Endolymphatic Sac Tumors Associated With von Hippel-Lindau: A Case Report Highlighting Opportunity for Novel Orphan Drug Therapy.

OBJECTIVE: To discuss the potential benefit of belzutifan therapy in a patient with von Hippel-Lindau (VHL) disease-associated endolymphatic sac tumor (ELST). PATIENTS: Case report. INTERVENTIONS: Clinical details of a patient with residual ELST after hearing preservation surgery who initiated belzutifan therapy postoperatively for concurrent renal cell carcinoma, as well as literature review of belzutifan and ELST. MAIN OUTCOME MEASURES: The patient remained without radiologic evidence of growth of her residual tumor at 17 months post-initiation of belzutifan. It is unknown whether this represents therapeutic drug effect, nonviability of residual tumor, or slow tumor growth not captured radiographically within the duration of follow-up. CONCLUSIONS: Belzutifan could have direct therapeutic benefit in patients with VHL-associated ELST.

Current Issues With Pediatric Cochlear Implantation.

Cochlear implants (CIs) have demonstrated a clear functional benefit in children with severe-to-profound sensorineural hearing loss (SNHL) and thus have gained wide acceptance for treating deafness in the pediatric population. When evaluating young children for cochlear implantation, there are unique considerations beyond the standard issues addressed during surgery in adults. Because of advances in genetic testing, imaging resolution, CI technology, post-implant rehabilitation, and other factors, issues related to CI surgery in children continue to evolve. Such factors have led to changes in candidacy guidelines, vaccine requirements, and lowering of age requirement for surgery. In addition, differences in the anatomy and physiology of infants require special attention to ensure safety when operating on young children. This review summarizes these issues and provides guidance for surgeons treating children with SNHL.

The time of cure: hepatitis C treatment and the matter of reinfection among people who inject drugs.

Australia has made considerable progress towards the public-health 'elimination' of the hepatitis C virus. Nonetheless, reinfection remains a key challenge, with little understanding regarding the lived complexities of post-cure life among people who inject drugs. Our analysis examines reinfection through the lens of 'time', a largely overlooked and under-utilised analytical concept within the field of hepatitis C. Drawing on qualitative data from a study examining treatment outcomes and reinfection, our analysis concentrates on three participant accounts or 'cases'. Working within a new materialist framework, we combine recent social science scholarship which, firstly, posits cure as a socio-material 'gathering', and secondly, proposes a 'futurology' of hepatitis C and its treatment. We found participant accounts troubled the neat binary of pre- and post-treatment life, instead detailing the challenges of remaining virologically safe while navigating complex, local life-worlds. Rather than a singular, post-treatment future instantiated by cure, participants described the fluid, emergent nature of what we might describe as 'lived' or 'embodied' time, including multiplicities of becoming in a perpetual present. We conclude that our understanding of reinfection needs to move beyond its current, narrow biomedical conception and organising temporal logic to honour and incorporate complexity in practice.

Temporal Trends in Early Pediatric Cochlear Implantations in California from 2018 to 2020.

OBJECTIVE: To characterize the demographics of children receiving cochlear implantations, identify factors associated with delayed implantations, and trend these factors over time. DESIGN: Retrospective cross-sectional study. SETTING: Healthcare Cost and Utilization Project California State Ambulatory Surgery Database for calendar years 2018-2020. PATIENTS: Children 5 years or younger undergoing cochlear implantation. INTERVENTIONS: Cochlear implantation. MAIN OUTCOMES MEASURES: The population-controlled number of cochlear implantations was calculated and stratified by race and insurance. Early implantation was defined as implantation at age 2 years or younger. A mixed-effects logistic regression model was generated to identify factors associated with early implantation and how that association changed from 2018 to 2020. RESULTS: The final cohort included 467 children. The number of implantations increased from 141 to 175 implants from 2018 to 2020 (24.1% increase); 229 (49.0%) children were implanted at 2 years or younger. Medicaid insurance was associated with decreased odds of early implantation (odds ratio, 0.18 [95% confidence interval, 0.15-0.23], p < 0.001); this association with Medicaid insurance was significant when stratified across all racial groups. The percentage of children with Medicaid who were implanted at 2 years or younger increased from 20.9 to 62.0% from 2018 to 2020. CONCLUSIONS AND RELEVANCE: Among children in California, socioeconomic factors, in particular public insurance, are correlated with age of cochlear implantation. These disparities improved significantly from 2018 to 2020. Further investigation into changes and initiatives in California during this time frame may aid in directing national efforts to improve pediatric cochlear implantation access.

