Opioid versus non-opioid postoperative pain management in otolaryngology.

BACKGROUND: The opioid epidemic in the United States has had devastating consequences, with many opioid-related deaths and a significant economic toll. Opioids have a significant role in postoperative pain management. Here we aim to analyze differences in postoperative opioid and non-opioid pain medications regimens following common otolaryngological surgeries between two large tertiary care medical centers: the Milton S. Hershey Medical Center, USA (HMC) and The Chaim Sheba Medical center, Israel (SMC). METHODS: A retrospective chart review of patients undergoing common otolaryngological procedures during the years 2017-2019 was conducted at two tertiary care centers, one in the U.S. and the other in Israel. Types and doses of postoperative pain medications ordered and administered during admission were analyzed. Average doses ordered and administered in 24 h were calculated. Opioid medications were converted to a standardized unit of morphine milliequivalents (MME). Chi-square test and Wilcoxon rank-sum test were used to compare the groups. RESULTS: The study included 204 patients (103 U.S., 101 Israel). Patient demographics were similar except for a longer length of stay in Israel (p < 0.01). In the U.S., 95% of patients were ordered opioids compared to 70% in Israel (P < 0.01). In the U.S., 68.9% of patients ordered opioids received the medications compared to 29.7% in Israel. The median opioid dose ordered in the U.S. was 45MME/24 h compared to 30MME/24 h in Israel (P < 0.01), while median dose received in the U.S. was 15MME/24 h compared to 3.8MME/24 h in Israel (P < 0.01). Opioid prescriptions at discharge were given to 92% of patients in the U.S. compared to 4% of patients in Israel (p < 0.01). A significantly higher number of patients in the U.S. were prescribed acetaminophen and ibuprofen (p < 0.0001). Dipyrone was prescribed to 78% of patients in Israel. CONCLUSIONS: HMC demonstrated a significantly more permissive approach to both prescribing and consuming opioid medications for postoperative pain management than SMC for similar, common otolaryngological surgeries. Non-opioid alternatives and examining the cultural and medical practice-based differences contributing to the opioid epidemic should be discussed and reevaluated.

Preoperative Anxiety Levels and Postoperative Middle Ear Surgery Pain Levels.

OBJECTIVE: This study aimed to characterize self-reported postoperative pain after tympanoplasty and tympanomastoidectomy and correlate pain severity with the patient's preoperative anxiety state. STUDY DESIGN: Prospective cohort study. SETTING: Tertiary referral medical center. PATIENTS: Adult patients undergoing any middle ear surgery between July 2018 and July 2019. MAIN OUTCOME MEASURES: Patient responses to an otology questionnaire (OQ) for scoring pain intensity on a visual analog scale preoperatively and on postoperative days (PODs) 1-4, 21, and 63. The responses were correlated with anxiety state (assessed by State-Trait Personality Inventory [STPI] scores) and clinical and operative data, including surgical technique-related details. RESULTS: Sixty patients were enrolled (mean age ± standard deviation, 40 ± 19.7 yr, 26 men). Their median preoperative (baseline) visual analog scale pain score was 6 on POD1, 5 on POD3, and 1 at 3 and 7 weeks. Their median preoperative OQ score was 32 of 70 (45.7%), 37 of 70 (52.8%) on POD1, 33 of 70 (47.1%) on POD3, 6 of 70 (8.5%) at 3 weeks, and 6 of 70 at 7 weeks. Their overall mean preoperative anxiety level (STPI score) was 2.63 ± 1.50. STPI scores were significantly higher among patients who reported OQ scores equal to or higher than the median during PODs 1 to 4 in comparison to patients who reported OQ scores lower than the median. The α Cronbach correlation between anxiety and postoperative pain scores on POD1 was 0.97. CONCLUSION: Preoperative anxiety levels are closely associated with postoperative pain levels after any middle ear surgery. Measures to control preoperative anxiety are warranted to alleviate postoperative pain.

Comparison of clinical note quality between an automated digital intake tool and the standard note in the emergency department.

