Investigation of a Novel Activity-Based Checks (ABC) Functional Pain Scale in the Post-Operative Urologic Surgery Patient.

Introduction: The authors investigated a novel functional pain scale, the Activity-Based Checks (ABCs) of Pain, following open urologic surgery. The primary objectives were to establish the strength of the correlation between the ABCs and the numeric rating scale (NRS) and determine the impact of functional pain on the patient's opioid requirements. We hypothesized that ABC score would correlate strongly with NRS and that the ABC score during hospitalization would be more closely correlated with the number of opioids prescribed and used. Methods: This prospective study included patients at a tertiary academic hospital undergoing nephrectomy and cystectomy. The NRS and ABCs were collected pre-operatively, during the inpatient stay, and at the one-week follow-up. Milligrams of morphine equivalents (MMEs) prescribed at discharge and the MME reportedly taken during the first post-operative week were recorded. Spearman's Rho was used to assess the correlation between scale variables. Results: Fifty-seven patients were enrolled. The ABCs correlated strongly with the NRS at baseline and post-operative appointments (r = 0.716, p < 0.001 and 0.643, p < 0.001). Neither the NRS nor the composite ABCs score was predictive of outpatient MME requirements; the ABCs function, "Walking outside the room" significantly correlated to MMEs taken after discharge (r = 0.471, p = 0.011). The greatest predictor of MMEs taken was the number of MMEs prescribed (0.493, p = 0.001). Conclusions: This study highlighted the importance of post-operative pain assessment that takes functional pain into consideration to evaluate pain, inform management decisions, and reduce opiate reliance. It also emphasized the strong relationship between opioids prescribed and opioids consumed.

Prognostic Implications of Skin Invasion in Locally Advanced Oral Cavity Squamous Cell Carcinoma.

OBJECTIVE: To evaluate the effect of histopathologic skin invasion on 2- and 5-year disease-free survival (DFS) and overall survival (OS) in patients treated with primary surgery for locally advanced oral cavity squamous cell carcinoma (OCSCC). STUDY DESIGN: A retrospective case-control study was performed comparing previously untreated patients with pT4a OCSCC with and without skin invasion. SETTING: Academic medical center. METHODS: Propensity score-matched cohorts were derived by age, sex, surgical margins, pathologic N classification, adjuvant treatment, and primary tumor site. The Kaplan-Meier method was used to evaluate 2- and 5-year OS and DFS, which were compared between cohorts via the log rank (Mantel-Cox) test statistic. RESULTS: Overall 25 patients were identified to have pathologic skin invasion, and 50 were selected for the matched control group. OS was significantly lower for patients with skin invasion as compared with controls at 2 years (30.8% vs 53.3%, P = .018) and 5 years (16.6% vs 42.2%, P = .01). DFS was significantly lower for patients with skin invasion vs controls at 2 years (23.7% vs 47.7, P = .037) and 5 years (15.8% vs 41.4%, P = .024). CONCLUSION: Histopathologic skin invasion in OCSCC is associated with dismal prognosis in patients who underwent primary surgical treatment. OS outcomes for patients with skin invasion are comparable to survival of patients with recurrent/metastatic disease and T4N2 disease.

Decision regret 3 and 6 months after treatment for head and neck cancer: Observational study of associations with clinicodemographics, anxiety, and quality of life.

BACKGROUND: While quality of life (QOL), psychosocial health, and adverse treatment outcomes have been studied in head and neck cancer (HNC) patients, decision regret is an important and understudied complication that can negatively impact future health care decision making. METHODS: Data collected using a HNC patient registry with questionnaires administered at initial consultation visits plus 3 and 6 months after treatment completion was retrospectively analyzed. A visual analog anxiety scale and the University of Washington Quality of Life were given at clinic visits. Decision regret was determined using a validated scale. Demographic and clinical variables were collected retrospectively and at baseline. RESULTS: Patients with higher anxiety and lower self-reported QOL had higher concurrent regret at 3-month (n = 140) and at 6-month (n = 82) post-treatment. Later disease stage at presentation, nonprimary surgical treatment, and lower health literacy were associated with greater regret. CONCLUSIONS: Decision regret was highest in HNC patients with high anxiety, low QOL, and more advanced disease.

