Modern internet search analytics and thyroidectomy: What are patients asking?

Objectives: Thyroidectomy is among the most commonly performed head and neck surgeries, however, limited existing information is available on topics of interest and concern to patients. Study Design: Observational. Setting: Online. Methods: A search engine optimization tool was utilized to extract metadata on Google-suggested questions that "People Also Ask" (PAA) pertaining to "thyroidectomy" and "thyroid surgery." These questions were categorized by Rothwell criteria and topics of interest. The Journal of the American Medical Association (JAMA) benchmark criteria enabled quality assessment. Results: A total of 250 PAA questions were analyzed. Future-oriented PAA questions describing what to expect during and after the surgery on topics such as postoperative management, risks or complications of surgery, and technical details were significantly less popular among the "thyroid surgery" group (P < 0.001, P = 0.005, and P < 0.001, respectively). PAA questions about scarring and hypocalcemia were nearly threefold more popular than those related to pain (335 and 319 vs. 113 combined search engine response page count, respectively). The overall JAMA quality score remained low (2.50 ± 1.07), despite an increasing number of patients searching for "thyroidectomy" (r(77) = 0.30, P = 0.007). Conclusions: Patients searching for the nonspecific term "thyroid surgery" received a curated collection of PAA questions that were significantly less likely to educate them on what to expect during and after surgery, as compared to patients with higher health literacy who search with the term "thyroidectomy." This suggests that the content of PAA questions differs based on the presumed health literacy of the internet user.

Clinical practice guidelines in the management of pediatric foreign body aspiration and ingestion: a systematic evaluation using the AGREE II instrument.

PURPOSE: Several clinical practice guidelines (CPGs) have been produced to optimize the diagnosis and management of pediatric foreign body aspiration and ingestion. However, to date there have been no critical evaluations of their methodological rigor or quality. Herein, we address this need via the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. METHODS: A literature search of Embase, MEDLINE via PubMed, and Scopus was performed up until February 25, 2021. Identified CPGs were then assessed by four independent reviewers trained in AGREE II. A scaled domain score of >60% was indicated as satisfactory quality. Intraclass correlation coefficients (ICC) were calculated to assess inter-reviewer agreement. RESULTS: 11 guidelines were assessed with only one being classified as high quality and others being either average (two) or low quality (eight). Domain 4 (clarity of presentation) achieved the highest mean score (66.41 ± 13.33%), while domain 5 (applicability) achieved the lowest score (10.80 ± 10.37%). ICC analysis revealed generally strong agreement between reviewers with a range of 0.60-0.98. CONCLUSION: Quality appraisal using the AGREE II instrument suggests that the methodologic rigor and quality of current guidelines for the diagnosis and management of pediatric foreign body aspiration and ingestion need significant improvement.

An Update on the Epidemiology and Clinicodemographic Features of Meniere's Disease.

OBJECTIVE: To characterize the estimated prevalence and clinicodemographic features of Ménière's disease (MD) using current diagnostic criteria. METHODS: A cross-sectional study was undertaken at our tertiary academic referral center. All patients seen in Otolaryngology clinic with ICD-10 diagnoses of MD, from January 1, 2013 to July 31, 2022 were identified. Chart review was undertaken to determine the estimated prevalence of MD meeting AAO-HNS diagnostic criteria. Clinicodemographic features were evaluated against a comparator group without MD seen in our health system. RESULTS: Of 806 ICD-10 diagnoses of MD, we identified 480 MD cases meeting diagnostic criteria (168 definite). Mean age at presentation for MD cases was 49 years. Forty-seven percent of cases were male. A significantly higher proportion of MD cases than comparators were white (76% vs. 66%, p < 0.001). Mean time since MD symptom onset was 6.7 years, with a mean attack duration of 4.6 h; 7.5% of MD cases reported a positive family history, and 7% had bilateral disease. The odds of reporting migraine were significantly greater among MD patients than comparators (OR 1.74 [1.26-2.42]); the odds of having autoimmune conditions were lower (OR 0.45 [0.28-0.74]); and the odds of reporting allergies were no different (OR 0.96 [0.74-1.25]) versus comparator patients after controlling for demographic characteristics. CONCLUSIONS: Among MD diagnoses, there is a low estimated prevalence of MD meeting diagnostic criteria, and an even lower prevalence of definite MD. Compared to a comparator group of patients seen for any disorder, patients with MD are more likely to be white, male, and have a history of migraine. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:3310-3315, 2024.