Morphometric Analysis and Linear Measurements of the Scala Tympani and Implications in Cochlear Implant Electrodes.

HYPOTHESIS: The objective of this study was to perform detailed height and cross-sectional area measurements of the scala tympani in histologic sections of nondiseased human temporal bones and correlate them with cochlear implant electrode dimensions. BACKGROUND: Previous investigations in scala tympani dimensions have used microcomputed tomography or casting modalities, which cannot be correlated directly with microanatomy visible on histologic specimens. METHODS: Three-dimensional reconstructions of 10 archival human temporal bone specimens with no history of middle or inner ear disease were generated using hematoxylin and eosin histopathologic slides. At 90-degree intervals, the heights of the scala tympani at lateral wall, midscala, and perimodiolar locations were measured, along with cross-sectional area. RESULTS: The vertical height of the scala tympani at its lateral wall significantly decreased from 1.28 to 0.88 mm from 0 to 180 degrees, and the perimodiolar height decreased from 1.20 to 0.85 mm. The cross-sectional area decreased from 2.29 (standard deviation, 0.60) mm 2 to 1.38 (standard deviation, 0.13) mm 2 from 0 to 180 degrees ( p = 0.001). After 360 degrees, the scala tympani shape transitioned from an ovoid to triangular shape, corresponding with a significantly decreased lateral height relative to perimodiolar height. Wide variability was observed among the cochlear implant electrode sizes relative to scala tympani measurements. CONCLUSION: The present study is the first to conduct detailed measurements of heights and cross-sectional area of the scala tympani and the first to statistically characterize the change in its shape after the basal turn. These measurements have important implications in understanding locations of intracochlear trauma during insertion and electrode design.

Geographic Variations in Medicare Cochlear Implantations in the United States.

OBJECTIVE: To describe national practice patterns and detail geographic and temporal changes in cochlear implantations (CIs) in the Medicare population. STUDY DESIGN: Cross-sectional analysis. SETTING: Medicare B Public Use Files. PATIENTS: Medicare B fee-for-service patients who underwent CI from 2012 to 2019. INTERVENTIONS: Cochlear implantations (Current Procedural Terminology code 69930). MAIN OUTCOME MEASURES: Medicare Part B Public Use Files were used to identify all individual providers who performed CIs from 2012 to 2019. The total number of CIs performed annually was calculated for hospital referral regions (HRRs) as well as U.S. census regions to describe geographic variations and changes over the study period. Average Medicare reimbursement rates were tabulated. RESULTS: From 2012 of 2019, the number of CIs performed in the Medicare population increased from 1,239 to 2,429, representing a 96.0% increase. In each of the four U.S. census regions, there was a statistically significant increase in the number of CIs performed over the study period. However, of 306 HRR in the United States, cochlear implants were performed in only 117 (38.2%), with the median number of CIs in each HRRs 16.7 (interquartile range, 13-24.2) per year. The median weighted average Medicare reimbursement was $1205.49 (interquartile range, 1161.65-1253.46). CONCLUSIONS: The number of CIs in the Medicare population has increased from 2012 to 2019. However, widespread geographic variations continue to persist in the United States and represent opportunities toward identifying and acting on the etiologies of persistent disparities in CI.

"You need a designated officer" - Recommendations from correctional and justice health personnel for scaling up hepatitis C treatment-as-prevention in the prison setting.