Rates of bone reabsorption and union in mandibular reconstruction using the osteocutaneous radial forearm free flap.

BACKGROUND: Historical concerns over bone resorption and malunion of the osteocutaneous radial forearm free flap (OCRFFF) limited its widespread adoption for head and neck reconstruction, despite lack of outcomes data evaluating this notion. METHODS: A retrospective cohort study was performed including patients 18 years or older who underwent reconstruction of the mandible using an OCRFFF. Linear modeling and logistic regression were used to evaluate the change in bone volume and union over time. RESULTS: One hundred and twenty-one patients were included in the study. A mixed effects linear model incorporating age, sex, treatment type, and number of bone segments did not demonstrate a significant loss of bone volume over time. A logistic regression model identified lack of adjuvant treatment and time to be significantly associated with complete union. CONCLUSION: This study supports that the OCRFFF is a stable form of osseus reconstruction for defects of the head and neck.

ABCs of Pain: A Functional Scale Measuring Perioperative Pain in Total Hip Arthroplasty Patients.

INTRODUCTION: Functional pain assessments are critical in total hip arthroplasty. This pilot study investigated a novel functional pain scale-the Activity-Based Checks of Pain (ABCs)-and its correlations with the 0 to 10 numeric rating scale (NRS) and outpatient milligram of morphine equivalents (MMEs) prescribed and needed in the first 2 weeks after total hip arthroplasty. METHODS: ABCs and NRS were collected at the baseline, inpatient, and 2-week follow-up. Primary outcome metrics were needed for pain medication at the time of pain scale completion, MMEs prescribed at discharge, and MMEs taken. Individual ABC functions and composite score were analyzed using Spearman rho and Mann-Whitney U tests. RESULTS: ABC and NRS scores were greatest preoperatively (n = 39). At each stage, the ABCs correlated with the NRS (ρ = 0.450, P < 0.01; ρ = 0.402, P < 0.05; and ρ = 0.563, P < 0.01). ABC or NRS scores did not correlate with MMEs prescribed. Last in-house NRS correlated with MMEs taken postoperatively (r = 0.571, P < 0.01). Specific ABCs functions-"sitting up" (ρ = 0.418, P < 0.01), "walking in room" (ρ = 0.353, P < 0.05), and "walking outside room" (ρ = 0.362, P < 0.05)-on the day of discharge correlated with MMEs taken. CONCLUSION: ABCs scale correlates with NRS. Neither scale correlated with MMEs prescribed at discharge, suggesting pain is undervalued in analgesic planning. Clinicians should assess pain with functions found to correlate with MMEs taken-"sitting up," "walking in room," and "walking outside room."

Olfactory Phenotypes Differentiate Cognitively Unimpaired Seniors from Alzheimer's Disease and Mild Cognitive Impairment: A Combined Machine Learning and Traditional Statistical Approach.

BACKGROUND: Olfactory dysfunction (OD) is an early symptom of Alzheimer's disease (AD). However, olfactory testing is not commonly performed to test OD in the setting of AD. OBJECTIVE: This work investigates objective OD as a non-invasive biomarker for accurately classifying subjects as cognitively unimpaired (CU), mild cognitive impairment (MCI), and AD. METHODS: Patients with MCI (n = 24) and AD (n = 24), and CU (n = 33) controls completed two objective tests of olfaction (Affordable, Rapid, Olfactory Measurement Array -AROMA; Sniffin' Sticks Screening 12 Test -SST12). Demographic and subjective sinonasal and olfaction symptom information was also obtained. Analyses utilized traditional statistics and machine learning to determine olfactory variables, and combinations of variables, of importance for differentiating normal and disease states. RESULTS: Inability to correctly identify a scent after detection was a hallmark of MCI/AD. AROMA was superior to SST12 for differentiating MCI from AD. Performance on the clove scent was significantly different between all three groups. AROMA regression modeling yielded six scents with AUC of the ROC of 0.890 (p < 0.001). Random forest model machine learning algorithms considering AROMA olfactory data successfully predicted MCI versus AD disease state. Considering only AROMA data, machine learning algorithms were 87.5%accurate (95%CI 0.4735, 0.9968). Sensitivity and specificity were 100%and 75%, respectively with ROC of 0.875. When considering AROMA and subject demographic and subjective data, the AUC of the ROC increased to 0.9375. CONCLUSION: OD differentiates CUs from those with MCI and AD and can accurately predict MCI versus AD. Leveraging OD data may meaningfully guide management and research decisions.