Epidemiology and Management of Adult Laryngeal Trauma: An Analysis of the National Trauma Data Bank.

INTRODUCTION: Laryngeal injuries are rare but life-threatening airway emergencies. Increased understanding of the epidemiology of these injuries can inform treatment and improve outcomes. We aimed to characterize the demographics and management of adult laryngeal trauma. METHODS: The National Trauma Data Bank (NTDB) was queried from 2007 to 2015 for patients ≥18 years old with laryngeal trauma. Patient demographics, injury characteristics, and treatment course were collected. Outcomes were assessed via multivariate logistic regression. RESULTS: From 7.3 million patients, 6,890 (0.1%) patients with laryngeal trauma were identified. Eighty-five percent of patients were male, and the median age was 40. Of these patients, 343 (5.0%) were dead on arrival and of the remaining patients, 510 (7.8%) of patients were deceased at discharge. Common concomitant injuries included facial fractures (27%), intracranial injuries (21%), and rib and sternum fractures (19%). The most common cause of injury was motor vehicle accident (26%), followed by assault with firearms/explosives (12%) and assault with cutting instruments (8%). Forty-three percent of patients received mechanical ventilation and 15% received surgical repair. After correcting for gender, age, and injury severity, firearm injuries (odds ratio [OR] 3.46, 95% CI: [2.88-4.15]) and cutting/piercing injuries (OR 2.23, 95% CI: [1.89-2.64]) were positively associated with the need for mechanical ventilation. Motor vehicle trauma (OR 0.63, 95% CI: [0.46-0.84]) was negatively associated with surgical repair while striking injuries (OR 1.61, 95% CI: [1.25-2.06]) were positively associated. Lastly, shorter time to tracheostomy was significantly associated with shorter ICU stays (p < 0.0001). CONCLUSION: This study is the largest epidemiologic study of laryngeal trauma to date and identifies the risk of surgical intervention with firearm and cutting injuries as well as the importance of earlier time to tracheostomy for ICU management.

Exploring Olfactory Dysfunction as a Marker of Frailty and Postoperative Outcomes in Head and Neck Cancer.

Importance: Olfactory dysfunction (OD) is increasingly recognized as a robust marker of frailty and mortality. Despite broad recognition of frailty as a critical component of head and neck cancer (HNC) care, there is no standardized frailty assessment. Objective: To assess the prevalence of OD and its association with frailty and postoperative outcomes in HNC. Design, Setting, and Participants: In this prospective cohort study with enrollment between February 17, 2021, to September 29, 2021, at a tertiary academic medical center, 85 eligible adult patients with primary, treatment-naive HNC of mucosal or cutaneous origin were included. Patients with a history of COVID-19, neurocognitive, or primary smell/taste disorders were excluded. Exposures: Prospective olfactory assessments (self-reported, visual analog scale [VAS] and psychophysical, University of Pennsylvania Smell Identification Test [UPSIT]) with concurrent frailty assessment (Risk Analysis Index [RAI]) were used. Olfactory-specific quality of life (QOL) was examined with brief Questionnaire of Olfactory Disorders-Negative Statements (QOD-NS). Main Outcome(s) and Measure(s): The primary outcome was the prevalence of OD as assessed by VAS (0-10, no to normal smell) and UPSIT (0-40, higher scores reflect better olfaction) and its association with frailty (RAI, 0-81, higher scores indicate greater frailty). For surgical patients, secondary outcomes were associations between OD and postoperative length of stay (LOS), 30-day postoperative outcomes, and QOD-NS (0-21, higher scores indicate worse QOL). Results: Among 51 patients with HNC (mean [SD] age, 63 [10] years; 39 [77%] male participants; 41 [80%] White participants), 24 (47%) were frail, and 4 (8%) were very frail. Despite median (IQR) self-reported olfaction by VAS of 9 (8-10), 30 (59%) patients demonstrated measured OD with psychophysical testing. No meaningful association was found between self-reported and psychophysical testing (Hodges-Lehmann, <0.001; 95% CI, -2 to 1); a total of 46 (90%) patients did not report decreased olfaction-specific QOL. Median UPSIT scores were lower in frail patients (Hodges-Lehmann, 6; 95% CI, 2-12). Multivariate modeling demonstrated severe microsmia/anosmia was associated with 1.75 (95% CI, 1.09-2.80) times odds of being frail/very frail and approximately 3 days increased LOS (ß, 2.96; 95% CI, 0.29-5.62). Conclusions and Relevance: Although patients with HNC are unaware of olfactory changes, OD is common and may serve as a bellwether of frailty. In this prospective cohort study, a dose-dependent association was demonstrated between increasing degrees of OD and frailty, and the potential utility of olfaction was highlighted as a touchstone in the assessment of HNC frailty.