INTRODUCTION: Hepatitis C (HCV) is highly prevalent among people who are incarcerated. HCV treatment-as-prevention was implemented in the SToP-C trial in four correctional centres in New South Wales , Australia to determine whether prison-wide scale up of antiviral treatment was an effective strategy to reduce HCV incidence and prevalence in the prison setting. A qualitative assessment was undertaken with prison-based correctional and health personnel at each of the four prisons to understand operational, sociological, and cultural barriers and enablers to scale up. Informed by a framework for scaling up population health interventions, this analysis examines recommendations by correctional and justice health personnel for HCV treatment-as-prevention scale up in the prison setting. METHODS: Correctional (n=24) and justice health (n=17) personnel, including officers, nurses, and senior administrators, participated in interviews across the four prisons where SToP-C was delivered and included two maximum security, one minimum security, and one women's medium/minimum security prisons. RESULTS: Scaling up HCV treatment-as-prevention was contingent on compatibility (including sentence length), efficacy (securely funded positions for dedicated personnel and continuity of care for patients transferring between prisons), stakeholder analysis (generally the whole of prison workforce, particularly custodial officers and senior administrators), reach (reliant on peer and officer champions), and legitimised change (via dedicated officers who could instigate cultural shifts). CONCLUSION: Achieving scale up of such an intervention should be guided by an understanding of the potential barriers and enablers. This analysis showed key considerations for HCV treatment-as-prevention scale up in correctional centres.

Data Protection by Design Tool for Automated GDPR Compliance Verification Based on Semantically Modeled Informed Consent.

The enforcement of the GDPR in May 2018 has led to a paradigm shift in data protection. Organizations face significant challenges, such as demonstrating compliance (or auditability) and automated compliance verification due to the complex and dynamic nature of consent, as well as the scale at which compliance verification must be performed. Furthermore, the GDPR's promotion of data protection by design and industrial interoperability requirements has created new technical challenges, as they require significant changes in the design and implementation of systems that handle personal data. We present a scalable data protection by design tool for automated compliance verification and auditability based on informed consent that is modeled with a knowledge graph. Automated compliance verification is made possible by implementing a regulation-to-code process that translates GDPR regulations into well-defined technical and organizational measures and, ultimately, software code. We demonstrate the effectiveness of the tool in the insurance and smart cities domains. We highlight ways in which our tool can be adapted to other domains.

'Not just one box that you tick off' - Deconstructing the hepatitis C care cascade in the interferon-free direct acting antiviral era from the client perspective.

BACKGROUND: To achieve hepatitis C viral (HCV) elimination targets set by the World Health Organisation, pillars of the HCV care cascade are often referenced to track progress. The aim of this qualitative study was to explore the limitations of the care cascade framework through the real-world accounts of 'HCV journeys' among people who inject drugs (PWID), with particular attention to the intersection of PWID agency and structural determinants in the healthcare system. METHODS: An in-depth analysis was conducted on five case studies to better understand participant experiences 'behind the cascade pillars'. The five case studies were drawn from the ETHOS Engage cohort as exemplars of the real-world complexities of people's HCV cascade journeys. Inclusion criteria for the qualitative study were participant has voluntarily signed the informed consent form, aged ≥18 years, HCV antibody positive by self-report, clients of selected sites participating in the ETHOS Engage cohort, and sufficiently proficient in English to participate in an interview. Thirty-four semi-structured interviews were conducted with participants who had received or had not received HCV treatment to identify barriers and facilitators to HCV care. RESULTS: Participants 'housed' at the 'HCV RNA diagnosed pillar' (n = 2; Will; Julie) reported withholding their HCV serostatus in certain healthcare settings for fear that disclosure would lead to discriminatory decision-making from their treating physician. among participants who had completed treatment (n = 3; Corey; John; Nora) two reported still being unsure of their HCV status >6 months post-treatment. Ongoing feelings of frustration and shame were expressed in this 'post-cure care pillar' due to a perceived lack of quality care from clinic services and continued uneasiness when discussing drug use and reinfection while receiving opioid agonist treatment (OAT). Both case 'categories' described often tenuous therapeutic relationships with their physicians and recommended task-shifting to nurses and trusted case workers for ongoing care. CONCLUSION: The care cascade provides a linear, two dimensional snapshot of clinical targets. Our findings illuminate structural barriers not visible behind its 'static' pillars, presenting insights into experiences among PWID otherwise dismissed as 'disengaged' or 'lost to follow-up'.