Educational Informed Consent Video Equivalent to Standard Verbal Consent for Rhinologic Surgery: A Randomized Controlled Trial.

BACKGROUND: Informed consent is an integral part of pre-operative counseling. However, information discussed can be variable. Recent studies have explored the use of multimedia in providing informed consent for rhinologic surgery. OBJECTIVE: To measure impact of an educational video (Video) compared to verbal informed consent (Verbal) on knowledge gained, alleviation of concerns, and efficiency. METHODS: Patients undergoing endoscopic sinus surgery (ESS), septoplasty, or ESS+septoplasty were prospectively enrolled and randomized to receive Video or Verbal consent. The Video group watched an educational video; the Verbal group received standard verbal consent from an Otolaryngology resident per institutional protocol. Both groups had the opportunity to discuss questions or concerns with their attending surgeon. Prior to, and after, consent was signed, both groups completed surveys regarding knowledge of purpose, risks, and benefits of surgery as well as surgical concerns. Decision regret and patient satisfaction were also assessed post-operatively. RESULTS: 77 patients were enrolled (39 Video, 38 Verbal). Demographics were not significantly different between groups. Overall knowledge significantly improved (p < 0.005) and concerns significantly decreased (p < 0.001) following consent in both groups. Improvements in these metrics were equivalent between groups (p < 0.02). Furthermore, resident time to complete consent, patient satisfaction, and decision regret were not significantly different between groups. CONCLUSION: Use of an educational video was equivalent to standard verbal informed consent for patients undergoing rhinologic surgery. Otolaryngologists can consider developing procedure-specific videos to allow allocation of time to other tasks, standardized education of patients, and streamlining of the informed consent process.

Resident Education in Laryngeal Stroboscopy: Part II-Evaluation of a Multimedia Training Module.

OBJECTIVE: To evaluate the efficacy of a web-based training module for teaching interpretation of laryngeal stroboscopy in a cohort of otolaryngology residents. STUDY DESIGN: Randomized controlled trial. SETTING: Academic tertiary center. SUBJECTS AND METHODS: Residents from three training programs were invited to complete an assessment consisting of a survey and five stroboscopic exams. Subsequently, participants were randomized to receive teaching materials in the form of (1) a handout (HO) or (2) a multimedia module (MM) and asked to complete a post-training assessment. Responses were compared to responses provided by three fellowship-trained laryngologists. RESULTS: Thirty-five of 47 invited residents (74.4%) completed both assessments. Overall mean postassessment scores were 64.3% ± 7.0, with the MM group (67.0% ± 7.6, n = 17) scoring higher (P = 0.03) than the HO (61.6% ± 5.4, n = 18) cohort. Postassessment scores did not differ by postgraduate year (P = 0.75) or institution (P = 0.17). Paired analysis demonstrated an overall mean improvement of 7.4% in the handout (HO) cohort (P = 0.03) and 10.3% in the MM cohort (P = 0.0006). Subset analysis demonstrated higher scores for the MM cohort for perceptual voice evaluation (HO = 68.8% ± 11.0; MM = 77.3% ± 10.6, P = 0.03) and stroboscopy-specific items (HO = 55.5% ± 8.2; MM = 61.9% ± 10.8, P = 0.06). On a five-point Likert scale, residents reported improved confidence in stroboscopy interpretation (P < 0.0001), irrespective of cohort (P = 0.62). Residents rated the MM (median = 5) more favorably as a teaching tool compared to the HO (median = 4, P = 0.001). CONCLUSION: Use of both the written HO and MM module improved scores and confidence in interpreting laryngeal stroboscopy. The MM was more effective in perceptual voice evaluation and stroboscopy-specific items. The MM was also rated more favorably by residents and may be an ideal adjunct modality for teaching stroboscopy.

National Database Research in Head and Neck Reconstructive Surgery: A Call for Increased Transparency and Reproducibility.