Changes in otolaryngology application requirements and match outcomes: Are we doing any better?

Objectives: Otolaryngology-specific requirements were piloted to minimize applicant and program burdens. We investigated the impact of introducing and then removing these requirements on Match outcomes. Methods: 2014-2021 National Resident Matching Program® data were examined. The primary outcome was the impact of Otolaryngology Resident Talent Assessment (ORTA; prematch 2017, postmatch 2019) and Program-Specific Paragraph (PSP; implemented 2016, optional 2018) on applicant numbers and match rates. Secondary survey analysis assessed candidate perceptions of PSP/ORTA. Results: Applicant numbers declined significantly during PSP/ORTA (18.9%; p = 0.001). With the optional PSP and postmatch ORTA, applicant numbers increased significantly (39.0%; p = 0.002). Examined individually, mandatory PSP was associated with a significant decline in applicants (p = 0.007), whereas postmatch ORTA was associated with significant increases in applicants (p = 0.010). ORTA and PSP negatively impacted the decision to apply to otolaryngology in 59.8% and 51.3% of applicants, respectively. Conversely, match rate success improved significantly from 74.8% to 91.2% during PSP/ORTA (p = 0.014), followed by a significant decline to 73.1% after PSP was made optional and ORTA moved to postmatch (p = 0.002). Conclusions: ORTA and PSP correlated with decreased applicant numbers and increased match rate success. As programs seek ways to remove barriers to applying to otolaryngology, the potential consequences of an increasing pool of unmatched candidates must also be considered.

A comprehensive review and characterization of nasopharyngeal carcinoma clinical trials.

Objective: Although standard of care for primary nasopharyngeal carcinoma (NPC) is chemoradiotherapy, there remains no consensus on management of recurrent or metastatic disease. We characterized recent clinical trials on NPC to assess trends in NPC treatment and establish promising areas for future research. Study Design: Retrospective database study. Setting: ClinicalTrials.gov database. Methods: Retrospective review of all NPC trials from November 1999 to June 2021. For each study, the following variables were extracted: study characteristics, intervention, outcome measures, and inclusion criteria. Secondary searches via PubMed and Google scholar determined trial publication status. Results: A total of 448 clinical trials were identified: 72 (16%) observational and 376 (84%) interventional, of which there were 30 (8%) Phase I, 183 (49%) Phase II, 86 Phase III (23%), and 5 (1%) Phase IV trials. Fifty-four percent of trials included only primary NPC while 111 (25%) exclusively studied recurrent cancers. The most common interventions were cisplatin (n = 64) and intensity modulated radiation therapy (n = 54); there were 38 trials involving PD-1 monoclonal antibodies. Thirty-four studies examined quality of life measures, including xerostomia and mucositis. Of the completed studies, 53.2% have published manuscripts. Poor patient accrual was the most common reason for premature study termination. Conclusions: Novel immunotherapies have been increasingly incorporated into NPC studies in recent years, however, chemotherapy and radiation, despite their numerous side effects, are still widely used due to their clinical effectiveness. Future trials are warranted to determine the optimal therapeutic regimens to decrease relapse rates and side effects.