Association of Socioeconomic Characteristics With Receipt of Pediatric Cochlear Implantations in California.

Importance: Earlier cochlear implantation among children with bilateral severe to profound sensorineural hearing loss is associated with improved language outcomes. More work is necessary to identify patients at risk for delayed cochlear implantation and understand targets for interventions to improve cochlear implantation rates among children. Objective: To describe the demographics among children receiving cochlear implantations and variability in implantation rates in California and to investigate sociodemographic and parental factors associated with early pediatric cochlear implantation. Design, Setting, and Participants: This retrospective cross-sectional study was conducted using data from the Healthcare Cost and Utilization Project California State Ambulatory Surgery Database in calendar year 2018. Included patients were children aged 9 years old or younger undergoing cochlear implantation. Sociodemographic factors, location of treatment, and parental factors were collected. Data were analyzed from March through August 2021. Main Outcomes and Measures: Binary logistic regression was performed to investigate sociodemographic factors associated with early cochlear implantation (ie, before age 2 years). Geographic variability in pediatric cochlear implantation across hospital referral regions in California was described, and various parental factors associated with implantation before age 2 years were analyzed. Results: Among 182 children receiving cochlear implantations, the median (IQR) age was 3 (1-5) years and 58 children (31.9%) received implantations at ages 2 years or younger. There were 90 girls (49.5%) and 92 boys (50.5%), and among 170 children with race and ethnicity data, there were 27 Asian or Pacific Islander children (15.9%), 63 Hispanic children (37.1%), and 55 White children (32.4%). The risk of CI was significantly decreased among Black children compared with Asian or Pacific Islander children (relative risk [RR], 0.18 [95% CI, 0.07-0.47]; P = .001) and White children (RR, 0.24 [95% CI, 0.10-0.59]; P = .002) and among Hispanic children compared with Asian or Pacific Islander children (RR, 0.32 [95% CI, 0.21-0.50]; P < .001) and White children (RR, 0.42 [95% CI, 0.29-0.59; P < .001). Compared with private insurance, Medicaid insurance was associated with decreased odds of implantation at ages 2 years or younger (odds ratio [OR], 0.19 [95% CI, 0.06-0.64]; P = .007), and every 1 percentage point increase in maternal high school completion percentage in a given California hospital referral region was correlated with a 5-percentage point increase in percentage of cochlear implants performed at age 2 years or younger (b = 5.18 [95% CI, 1.34-9.02]; P = .008). There were no significant differences in rates of early implantation by race or ethnicity. Conclusions and Relevance: This study found significant variability in pediatric cochlear implantation rates in California. These findings suggest that socioeconomic and parental factors may be associated with differences in access to early cochlear implantation and suggest the need to invest in initiatives to address barriers to appropriate and timely access to care.

The impact of a double vein anastomoses on doppler's loss of signal rates.

BACKGROUND: Impact on blood flow by double vein anastomosis in head and neck free flaps is unclear. We aimed to assess venous doppler loss of signal (LOS) rates of double vein system compared with a single vein system. METHODS: Consecutive free flaps with implanted venous flow couplers between 2015-2017 were included. LOS rates were compared between groups and with regard to flap type, defect site and recipient vein within double vein group. RESULTS: 92 double-vein (184 veins) and 48 single-vein flaps were included. LOS was similar in single- and double-vein flaps (11/48 (25%) versus 46/184 (25%), p = 0.765). Double veins had fewer flap takebacks compared with single vein (4.3% vs. 12.5%, p = 0.075). Common facial vein (CFV) anastomosis showed superior LOS rates compared with external jugular and CFV branches (p = 0.026). CONCLUSIONS: Double vein anastomosis does not impact LOS rates, results in fewer flap takebacks, yet LOS rates depend on selected recipient vein.