OBJECTIVE: To reproduce a published study comparing outcomes of patients who underwent microvascular reconstruction by plastic surgeons and otolaryngologists and to examine how case selection and methodology using the National Surgical Quality Improvement Program (NSQIP) data set can affect results and conclusions. STUDY DESIGN: Cross-sectional analysis of US national database. SETTING: American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from 2005 to 2017. SUBJECTS AND METHODS: A recently published study that used the NSQIP database to compare outcomes after head and neck free tissue transfer between plastic surgeons and otolaryngologists was reproduced. Different approaches to case selection and statistical analysis were evaluated and their effects on statistical significance and study conclusions were compared. RESULTS: When all cases of free tissue transfer, captured in NSQIP between 2005 and 2017, were compared between plastic surgery and otolaryngology, plastic surgery patients appeared to have lower rates of complications and length of stay. However, a more in-depth analysis demonstrated that these results were confounded by older and sicker otolaryngology patients. A second analysis of the same NSQIP data, limited to only head and neck oncologic reconstructions, demonstrated that otolaryngology patients had fewer complications on univariate and multivariable analysis. CONCLUSION: We demonstrated how case selection and analysis can significantly affect results. It is incumbent upon researchers who use NSQIP and other publicly available data sets to fully detail their methodology to allow other researchers to reproduce and evaluate their work and for the journal editorial process to carefully evaluate the methodology and conclusions of their contributing authors.

Pathology protocol increases lymph node yield in neck dissection for oral cavity squamous cell carcinoma.

BACKGROUND: Lymph node yield (LNY) is a proposed quality indicator in neck dissection for oral cavity squamous cell carcinoma (OCSCC). METHODS: Retrospective series including 190 patients with OCSCC undergoing neck dissection between 2016 and 2018. A change in pathologic grossing protocol was initiated during the study period to assess residual adipose tissue. A generalized linear model was used to assess the impact of multiple variables on LNY. RESULTS: Mean LNY was 28.59 (SD = 17.65). The protocol identified a mean of 10.32 lymph nodes per case. Multivariable analysis identified associations between LNY and use of the pathology protocol (P = .02), number of dissected lymph node levels (P < .001), presence of pathologic lymph nodes (P = .002), body mass index (P = .02), prior neck surgery (P = .001), and prior neck radiation (P = .001). CONCLUSIONS: Assessment of residual adipose tissue within neck dissection specimens improves accuracy of LNY. LNY in neck dissection is influenced by multiple factors including methods of pathologic assessment.

Incidence and extent of sinus procedures in treatment of pediatric orbital cellulitis.

INTRODUCTION: It is unknown the optimal extent of sinus surgery in pediatric patients with orbital cellulitis. Our aim was to determine the nationwide incidence of sinus procedures used to treat pediatric orbital cellulitis. Additionally, we sought to identify patient-factors that influence a multi-procedural approach. METHODS: Cross-sectional analysis of 15,260 cases of primary pediatric orbital cellulitis identified in the Kids' Inpatient Database (KID) from January 1, 2003 to December 31, 2012. Cases were included if they contained a primary diagnosis code of orbital cellulitis. Frequency of sinus procedures in relation to pediatric age cohort were noted (≤8 years versus 9-20 years). Comorbidities, cost, and length-of-stay were compared between age cohorts. Multivariate models investigated patient-factors associated with multiple sinus procedures and patient-factors that affected hospital costs and length-of-stay. RESULTS: Children ≤8 years of age constituted 67% of cases (n = 10,290). 1103 cases (7.2%) were treated with at least one defined sinus procedure; and, 712 of these cases documented more than one sinus procedure. The younger cohort (≤8 years) exhibited fewer sinus procedures and a lower rate of reoperation (4.6% vs 12.8%, p < .001; 5.1% vs 7.7%, p < .001, respectively). Presence of cellulitis/abscess of the face was the strongest predictor of multiple sinus procedures (OR = 1.982, p = .033). Patients with acute sinusitis and those >8 years had similarly increased odds of a multi-procedural approach (OR = 1.333, p = .049; OR = 1.367, p = .032, respectively). Multivariate analysis of cost and length-of-stay found that patients >8 years incurred 14% longer hospital stays and an increase in costs of 9% compared to younger patients (p = .001, p = .039; respectively). The secondary diagnosis with the largest effect on length-of-stay and cost was an intracranical abscess (OR = 2.352, p < .001; OR = 2.752, p < .001; respectively). CONCLUSION: In a nationwide population of pediatric patients with primary orbital cellulitis there was an incidence of sinus surgery in 7.2% of cases - with patients over 8 years having a 2.8-fold increase compared to younger patients. Additionally, nearly two-thirds of patients treated with sinus surgery had multiple sinus procedures. The high incidence of multiple sinus procedures suggests that further prospective studies are needed to elucidate the extent of drainage associated with the best patient outcomes.