Gender Differences Among Head and Neck Microvascular Reconstructive Surgeons.

OBJECTIVE: To determine whether gender differences exist in the training history, practice patterns, and home lives of surgeons who perform microvascular reconstruction of the head and neck. STUDY DESIGN: Cross-sectional survey. SETTING: Medical facilities that employ surgeons who practice head and neck microvascular reconstruction in the United States. METHODS: A survey was created using the Research Electronic Data Capture Framework and was distributed via email to microvascular reconstructive surgeons. Descriptive statistics were performed using Stata software. RESULTS: No significant differences were found in training or current practice patterns between microvascular surgeons who identify as men versus those who identify as women. Women had fewer children (p = .020) and were more likely to be childless (p = .002). Whereas men were more likely to report a spouse/partner as primary caretaker, women were more likely to hire a professional caretaker or cite themselves as a primary caretaker (p < .001). Women were more likely to have finished residency (p = .015) and fellowship (p = .014) more recently and to practice in the Southeast (p = .006). Of the microvascular surgeons who reported practice setting switches, men more commonly changed positions for career advancement, whereas women were more likely to switch due to burnout (p = .002). CONCLUSION: This study found no gender-based differences in training or practice patterns. However, significant differences were identified in childbearing, family structure, geographic practice location, and motives for switching practice.

Meningitis Risk and Role of Prophylactic Antibiotics in Spontaneous Lateral Skull Base CSF Leaks.

OBJECTIVE: To review the literature and our institutional experience regarding the risk of meningitis in patients with spontaneous lateral skull base cerebrospinal fluid (sCSF) leaks awaiting surgical repair, and the roles of antibiotic prophylaxis and pneumococcal vaccination, if known. METHODS: A retrospective chart review and systematic review of the literature was undertaken to identify the incidence of meningitis in patients with sCSF leaks awaiting surgical repair. Adults managed surgically for sCSF leaks at an academic tertiary care center over a 10-year period were included. Data was collected on receipt of prophylactic antibiotics and/or pneumococcal vaccines during the timeframe between diagnosis and surgical repair. RESULTS: Institutional review identified 87 patients who underwent surgical repair of spontaneous leaks, with a 0% incidence of meningitis over a median duration of 2 months while awaiting surgery (mean 5.5 months, range 0.5-118 months). Eighty-eight percent of patients did not receive prophylactic antibiotics. No studies in the published literature demonstrated the impact of prophylactic antibiotics or pneumococcal vaccine on meningitis risk. CONCLUSIONS: There appears to be a low risk of meningitis among patients with lateral skull base sCSF leaks awaiting surgery for short durations (≤2 months), even in the absence of prophylactic antibiotics. There is a substantial gap in the published literature assessing the risk of meningitis and roles of antibiotics and vaccination in this patient population, indicating the need for large-scale study to conclusively elucidate the nature of this risk.

Feasibility and Cost of Telehealth Head and Neck Cancer Survivorship Care: A Systematic Review.