Cochlear Meniere's: A Distinct Clinical Entity With Isolated Cochlear Hydrops on High-Resolution MRI?

Objective: Describe the clinical characteristics of patients with isolated cochlear endolymphatic hydrops (EH). Study design: Clinical case series. Setting: Tertiary Neurotology referral clinic. Patients: All subjects presenting to a University Neurotology clinic during a 1-year period from July 2015 until August 2016 who had isolated cochlear EH on MRI. Patients with a history of temporal bone surgery prior to the MRI were excluded. Intervention: High-resolution delayed-intravenous contrast MRI. Main outcome measures: Audiometric and vestibular testing, clinical history analysis. Results: 10 subjects demonstrated isolated, unilateral cochlear hydrops on MRI. None of these patients met the criteria for Meniere's disease. Mean age of the group was 66.4 years and most were males (70%). Unilateral aural fullness (70%), tinnitus (80%), and hearing loss (90%) were frequently observed. Only one patient presented with unsteadiness (10%) and one patient had a single isolated spell of positional vertigo 1 month prior to the MRI (10%) but no further vertigo spells in the 4 years following the MRI. The mean PTA was 37.8 dB which was significantly decreased from the non-affected ear with PTA of 17.9 (p < 0.001). One patient developed vertiginous spells and unsteadiness 4 years after initial presentation and a repeat MRI revealed progression to utricular, saccular and cochlear hydrops. Vestibular testing was obtained in five patients with one patient presenting with 50% caloric paresis and all others normal. The most common treatment tried was acetazolamide in seven patients with 86% reporting subjective clinical improvement. Two out of the 10 patients had a history of migraine (20%). Conclusions: Patients with MRI exhibiting isolated cochlear EH present with predominantly auditory symptoms: mild to moderate low-frequency hearing loss, aural fullness, tinnitus without significant vertigo. Isolated cochlear hydrops is more common in males, average age in mid-60's and there is a low comorbidity of migraine headaches. This contrasts significantly with patients with isolated saccular hydrops on MRI from our prior studies. We believe that isolated cochlear EH with hearing loss but no vertigo is distinct from Meniere's disease or its variant delayed endolymphatic hydrops. We propose that cochlear Meniere's disease represents a distinct clinical entity that could be a variant of Meniere's disease.

Hepatitis C treatment as prevention in the prison setting: Assessments of acceptability of treatment scale up efforts by prison correctional and health personnel.

BACKGROUND: Hepatitis C (HCV) infection is prevalent in the prison setting, with sharing of unsterile injecting equipment the most common mode of transmission in high income countries. Mathematical modelling suggests that HCV treatment scale-up could prevent onward transmission, known as treatment as prevention. Direct-acting antivirals have enabled rapid scale up of HCV treatment, underpinning the first clinical trial of treatment as prevention in the prison setting. The Surveillance and Treatment of Prisoners with hepatitis C (SToP-C) study was carried out in four correctional centres in New South Wales, Australia. This paper utilises Sekhon's Theoretical Framework of Acceptability to examine correctional, prison health, and study personnel's assessments of acceptability of HCV treatment as prevention in the prison setting. METHODS: Correctional (n=24) and health personnel (n=17) including officers, nurses (including seven study nurses), and senior administrators across the four prisons where SToP-C was delivered, participated in interviews. This included two maximum security, one minimum security, and one women's medium/minimum security prison. Data analysis was informed by a seven-component theory of acceptability. RESULTS: Participants reported broad acceptability of HCV treatment as prevention in the prison setting across five components of acceptability (affective attitude, burden, ethicality, perceived effectiveness, and self-efficacy). Attributes contributing to acceptability included reduced HCV prevalence within the prison, and public health benefits for the community when people are released without HCV (affective attitude). Elements which may negatively impact on acceptability included limited clinic space (burden) and lack of correctional officers' understanding of availability of equivalent healthcare in the community (ethicality). System-wide prison participation was viewed as necessary for treatment as prevention to be successful (perceived effectiveness), while nonjudgmental care was seen as instrumental to HCV treatment scale up efforts (self-efficacy). CONCLUSION: Correctional and prison-based health personnel view HCV treatment as prevention as an acceptable health intervention. Overall, environmental issues relating to implementation (i.e., clinic space) were viewed as requiring a strategic approach to support prison-wide HCV treatment scale up.