Essential Oil Olfactory Test: Comparison of Affordable Rapid Olfaction Measurement Array (AROMA) to Sniffin' Sticks 12.

OBJECTIVES: To further demonstrate the validity of Affordable Rapid Olfaction Measurement Array (AROMA), an essential oil-based smell test, and compare it to the Sniffin' Sticks 12 Test (SST12). STUDY DESIGN: Prospective cross-sectional study. SETTING: Academic medical center. METHODS: Fifty healthy individuals without sinonasal disease were recruited to the study. AROMA has been previously validated against the University of Pennsylvania Smell Identification Test. The current study tests 2 additional higher concentrations to increase the ability to detect olfactory reserve. Healthy participants completed AROMA, SST12, Sino-Nasal Outcome Test (SNOT-22), and Questionnaire of Olfactory Disorders (QoD). Spearman correlations were used to evaluate AROMA, SST, SNOT-22, and QoD. RESULTS: AROMA demonstrated strong test-retest reliability (r = 0.757, P < .01). AROMA showed a moderate correlation to SST12 (ρ = 0.412, P < .01). Age and SNOT-22 were significantly correlated (P < .05) with AROMA (ρ = -0.547, -0.331, respectively), and age was weakly correlated with SST (ρ = -0.377, P < .01). Median percent correct scores were as follows: SST12 identification, 92%; AROMA detection, 90%; and AROMA identification, 81%. Median correct odor identification of AROMA concentrations at 1×, 2×, 4×, and 8× were 64%, 75%, 92%, and 92%, respectively. CONCLUSION: AROMA has a moderate correlation with SST12. AROMA is more strongly correlated than SST12 to age and SNOT-22. AROMA's stronger correlation with subjective olfactory status, low cost, and adaptability may help remove barriers to routine olfactory testing in the clinic.

EMR quantity autopopulation removal on hospital discharge prescribing patterns: Implications for opioid stewardship.

WHAT IS KNOWN AND OBJECTIVE: Prescription drug stewardship is critical. Autopopulation(AP) of medication quantities may influence prescriber behaviour. We investigate the impact of AP removal(APR) on opioid prescribing. METHODS: Inpatient and emergency department(ED) discharges with opioid pain medications 2 years before and after APR were identified. Milligrams of morphine equivalents(MMEs) prescribed were recorded. Group comparisons were performed using Mann-Whitney U tests. Spearman's rho was used to analyse correlations between pain level and quantity of prescribed opioids. Mann-Kendall tests assessed trends in prescription patterns. Generalized estimating equations assessed trends in total quantity of prescribed MME. RESULTS AND DISCUSSION: A total of 53 608 patient encounters were included for analysis. In surgical patients, there were no trends in the frequency of prescriptions below, at or above the AP quantity pre-APR. Post-APR, there was a decrease in the percentage of prescriptions written for the AP quantity(τ = -.493, P = .001) and an increase in prescriptions for <30 tablets(τ = .468,P = .001). In non-operative patients, the pre-APR period was associated with a lower percentage of prescriptions >30 tablets and a greater percentage of prescriptions for <30 tablets. Interestingly, APR reversed this trend in prescriptions for >30 tablets and resulted in an increase in larger prescriptions. Multivariate analysis of the total prescribed quantity of MME found no significant trend across months for inpatients prior to and after APR (0.997, P = .065 and 1.003, P = .142; respectively). The ED model found a monthly downward trend in amount of prescribed MME prior to and after APR (0.986, P < .001 and 0.990, P < .001; respectively). In the inpatient setting, pain was positively correlated to discharge MME (ρ = .028, P < .001); with those reporting the highest pain receiving the greatest amount of opioids both pre- and post-APR. Interestingly, in the ED, this finding was negatively correlated (ρ = -.086, P < .001); with those reporting the lowest pain receiving the greatest amount of opioids both pre- and post-APR. WHAT IS NEW AND CONCLUSIONS: AP removal may have unintended consequences, such as increased prescriptions for greater quantities. To drive down prescription amounts, lower anchor values may be of more utility than APR. The poor correlation of pain values with prescribed medications warrants further investigation.