OBJECTIVE: Evaluate the feasibility and cost-effectiveness of telehealth head and neck cancer (HNC) survivorship care. DATA SOURCES: Ovid MEDLINE, Embase, Scopus, CINAHL. REVIEW METHODS: A systematic search for peer-reviewed feasibility studies on telehealth models for HNC survivorship care published between 2005 and 2021 was conducted using the terms "head and neck cancer" and "telehealth" and their synonyms. Inclusion criteria were studies on telehealth survivorship program interventions for HNC patients with quantitative feasibility outcome measures (eg, enrollment, retention, attrition/dropout rate, adherence/task completion rate, patient satisfaction, cost). RESULTS: Thirty-eight studies out of 1557 identified met inclusion criteria and were included for analysis. Feasibility outcomes evaluated were enrollment and attrition rates, adherence/task completion rates, patient satisfaction, and user feedback surveys in different survivorship domains. Patient enrollment ranged from 20.8% to 85.7%, while attrition ranged from 7% to 47.7%. Overall, adherence was 30.2% higher in the intervention group than in the control group (46.8% vs 16.6%). Studies with cost analysis found telehealth models of care to be statistically significantly less expensive and more cost-efficient than the standard model of care, with a $642.30 saving per patient (n = 3). Telehealth models also substantially reduced work time saving per visit (on average, 7 days per visit). CONCLUSION: While telehealth survivorship programs are feasible and cost-effective and are associated with improved patient outcomes, they might not be ideal for every patient. Further investigations are needed to understand the role of telehealth in survivorship care, given the variability in study design, reporting, measures, and methodological quality.

Evaluating the Efficacy of Topical Intranasal Fluorescein for Localizing CSF Rhinorrhea: A Systematic Review.

OBJECTIVE: To assess existing literature on topical intranasal fluorescein (TINF) for the diagnosis and localization of nasal cerebrospinal fluid (CSF). STUDY DESIGN: Systematic review. METHODS: A 6-database literature search was conducted to identify articles providing insight into TINF for the diagnosis and treatment of sinonasal CSF leak. Demographic characteristics, technical details, efficacy, and safety data were extracted and analyzed. Methodological quality was assessed using Methodological Items for Non-Randomized Studies (MINORS) criteria. RESULTS: All studies reported a diagnostic accuracy rate ≥96%. There were no major complications reported for any patient (n=99) with either 5% or 10% fluorescein use. The MINORS instrument of methodological quality indicated that the assessed studies were of moderate quality (7.29 out of a maximum score of 24). CONCLUSION: This systematic review indicates that TINF is an easy, safe, inexpensive, and sensitive approach for the diagnosis and treatment of sinonasal CSF leakage. For these reasons, it may be especially well suited for resource-limited clinical scenarios.

Epidemiology of Anterior and Lateral Basilar Skull Fractures With CSF Leak: A National Trauma Data Bank Analysis.

OBJECTIVE: Cerebrospinal fluid (CSF) leaks are a complication from dural violations that can occur in the setting of skull base fractures. No prior study provides a nationwide epidemiological analysis of traumatic CSF leaks. The objective of this report is to characterize patient demographics, injury-related variables, and operative management. METHODS: The national trauma data bank was queried for both anterior and lateral skull base fracture cases between 2008 and 2016. Clinical data were extracted. RESULTS: A total of 242 skull base fractures with CSF leak were identified. Most patients were male (84.3%), and the median patient age was 39.7±17.6 years old. Glasgow Coma Scale was 14.0 [interquartile range (IQR): 6.5-10.6] for lateral fractures, 13.0 (IQR: 3.0-10.0) for anterior fractures, and severe range for combined fractures at 7.0 (IQR: 5.0-9.0) (analysis of variance, P =0.122). Common mechanisms of injury were motor vehicle accidents (107, 44.2%), followed by falls and firearms (65, 26.9% and 20, 8.3%, respectively). The median length of stay was 2 weeks, with a median of 14 days (IQR: 10-25) for the anterior fractures and 10 days (IQR 5-19) among the lateral fractures ( P =0.592). Patients were most commonly discharged home in both the anterior (43.8%) and lateral (49.2%) groups. CONCLUSIONS: The prototypical patient tends to be a young adult male presenting with moderate-to-severe range neurological dysfunction after a vehicular accident. The overall prognosis of skull base fractures with CSF leak remains encouraging, with nearly half of these patients being discharged home within 2 weeks.

Association of Head and Neck Anatomic Zones with Microvascular Reconstruction Outcomes.