Temporal Trends and Regionalization of Acute Mastoiditis Management in the United States.

OBJECTIVE: To describe demographics and to analyze temporal trends in the inpatient management of acute mastoiditis admissions. STUDY DESIGN: Cross-sectional analysis. SETTING: National Inpatient Sample, 2002-2014. PATIENTS: 26,072 nonelective inpatient admissions with primary diagnosis of acute mastoiditis. INTERVENTION: Myringotomy, mastoidectomy, or no procedure. MAIN OUTCOME MEASURES: We described the patient- and hospital-level demographics of acute mastoiditis admissions and the frequency of complications. We evaluated the percentage of patients requiring surgical management. Binary logistic regression was performed to determine whether there was a significant increase in the percentage of patients treated at academic institutions. RESULTS: The majority of patients were ≤40 years old (64.9%) and Elixhauser comorbidity index ≥4 (57.4%); 23.3% (SE 0.8%) presented with complications associated with acute mastoiditis, the most common of which was a subperiosteal abscess (11.5%, SE 0.7%). Among all admissions, 30.9% (SE 1.1%) underwent myringotomy, 13.8% (SE 0.8%) required both myringotomy and mastoidectomy. On multivariate analysis, there was a statistically significant increase in the percentage of mastoiditis admissions to teaching hospitals for all admissions (OR 1.55 [CI 1.22-1.97], p < 0.001) and even more evident for cases with associated complications (OR 1.85 [CI 1.21-2.83], p = 0.004). CONCLUSIONS AND RELEVANCE: A sizeable percentage of patients with acute mastoiditis present with complications which may require surgical intervention. From 2002 to 2014, inpatient care of acute mastoiditis became increasingly regionalized to teaching hospitals, suggestive of increased specialization within certain facilities. This trend may have significant impacts on the cost and subsequent quality of care provided to these patients.

Exploring maternal and health professional beliefs about the factors that affect whether women in Saudi Arabia attend antenatal care clinic appointments.

OBJECTIVE: Effective antenatal care is important for the health and wellbeing of pregnant women and infants. However, in Saudi Arabia, attendance rates are low, increasing the risk of negative birth outcomes. The aim of this research is to understand the beliefs of pregnant women and health professionals about the factors leading to these low attendance rates. METHODOLOGY: A qualitative exploratory study-using semi structured face-to-face interviews. Interviews were conducted exploring (a) attitudes to the use of antenatal care by pregnant Saudi women, (b) beliefs of women regarding the value of antenatal care and (c) perceived barriers to attendance. SETTING: Data were collected from three hospitals in two regions of Saudi Arabia. PARTICIPANTS: Women at any stage of their pregnancy attending for antenatal care or ultrasound, women attending postnatal clinic, and health professionals (obstetricians) who support women during pregnancy and birth. FINDINGS: Although mothers viewed antenatal care as important for maternal and infant health, several barriers to attending care were identified by mothers and professionals. These factors were classified into three themes: physical barriers (e.g., lack of transport), low maternal education, and inadequate healthcare facilities (including negative staff attitudes and poor communication). These factors were exacerbated by the beliefs of partners and family. Notably, the theme of low maternal education was raised only by health professionals, whilst the theme of staff attitudes and communication was raised only by mothers. KEY CONCLUSIONS: Barriers to antenatal care exist at the personal, social, socioeconomic and health services level. Some health professionals may be unaware of the importance of their communication style. Interventions to improve attendance must be multifaceted rather than focussing on individual women alone. IMPLICATIONS FOR PRACTICE: Barriers for women attending antenatal healthcare must be addressed in order to increase attendance rates. Specific practice-based interventions may involve changing the time or location of services and exploring changes to staff communication with women.

Positive surgical margins in parotid malignancies: Institutional variation and survival association.