The false vital sign: When pain levels are not predictive of discharge opioid prescriptions.

BACKGROUND: Pain gained recognition as a vital sign in the early 2000s, underscoring the importance of accurate documentation, characterization, and treatment of pain. No prior studies have demonstrated the utility of the 0-10 pain scale with respect to discharge opioid prescriptions, nor characterized the most influential factors in discharge prescriptions. METHODS: Inpatient and emergency department(ED) encounters from July 1, 2012 to April 1, 2018 resulting in a discharge prescription for tablet opioid medications were identified. The primary outcome was to determine if pain levels in 24 h prior to discharge correlated with opioids (in milligrams of morphine equivalents (MME)) prescribed. Secondary outcomes included the impact of patient and prescriber demographics, demographics. A generalized linear model was created to investigate factors affecting the quantity of prescribed opioids. RESULTS: n = 78,691 patient encounters. Overall mean adjusted MME for non-ED visits was 378 versus 197 for ED visits. Whites received the highest quantities; those identifying as non-white and non-black received the lowest. Women received significantly fewer discharge MMEs in both the ED and inpatient cohorts. Provider prescribing patterns exhibited the most profound effect on discharge MMEs. The most prolific (≥300 prescriptions over the study period) writing the largest amount. In the ED, there was a significant negative correlation between documented pain levels and discharge MMEs(ρ = 0.074,p < 0.001). CONCLUSIONS: Pain scale was significantly negatively correlated with discharge MMEs in the ED and positively correlated in the inpatient population. Individual prescriber characteristics were the more influential variable, with prolific high prescribers writing for the largest MME amounts. The inverse association of pain and MMEs at discharge in the ED, and the large effect pre-existing prescriber patterns exhibited, both improved methodology for assessing and appropriately treating pain, and effective prescriber-targeted interventions, must be a priority.

Clinical and Economic Impact of Time From Admission for CSF Rhinorrhea to Surgical Repair.

BACKGROUND: If conservative management of CSF leak is unsuccessful, surgical repair is indicated for the prevention of severe complications such as meningitis. This study investigated the influence of surgical timing on clinical and economic outcomes. METHODS: Retrospective review of the National Inpatient Sample (2012) and the Nationwide Inpatient Sample (2002-2011) for nonelective admissions with a principal diagnosis of CSF rhinorrhea treated with surgical repair of the meninges. Demographics and outcomes of patients undergoing meningeal repair for CSF rhinorrhea were analyzed. Cases were classified into four groups based on timing of surgical intervention: 1) performed on the day of admission (day 0), 2) performed between days 1 and 3, 3) performed between days 4 and 7, and 4) performed between days 8 and 14. RESULTS: A total of 1,088 emergent admissions were analyzed. On average, patients underwent surgical repair between the second and fourth day of admission. Lowest rates of meningitis were in patients treated on the day of admission (6.1%); those treated at 2 weeks had a 34.7% incidence. Multivariate analysis controlling for comorbidity burden, gender, and surgical timing found the highest odds of meningitis in patients treated with surgical repair during the second week of admission compared to repair on the day of admission (OR 8.2, P < .001). Length of stay (LOS) and hospital costs increased as time to repair increased. CONCLUSION: Multiple factors influence outcomes in patients with CSF rhinorrhea. Early surgical repair was significantly associated with decreased rates of meningitis, LOS, and hospital costs. Expedient treatment of patients admitted for CSF rhinorrhea may prove to be both a cost- and morbidity-saving measure. LEVEL OF EVIDENCE: 2C Laryngoscope, 129:539-543, 2019.

Using word clouds to Re-envision letters of recommendation for residency applicants.