Background: Head and neck free flap survival relies on adequate tissue perfusion from the external carotid artery (ECA), and vessel length is inversely proportional to blood flow rate. Objective: Investigate whether distance from the ECA (as a proxy for pedicle vessel length) predicts flap survival or complications. Methods: Retrospective review of free flaps performed at three academic centers from 9/2006 to 8/2021. Flaps were categorized by distance from the ECA: orbit and above (zone 1), maxilla to parotid (zone 2), and mandible and below (zone 3). Secondary analysis assessed flap outcomes stratified by average historical pedicle length. Results: A total of 2,369 flaps were identified in zones 1 (n = 109), 2 (n = 1878), and 3 (n = 382). Rates of flap failure (4.9%) and perioperative complications (36.3%) did not differ by zone or pedicle length. Zone 3 flaps, most commonly located in the larynx and hypopharynx, had significantly higher rates of fistula and infection. Conversely, 30-day readmission rates were significantly lower in patients with zone 2 flaps (p < 0.001). Rates of all other complications did not differ significantly between zones. Conclusions: Proximity to mucosal anatomic sites was a more powerful predictor of free flap viability than pedicle length or ECA proximity.

Medical malpractice in robotic surgery: a Westlaw database analysis.

Malpractice claims involving robot-assisted surgical procedures have increased more than 250% in the past 7 years compared to the seven years prior. We examined robotic surgery malpractice claims to identify trends in claimed liabilities, describe legal outcomes, and determine strategies to minimize future litigation. The Westlaw legal database was queried retrospectively for U.S. state and federal trials regarding robot-assisted surgical procedures from 2006 to 2013 and 2014 to 2021. Data abstracted from verdict reports included year, state, court type, defendant specialty, procedure performed, claimed injuries and liabilities, verdict, and damage amount awarded. Sixty-one cases across 25 states were identified, 16 cases between 2006 and 2013, and 45 from 2014 to 2021. Among those 45 cases, defendant verdicts predominated (n = 35, 77.8%), with only four plaintiff verdicts (8.9%) and six settlements (13.3%). Overall, 169 liabilities were claimed, most commonly negligent surgery (82.2%), misdiagnosis/failure to diagnose (46.7%), delayed treatment (35.6%), and lack of informed consent (31.1%). Thirteen cases resulted in indemnity payments (mean = $1,251,274), with damages ranging from $10,087 (infection and retained foreign body) to $5,008,922 (patient death). Hysterectomy (n = 19, 42.2%) was the most commonly litigated surgery, followed by prostatectomy (n = 5) and hernia repair (n = 4). The most litigated specialties were obstetrics/gynecology (48.9%), general surgery (28.9%), and urology (15.6%). Malpractice litigation in robot-assisted surgery is infrequent. As robotic procedures become more commonplace, surgeons must keep common liabilities in mind, as there are valuable and actionable lessons to be learned from these cases. Malpractice reform, continuing medical education activities, and improved informed consent protocols may help minimize future litigation.

Post-operative Monitoring for Head and Neck Microvascular Reconstruction in the Era of Resident Duty Hour Restrictions: A Retrospective Cohort Study Comparing 2 Monitoring Protocols.

OBJECTIVES: To determine whether 2 different methods of post-operative head and neck free flap monitoring affect flap failure and complication rates. METHODS: A retrospective chart review of 803 free flaps performed for head and neck reconstruction by the same microvascular surgeon between July 2013 and July 2020 at 2 separate hospitals within the same healthcare system. Four-hundred ten free flaps (51%) were performed at Hospital A, a medical center where flap checks were performed at frequent, scheduled intervals by in-house resident physicians and nurses; 393 free flaps (49%) were performed at Hospital B, a medical center where flap checks were performed regularly by nursing staff with resident physician evaluation as needed. Total free flap failure, partial free flap failure, and complications (consisting of wound infection, fistula, and reoperation within 1 month) were assessed. RESULTS: There were no significant differences between Hospitals A and B when comparing rates of total free flap failure, partial free flap failure, complication, or re-operation (P = .27, P = .66, P = .65, P = .29, respectively). There were no significant differences in urgent re-operation rates for flap compromise secondary to thrombosis and hematoma (P = .54). CONCLUSIONS: In our series, free flap outcomes did not vary based on the degree of flap monitoring by resident physicians. This data supports the ability of a high-volume, well-trained, nursing-led flap monitoring program to detect flap compromise in an efficient fashion while limiting resident physician obligations in the age of resident duty hour restrictions.