BACKGROUND: Medical encounters require an efficient and focused history of present illness (HPI) to create differential diagnoses and guide diagnostic testing and treatment. Our aim was to compare the HPI of notes created by an automated digital intake tool versus standard medical notes created by clinicians. METHODS: Prospective trial in a quaternary academic Emergency Department (ED). Notes were compared using the 5-point Physician Documentation Quality Instrument (PDQI-9) scale and the Centers for Medicare & Medicaid Services (CMS) level of complexity index. Reviewers were board certified emergency medicine physicians blinded to note origin. Reviewers received training and calibration prior to note assessments. A difference of 1 point was considered clinically significant. Analysis included McNemar's (binary), Wilcoxon-rank (Likert), and agreement with Cohen's Kappa. RESULTS: A total of 148 ED medical encounters were charted by both digital note and standard clinical note. The ability to capture patient information was assessed through comparison of note content across paired charts (digital-standard note on the same patient), as well as scores given by the reviewers. Reviewer agreement was kappa 0.56 (CI 0.49-0.64), indicating moderate level of agreement between reviewers scoring the same patient chart. Considering all 18 questions across PDQI-9 and CMS scales, the average agreement between standard clinical note and digital note was 54.3% (IQR 44.4-66.7%). There was a moderate level of agreement between content of standard and digital notes (kappa 0.54, 95%CI 0.49-0.60). The quality of the digital note was within the 1 point clinically significant difference for all of the attributes, except for conciseness. Digital notes had a higher frequency of CMS severity elements identified. CONCLUSION: Digitally generated clinical notes had moderate agreement compared to standard clinical notes and within the one point clinically significant difference except for the conciseness attribute. Digital notes more reliably documented billing components of severity. The use of automated notes should be further explored to evaluate its utility in facilitating documentation of patient encounters.

Pediatric Burns Unique Characteristics Among Ultra-Orthodox Jewish Minority-Retrospective Study.

Burn injuries are a significant cause of morbidity among children. Ultra-Orthodox Jewish children are at higher risk for burn injuries. The goal of this study was to examine the clinical characteristics of moderate to severe burns in this population in comparison to the general population in Israel. This retrospective cohort study included all pediatric patients 0 to 18 years of age admitted with burn injuries from January 1, 2015 through December 31, 2018. Data were collected regarding demography, etiology, and clinical characteristics. Of 778 burns injuries presented to our tertiary center, 385 (49.5%) were hospitalized. Of those 212 (55%) were non-ultra-Orthodox Jews, 135 (35%) were ultra-Orthodox Jews, and 38 (10%) were non-Jewish patients. The total body surface area percentage (TBSA%) of scald-type burns was larger in ultra-Orthodox compared to non-ultra-Orthodox children (median TBSA% of 7% vs 5%, respectively, P < .05). Among the ultra-Orthodox group, the median TBSA% during weekdays was 6%, and for weekends, the TBSA% was 7.5% (P < .05). Females demonstrated the greatest diversity between subgroups. On weekends, ultra-Orthodox female's median TBSA% was 10%, and non-ultra-Orthodox female's TBSA% was 4.5% (P < .05). Ultra-Orthodox children and especially girls had a significantly higher median TBSA% than non-ultra-Orthodox children for burns occurring during weekends. This may be the result of the unique cultural norms of the ultra-Orthodox Jewish community, in particular, their lifestyle and observation of the Sabbath. These findings provide a focus for better intervention and prevention of pediatric burns among this unique population.

Trends in Psychiatric Emergency Department Visits in Northern Israel During the COVID-19 Outbreak.

Background: During the spread of coronavirus disease (COVID-19), mandatory quarantines increased social isolation and anxiety, with inevitable consequences on mental health and health seeking behavior. We wished to estimate those trends. Methods: We examined all psychiatric visits to the emergency department (ED) during March, April 2020, compared to identical months in 2018, 2019. We evaluated both number and nature of referrals. Results: Throughout the years, psychiatric referrals comprised about 5% of the total number of ED visits. In March-April 2020, 30% decreases were observed in overall ED visits and in psychiatric referrals in the ED. Compared to 2018-2019, in 2020, the proportions of these diagnoses were higher: anxiety disorders (14.5 vs. 5.4%, p < 0.001), personality disorders (6.7 vs. 3.2%, p = 0.001), psychosis (9.5 vs. 6.7%, p = 0.049), post-traumatic stress disorder (3.2 vs. 1.5%, p = 0.023). Compared to 2018-2019, in 2020, proportions were lower for adjustment disorder (5.8 vs. 8.9%, p = 0.036) and for consultation regarding observation (11.7 vs. 31.6%, p < 0.001). Differences were not observed between 2018-2019 and 2020 in the proportions of other diagnoses including suicide and self-harm disorders. Referrals concerning suicide and self-harm in a rural hospital and community clinic were 30% lower in the COVID-19 lockdown than in the same months in 2018, 2019. Conclusion: Psychiatric ED visits decreased by the same proportion as overall visits to the ED, apparently driven by fears of COVID-19. Referrals relating suicidality and self-harm shown nominal decrease, but their proportioned share remained constant. Increased anxiety and delayed care may eventually lead to increased mental health needs.