OBJECTIVES/HYPOTHESIS: To develop a "word cloud"-based visual letter of recommendation (VLOR) and to evaluate its efficiency in discerning applicant quality compared to narrative letters of recommendation (NLORs). STUDY DESIGN: Cross-sectional cohort study. METHODS: NLORs for 48 otolaryngology residency applicants interviewed from the 2016 application cycle were identified and mined for descriptive terms to generate a word cloud, referred to as a VLOR. Eight individuals reviewed and rated a total of 187 blinded NLORs and 48 VLORs on a four-point scale (negative to exceptional). Median VLOR and NLOR scores and the time to review for each candidate were compared using the Wilcoxon signed rank test. RESULTS: It took significantly more time to review the NLORs in comparison to the VLORs (67 seconds, interquartile range [IQR]: 41-98 seconds vs. 17 seconds, IQR: 11-26 seconds, P < .001). There was no significant difference between median scores for VLORs and NLORs (P = .136). Review time and score correlated positively for VLORs and was statistically significant (ρ = 0.459, P = .001), indicating that more time spent reviewing equates to higher scores. The same relationship appeared with NLORs, but was not statistically significant (ρ = 0.276, P = .058). CONCLUSIONS: VLORs are a novel and efficient additive tool for screening candidates for otolaryngology residency interview slots. Their scores do not significantly vary from NLOR scores and are significantly faster to evaluate. LEVEL OF EVIDENCE: 2b Laryngoscope, 129:2026-2030, 2019.

Analysis of Facial Reanimation Procedures Performed Concurrently With Total Parotidectomy and Facial Nerve Sacrifice.

IMPORTANCE: Facial reanimation procedures share the same surgical field as a parotidectomy and are most easily accomplished at the time of facial nerve sacrifice. Early reanimation would also reduce the duration of paralysis and may lead to better functional outcomes. OBJECTIVE: To assess the incidence and types of facial nerve reanimation performed concurrently with total parotidectomy and facial nerve sacrifice using the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study identified 285 patients who underwent total parotidectomy with facial nerve sacrifice (Current Procedural Terminology code 42425) and evaluated the various types of facial reanimation procedures performed concurrently. Patients were identified from the ACS-NSQIP database encompassing 603 community and academic hospitals and underwent treatment from January 1, 2010, through December 31, 2015. Data were analyzed from September 20, 2017, through February 21, 2018. MAIN OUTCOMES AND MEASURES: Comparison of demographics in nonreanimation and reanimation groups and subgroups of nerve- and sling-type reanimation procedures. RESULTS: Of 285 patients who underwent total parotidectomy with facial nerve sacrifice (61.8% men; mean [SD] age, 64 [15] years), 89 (31.2%; 95% CI, 26.0%-37.0%) underwent at least 1 concurrent facial reanimation procedure. Of the facial nerve procedures performed, 41 (46.1%; 95% CI, 36.0%-56.0%) were nerve-type repairs, 31 (34.8%; 95% CI, 26.0%-45.0%) were sling-type repairs, and 17 (19.1%; 95% CI, 12.0%-29.0%) included both types. Patients treated with nerve-type repairs only were significantly younger than those treated with sling-type repairs only (mean [SD] age, 57.6 [16.0] vs 72.1 [13.8] years; P < .001). Forty-nine patients underwent free tissue reconstruction. Of those, 24 patients (49.0%) had concurrent facial reanimation procedure(s) performed; this proportion was significantly more than those who did not undergo free tissue reconstruction (65 of 236 [28.0%]; P = .003). CONCLUSIONS AND RELEVANCE: In patients undergoing total parotidectomy with facial nerve sacrifice, many are not receiving a concurrent facial reanimation procedure at the time of their tumor resection. Those patients who underwent free tissue reconstruction were significantly more likely to receive a concurrent facial reanimation procedure. These findings may reveal an opportunity for earlier facial reanimation in this patient population. LEVEL OF EVIDENCE: NA.

Proliferation and Contributions of National Database Studies in Otolaryngology Literature Published in the United States: 2005-2016.