Effect of ibuprofen on severity of surgically-managed pediatric post-tonsillectomy hemorrhage.

OBJECTIVES: The association between ibuprofen use and severity of post-tonsillectomy hemorrhage (PTH) remains unclear. We aimed to compare PTH severity in patients who did or did not receive ibuprofen. METHODS: A retrospective cohort study of pediatric patients requiring operative control of PTH at a tertiary children's hospital between 2015 and 2019 was performed. PTH severity was assessed using pre-tonsillectomy and post-hemorrhage hemoglobin and hematocrit values, estimated intraoperative blood loss, estimated hemorrhage flow rate, and need for transfusion. Differences in hemorrhage severity markers between the two cohorts were compared. RESULTS: A total of 168 consecutive patients were included in this study. The mean age was 8.8 years, and 55.4% of patients were male. Sixty-five patients (38.7%) received ibuprofen postoperatively. There was no statistically significant difference in the mean change in hemoglobin (1.1 vs. 1.1, P = 0.85) or hematocrit (3.1 vs. 3.2, P = 0.97) between patients who received ibuprofen compared to those who did not. Similarly, there were no significant differences in need for transfusion (3.1% vs. 3.9%, P = 1.00) or occurrence of high-flow (arterial) blood loss (33.8% vs. 40.8%, P = 0.42) between the two groups. CONCLUSION: Postoperative ibuprofen use does not appear to significantly increase PTH severity, as measured by change in hemoglobin and hematocrit values, need for transfusion, or presence of high-flow blood loss. This study introduces previously unexplored markers to assess PTH severity and supports further prospective studies to determine the effect of ibuprofen on PTH severity.

Clinical practice guidelines for the management of recurrent head and neck cancer: a systematic review and quality appraisal.

PURPOSE: Recurrent head and neck cancer (HNC) has a significant global disease burden and its treatment is complex. Multiple clinical practice guidelines (CPGs) have been developed to improve management of these patient populations; however, no study has systematically reviewed the quality and rigor in development of these guidelines. Here, we identify and systematically appraise existing recommendations for the management of recurrent HNC and assess their clinical applicability, methodologic rigor, and transparency of development. METHODS: A systematic search of the PubMed, Embase, and Scopus databases was conducted for recurrent HNC CPGs. Each guideline was scored independently by four reviewers trained in the Appraisal of Guidelines for Research and Evaluation, 2nd edition (AGREE II) methodology. Salient recommendations from the selected guidelines were summarized. RESULTS: Our literature search yielded 1799 articles; after iterative title/abstract and full text screening, five remaining guidelines met inclusion criteria. CPGs received the lowest scores in 'Applicability' and 'Rigor of development,' with scores of 12.9% and 22.3%, respectively. Overall quality of available guidelines for management of recurrent HNC is poor, with an average overall scaled domain score of 40.9% (± 11.0), and with four guidelines (80.0%) receiving an overall quality rating of 'low'. CONCLUSION: We found significant variability in quality and overall lack of methodologic rigor among available guidelines for the management of recurrent HNC. Future groups developing recommendations for this purpose should implement the AGREE II framework to improve quality and standardization of their guidelines.

Assessment of clinical guidelines for medication-related osteonecrosis of the jaw: current status and future directions.