OBJECTIVES/HYPOTHESIS: To establish benchmarks for positive margin incidence in parotid cancers, associate positive margin status with patient, tumor, and institutional factors and overall survival, and characterize institutional variation in positive margin incidence. STUDY DESIGN: Retrospective database analysis. METHODS: We identified patients surgically treated for a parotid malignancy 2004 to 2013 in the National Cancer Database. We associated positive margins with patient, tumor, and treatment factors by multivariable logistic regression and with overall survival by Cox proportional hazards regression. We characterized institutional variation in positive margin rates by facility type and volume. RESULTS: A total of 5,639 patients were identified. The overall positive margin rate was 31%. By institution, positive margin rates varied from 0% to 100%, with a median rate of 31% (interquartile range = 18%-43%). Adenoid cystic carcinoma was associated with increased, and low-grade mucoepidermoid carcinoma with decreased, odds of positive margins, (odds ratio [OR] = 1.91 [95% confidence interval {CI}: 1.54-2.38], P < .001 and OR = 0.68 [95% CI: 0.53-0.87], P = .002, respectively). Treatment at academic or high-volume facilities was associated with decreased odds of positive margins (OR = 0.79 [95% CI: 0.68-0.91], P = .001 and OR = 0.76 [95% CI: 0.63-0.91], P = .004). Positive surgical margins were associated with decreased overall survival (62% vs. 79% 5-year overall survival, hazard ratio [HR] = 1.34 [95% CI: 1.20-1.49], P < .001). Upon stratification by histology, this association was maintained for high-grade, but not low-grade, mucoepidermoid carcinoma (52% vs. 74%, HR = 1.56 [95% CI: 1.31-1.86], P < .001 and 89% versus 91%, HR = 1.05 [95% CI: 0.60-1.83], P = .874, respectively). CONCLUSIONS: Tumor and institutional factors are associated with positive surgical margins. Positive margin rates vary substantially between facilities and are less likely at academic and high-volume facilities. Positive surgical margins are associated with decreased overall survival and could be considered quality indicators in parotid malignancies. LEVEL OF EVIDENCE: 2c Laryngoscope, 129:129-137, 2019.

Industry Payments to Physicians and Prescriptions of Brand-Name Proton-Pump Inhibitors.

OBJECTIVE: To characterize the association between industry payments and prescriptions of 2 brand-name proton-pump inhibitors (PPIs). STUDY DESIGN: Cross-sectional retrospective. SETTING: Physicians nationwide. SUBJECTS AND METHODS: We identified all physicians receiving industry payments for Dexilant and Nexium 2014-2015 from the Open Payments database. We linked this to records of prescriptions for PPIs paid for by Medicare Part D these same years and compared the proportion of prescriptions written for Dexilant and Nexium in industry-compensated vs nonindustry compensated physicians. The number and dollar amount of payments were associated with the rate of drug prescriptions. RESULTS: We identified 254,452 physicians prescribing PPIs; 8586 and 2766 physicians received industry payments for Dexilant and Nexium, respectively. A total of 5052 of 7876 (64%) physicians compensated for Dexilant prescribed Dexilant vs 39,778 of 246,571 (16%) noncompensated physicians ( P < .001). For Nexium, 2525 of 2654 (95%) compensated physicians prescribed Nexium, compared to 123,913 of 252,067 (49%) noncompensated physicians. For both Dexilant and Nexium, there was a significant correlation between the number (ρ = 0.22, P < .001 and ρ = 0.12, P < .001) and dollar amount (ρ = 0.22, P < .001 and ρ = 0.13, P < .001) of payments and the percentage of prescriptions written for the compensated drug. Industry payments for Nexium remained associated with rate of prescription even after generic esomeprazole became available. CONCLUSION: Both the number and dollar amount of industry payments were associated with increased prescriptions for both Dexilant and Nexium. Although unable to show causality, this study suggests that industry payments may increase physician prescriptions of costly, brand-name drugs.

The Association of Industry Payments to Physicians with Prescription of Brand-Name Intranasal Corticosteroids.