OBJECTIVE: Health registries and discharge-level databases are powerful tools. Commonly used data sets include the Nationwide Inpatient Sample (NIS); Surveillance, Epidemiology, and End Results Program (SEER); National Cancer Database (NCDB); and American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). This study investigated the frequency with which these resources are being used and categorized their contributions to literature. DESIGN: A literature review from 2005 to 2016 for papers utilizing the aforementioned databases and publishing in The Laryngoscope, JAMA-Otolaryngology, Head and Neck, Otolaryngology-Head and Neck Surgery, and International Forum of Allergy and Rhinology was conducted. Results were categorized based on the contribution(s) of the paper. The incidence rate of database publications was calculated for each year along with the 95% confidence intervals using a Poisson distribution. RESULTS: Three hundred ten studies were identified. Seventy percent report descriptive findings, and 65% report outcomes/survival. Approximately 18% made clinical recommendations. In 2005, the incidence rate of database publications was 3 per 1000 journal publications (95% CI, 1-9) and remained relatively stable until 2008. From 2010 onward, there was a persistent increase in publications, culminating in the highest incidence rate in 2016 of 26 database publications per 1000 journal publications (95% CI, 20-32). CONCLUSIONS: There was a nearly 10-fold increase in database publications in 2016 compared to 2005. The majority provide descriptive data and outcomes measures. The role of these studies warrants further investigation.

Primary Angioplasty Versus Stenting for Endovascular Management of Intracranial Atherosclerotic Disease Following Acute Ischemic Stroke.

BACKGROUND: The future of neuroendovascular treatment for intracranial atherosclerotic disease (ICAD) has been debated since the results of SAMMPRIS reflected poor outcomes following endovascular therapy. There is currently a large spectrum of current management strategies. We compared historical outcomes of patients with ICAD and stroke that were treated with angioplasty-alone versus stent placement. METHODS: We extracted a population from the Nationwide Inpatient Sample (NIS) (2005-2011) and the National Inpatient Sample (NIS) (2012) composed of patients with ICAD and infarction that were admitted nonelectively and received endovascular revascularization. Patients treated with thrombectomy or thrombolysis were excluded. Categorical variables were compared with Chi-squared tests. Binary logistic regression was performed to evaluate mortality while controlling for age, sex, severity, and comorbidities. RESULTS: About 2059 admissions met our criteria. A majority were treated via stent placement (71%). Angioplasty-alone had significantly higher mortality (17.6% vs. 8.4%, P<0.001), but no difference in iatrogenic stroke rate (3.4% vs. 3.6%, P=0.826), compared to stent placement. The adjusted odds ratio of mortality for stented patients was 0.536 (95% CI: 0.381-0.753, P<0.001) in comparison to patients treated with angioplasty alone. CONCLUSIONS: This study found the risk of mortality to be elevated following angioplasty alone in comparison to revascularization with stent placement, without a corresponding significant difference in iatrogenic stroke rate. This may represent selection bias due to patient characteristics not defined in the database, but it also may indicate that patients with ICAD and acute stroke have increased odds of stenosis that is refractory to angioplasty alone and have a high risk of mortality without revascularization.

Trends in mortality following mechanical thrombectomy for the treatment of acute ischemic stroke in the USA.

BACKGROUND AND PURPOSE: Mechanical thrombectomy (MT) for the treatment of acute ischemic stroke has been growing in popularity while the therapeutic benefit of MT has been increasingly debated. Our objective was to examine national trends in mortality following MT. METHODS: We analyzed the National Inpatient Sample (2012) and the Nationwide Inpatient Sample (2008-2011) for patients with a primary diagnosis of acute ischemic stroke that received MT. Temporal trends in mortality were examined using Spearman's rank correlation. To account for confounding factors, mortality was further analyzed in binary logistic regression. RESULTS: Hospitals performing MT comprised 8% of all hospitals treating ischemic stroke. The percentage of stroke cases treated with MT increased from 0.6% of cases in 2008 to 1.1% in 2012, totaling 16 307 MT cases in a 5 year period. Inhospital mortality decreased over the study period from 25.4% in 2008 to 16.1% in 2012 (r=-0.081, p<0.001). This finding was supported by regression analysis as each incremental year reduced the odds of mortality by 20% (OR=0.832, p<0.001). Administration of recombinant tissue plasminogen activator was associated with a decrease in the odds of mortality (OR=0.805, p<0.001). CONCLUSIONS: Utilization of MT represents a small percentage of stroke cases, although the trend is increasing. Mortality following MT has been showing a steady decline over the past 5 years. This may be a result of a learning curve, improved patient selection, and/or device improvements. Randomized trials remain essential to evaluate the potential benefit of endovascular devices and identify the most appropriate patients.