OBJECTIVE: To evaluate the current quality and utility of clinical practice guidelines (CPGs) issued for the diagnosis, prevention, and treatment of medication-related osteonecrosis of the jaw (MRONJ). STUDY DESIGN: We performed a systematic literature search of guidelines for MRONJ diagnosis, staging, prevention, or management. An appraisal of guidelines was completed using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. Scaled domain scores were calculated for each domain. Key recommendations were abstracted from guidelines distinguished as "high" quality. RESULTS: Six CPGs were identified from systematic review. Four of 6 (66.7%) guidelines were published within the last 2 years. Each guideline discussed management of antiresorptive and antiangiogenic therapy-associated osteonecrosis of the jaw. The highest-scoring domain was domain 1: "Scope and purpose," with an average score of 85.0% (range: 76.4%-100.0%). The lowest domain score was in domain 5: "Applicability," with an average score of 41.7% (range: 22.9%-92.7%). Only 2 guidelines (33.3%) met the quality threshold of > 60% in 5 or more AGREE II domains, distinguishing them as "high"-quality guidelines. The average kappa statistic calculated across domains was 0.77, suggesting substantial interrater correlation in the CPG appraisal process. CONCLUSIONS: Despite the increasing recognition of MRONJ as a debilitating consequence of antiresorptive and antiangiogenic therapy, clinical guideline recommendations may be lacking in overall quality and clinical utility.

Clinical Practice Guidelines on Sentinel Lymph Node Biopsy for Melanoma: A Systematic Review and Quality Appraisal Using the AGREE II Instrument.

Sentinel lymph node biopsy (SLNB) is a minimally invasive surgical procedure that is standard of care for the evaluation of clinically negative regional lymph nodes in patients with cutaneous melanoma. As the presence of metastases dictates patient prognosis and determines the need for further regional disease control or adjuvant therapy, SLNB is invaluable to clinical decision-making in patients presenting with melanoma. However, the indications for SLNB, specifically among patients with thin (<1 mm) or thick (>4 mm) melanomas, remain unclear. A number of clinical practice guidelines (CPGs) have been developed outlining recommendations for the role of lymph node biopsy in the management of melanoma. However, to date, their quality has not been critically appraised. Our objective was to systematically evaluate all available CPGs on this topic using the validated Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. Four total guidelines met the inclusion criteria and underwent appraisal. Only one CPG achieved a "high" quality rating, indicating scores of >60% in at least five of the six AGREE II domains. Across all CPGs, the lowest scoring domains were "Applicability" and "Stakeholder involvement," which had average scores of 41.2% and 48.3%, respectively. Based on the AGREE II instrument, the quality of existing CPGs for the indications of SLNB for melanoma is low. Future guidelines should be pilot tested to evaluate barriers to application and should utilize multidisciplinary guideline development teams that include patients and key stakeholders in addition to clinical experts from all relevant disciplines.

Clinical practice guidelines for management of medullary thyroid carcinoma: An AGREE II appraisal.

PURPOSE: Medullary thyroid carcinoma (MTC) is a rare and aggressive form of thyroid neoplasia that requires multidisciplinary collaboration for effective management. We systematically appraise the quality of clinical practice guidelines (CPG) for the diagnosis and treatment of MTC using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. MATERIALS AND METHODS: A systematic literature search was performed to identify CPGs pertaining to the diagnosis and treatment of MTC. Data were abstracted from guidelines meeting inclusion criteria and appraised by four independent reviewers in the six domains of quality defined by the AGREE II. Intraclass correlation coefficients (ICC) were calculated across domains to qualify interrater reliability. RESULTS: Fourteen guidelines met inclusion criteria. No guideline achieved a score of >60 % in five or more AGREE II quality domains, which is required to gain designation as 'high' quality. One "average quality" guideline authored by the British Thyroid Association achieved a score of >60 % in three quality domains. The remaining thirteen (92.9 %) CPGs demonstrated low quality content, with deficits most pronounced in domains 3, 5, and 6, suggesting a lack of rigorously developed, clinically applicable, and transparent information. CONCLUSIONS: As the diagnosis and treatment of MTC continues to evolve, the development of high-quality guidelines becomes increasingly important; few existing meet appropriate standards.