. Analysis of variance was used to compare sites that discuss voice feminization, masculinization, both, or neither. RESULTS: Average scores across the cohort for FRES, FKGL, and SMOG were 43.77 ± 13.52, 12.14 ± 2.66, and 11.30 ± 1.93, respectively, indicating materials were above a 12th-grade reading level. PEMAT-P scores for understandability and actionability were 64.95% ± 15.78% and 40.55% ± 23.86%, respectively. Patient-oriented sites were significantly more understandable and actionable than clinician-oriented sites (P < .02). Websites that discussed only voice feminization were significantly more readable according to objective metrics (FKGL, SMOG) than websites that discussed both feminization and masculinization or those that did not differentiate care types (P < .05). CONCLUSION: Online information written about transgender voice care is written at a level above what is recommended for patient education materials. Providers may improve accessibility of transgender voice care by enhancing readability of online materials.

Zenker's Diverticulum: Readability and Quality of Online Written Education Materials.

To assess the readability and quality of online materials for Zenker's diverticulum. A Google search of "Zenker's diverticulum" was performed and the first 50 websites were reviewed. Readability was measured by Flesch Reading Ease (FRES), Flesch-Kincaid Grade Level (FKGL) and the Simple Measure of Gobbledygook (SMOG) scores using an online calculator. Understandability and actionability were assessed with the Patient Education Materials Assessment Tool for Printed Materials (PEMAT-P). Websites were categorized as either patient-targeted or physician-targeted and unpaired t tests were used to compare scores between these two groups. A total of 31 websites (23 patient-oriented sites and 8 physician-oriented sites) were analyzed. The average FRES, FKGL, and SMOG scores were 29.96 ± 14.72, 13.75 ± 2.78, and 12.19 ± 2.02, respectively, for the entire cohort. Readability scores for the patient-oriented sites were better than the physician-oriented sites for each measure (FRES 36.21 ± 8.86 vs 11.96 ± 13.54, FKGL 12.68 ± 1.58 vs 16.85 ± 3.25, and SMOG 11.37 ± 1.26 vs 14.53 ± 1.98; p < 0.001 for all comparisons). PEMAT-P understandability and actionability scores for the entire cohort were 68.20% ± 10.19% and 10.75% ± 16.52% respectively, and did not differ between patient-oriented and physician oriented sites. Though patient-oriented sites had better readability than physician-oriented sites for Zenker's Diverticulum, both categories had readability levels more advanced than what is recommended for medical education materials.

Readability of Online Materials Related to Vocal Cord Leukoplakia.

OBJECTIVES: To assess readability and understandability of online materials for vocal cord leukoplakia. STUDY DESIGN: Review of online materials. SETTING: Academic medical center. METHODS: A Google search of "vocal cord leukoplakia" was performed, and the first 50 websites were considered for analysis. Readability was measured by the Flesch Reading Ease Score (FRES), Flesch-Kincaid Grade Level (FKGL), and Simple Measure of Gobbledygook (SMOG). Understandability and actionability were assessed by 2 independent reviewers with the PEMAT-P (Patient Education Materials Assessment Tool for Printable Materials). Unpaired t tests compared scores between sites aimed at physicians and those at patients, and a Cohen's kappa was calculated to measure interrater reliability. RESULTS: Twenty-two websites (17 patient oriented, 5 physician oriented) met inclusion criteria. For the entire cohort, FRES, FKGL, and SMOG scores (mean ± SD) were 36.90 ± 20.65, 12.96 ± 3.28, and 15.65 ± 3.57, respectively, indicating that materials were difficult to read at a >12th-grade level. PEMAT-P understandability and actionability scores were 73.65% ± 7.05% and 13.63% ± 22.47%. Statistically, patient-oriented sites were more easily read than physician-oriented sites (P < .02 for each of the FRES, FKGL, and SMOG comparisons); there were no differences in understandability or actionability scores between these categories of sites. CONCLUSION: Online materials for vocal cord leukoplakia are written at a level more advanced than what is recommended for patient education materials. Awareness of the current ways that these online materials are failing our patients may lead to improved education materials in the future.