Objectives To examine the association of industry payments for brand-name intranasal corticosteroids with prescribing patterns. Study Design Cross-sectional retrospective analysis. Setting Nationwide. Subjects and Methods We identified physicians prescribing intranasal corticosteroids to Medicare beneficiaries 2014-2015 and physicians receiving payment for the brand-name intranasal corticosteroids Dymista and Nasonex. Prescription and payment data were linked by physician, and we compared the proportion of prescriptions written for brand-name intranasal corticosteroids in industry-compensated vs non-industry-compensated physicians. We associated the number and dollar amount of industry payments with the relative frequency of brand-name prescriptions. Results In total, 164,587 physicians prescribing intranasal corticosteroids were identified, including 7937 (5%) otolaryngologists; 10,800 and 3886 physicians received industry compensation for Dymista and Nasonex, respectively. Physicians receiving industry payment for Dymista prescribed more Dymista as a proportion of total intranasal corticosteroid prescriptions than noncompensated physicians (3.1% [SD = 9.6%] vs 0.2% [SD = 2.5%], respectively, P < .001). Similar trends were seen for Nasonex (12.0% [SD = 16.8%] vs 4.8% [SD = 13.6%], P < .001). The number and dollar amount of payment were significantly correlated to the relative frequency of Dymista (ρ = 0.26, P < .001 and ρ = 0.20, P < .001, respectively) and Nasonex prescriptions (ρ = 0.09, P < .001 and ρ = 0.15, P < .001, respectively). For Dymista, this association was stronger in otolaryngologists than general practitioners ( P < .001). There was a stronger correlation between the percentage of prescriptions and the number and dollar amount of payments for Dymista than for Nasonex ( P = .014 and P < .001). Conclusions Industry compensation for brand-name intranasal corticosteroids is significantly associated with prescribing patterns. The magnitude of association may depend on physician specialty and the drug's time on the market.

Treatment delays in laryngeal squamous cell carcinoma: A national cancer database analysis.

OBJECTIVE: To characterize treatment delays in laryngeal cancer and associate delays with patient, tumor, and treatment factors and with overall survival. METHODS: We identified 33,819 adults with laryngeal squamous cell carcinoma (LSCC) in the National Cancer Database from 2004 to 2013. We calculated durations of diagnosis-to-treatment initiation, surgery-to-adjuvant treatment, radiotherapy duration, total treatment package, and diagnosis-to-treatment end intervals. Delays were associated with patient, tumor, and treatment characteristics via multivariable logistic regression and with overall survival by Cox proportional hazards regression. RESULTS: Median durations of diagnosis-to-treatment initiation, surgery-to-radiation initiation, radiation treatment, total treatment package, and diagnosis-to-treatment end were 28, 42, 48, 91, and 107 days in surgical patients; median durations of diagnosis-to-treatment initiation, radiation treatment, and diagnosis-to-treatment end were 33, 50, and 85 days in nonsurgical patients. Race and insurance status were linked to delays in most intervals. Academic and high-volume facilities had less delayed radiation treatment but increased delays in most other intervals. Delayed surgery-to-radiation and total treatment package intervals were associated with overall survival in surgical patients (hazard ratio [HR] = 1.15 [1.03-1.29], P = 0.015; HR = 1.16 [1.02-1.31], P = 0.025). Diagnosis-to-treatment initiation and diagnosis-to-treatment end intervals were associated with overall survival in nonsurgical patients (HR = 1.08 [1.02-1.14], P = 0.007; HR = 1.09 [1.03-1.16], P = 0.003, respectively) but not in surgical patients (HR = 0.96 [0.87-1.06] P = 0.440; HR = 1.13 [0.99-1.29], P = 0.062). Radiation delays were associated with overall survival in surgical and nonsurgical patients (HR = 1.21 [1.09-1.36], P = 0.001; HR = 1.37 [1.30-1.44], P < 0.001). CONCLUSION: These durations can serve as national benchmarks. Delays could be considered quality indicators in LSCC. LEVEL OF EVIDENCE: 2b Laryngoscope, 128:2751-2758, 2018.