The Value of Neurological Assessment for Prediction of Subtle Cerebral Infarction.

We examined to what extent clinical assessment alone can predict subtle acute cerebral infarction on magnetic resonance imaging (MRI). Of the 72 patients presented to the emergency department (ED) with transient neurological deficits, 26 (36.1%) were predicted to be "positive" and 46 (63.9%) "negative" for transient ischemic attack/minor stroke by two independent neurologists. Twenty patients (27.8%) had acute restricted diffusion on MRI. Clinical assessment showed substantial agreement with MRI findings (Kappa = 0.75), sensitivity (95.0%), specificity (86.5%), positive-likelihood ratio 7.06, and negative-likelihood ratio 0.06. Neurological assessment has an excellent predicting value for MRI-confirmed acute cerebral infarction and a key role in the facilitation of effective patient care in the ED.

Utilization of health services for skin disorders during military operations. A population- based study.

In addition to the immediate casualties of armed conflicts, their indirect impact may bring even more damage by causing malfunctioning of health systems and impaired access to diagnosis and treatment. We conducted a population-based study, to assess the utilization rates of health services due to skin disorders, among civilians exposed to missile attacks and siren alarms during three military operations in Israel. The study was designed as a natural experiment, whereas periods of military operations were compared to the non-military times. During the military operations, when sirens and missiles were an everyday experience, the number of visits to dermatologists was 1.07-1.16 times lower [Relative Risk (RR)=0.86-0.92] as compared to the non-military periods, especially evident for patients residing closer to the military zone, where it dropped almost 2- folds (RR=0.52). Although perceived nonurgent in their majority, the routine care should not be delayed to prevent more serious skin conditions.

Real-Time Audiovisual Feedback Training Improves Cardiopulmonary Resuscitation Performance: A Controlled Study.

OBJECTIVE: The aim of the study was to quantitatively measure the effect of teaching cardiopulmonary resuscitation (CPR) using a real-time audiovisual feedback manikin system on first-year medical student's CPR performance. METHODS: This is a prospective, manikin-based intervention study, including 2 consecutive classes of medical school students enlisted to a mandatory first aid course. One class (control group) was taught using manikin-based standard CPR education models. The second class (intervention group) was taught similarly, but with the addition of real-time CPR quality feedback provided by the manikins. Students' performance was assessed using a standardized Objective Structured Clinical Examination scenario, during which no real-time feedback was provided. Critical CPR parameters were measured including compression depth, chest recoil, ventilation volume, and "hands-off" time. RESULTS: A total of 201 participants were included in the study, 106 in the control group and 95 in the intervention group. Baseline demographic characteristics and previous medical knowledge were similar for the 2 groups. A significant improvement was observed for all primary study outcomes in favor of the real-time feedback group for median (interquartile range) chest compression fraction [57 (52.75%-60%) vs. 49 (43%-55%), P < 0.001], compressions with adequate depth [66.5 (19.5%-95.25%) vs. 0 (0%-12%), P < 0.001], ventilations with adequate volume [68.5 (33%-89%) vs. 37 (0%-70%), P < 0.00], and a simulator-derived composite "total CPR score" [39 (24%-61.25%) vs. 13 (3.5%-22%), P < 0.001]. In multiple regression analysis, the real-time feedback group's performance was significantly better than the control group in all primary outcomes, adjusting for participant's characteristics of age, sex, and body mass index. CONCLUSIONS: The use of audiovisual feedback techniques to teach CPR improves skill acquisition with significant improvement in crucial prognosis-improving parameters, as tested in a "no-feedback" test scenario.

Estimation of fetal weight using Hadlock's formulas: Is head circumference an essential parameter?

OBJECTIVES: To test the equivalence of two fetal weight estimation formulas generated by Hadlock, a formula that includes head circumference parameter (H1), and another (H2) which excludes this parameter. A secondary aim was to identify the patients in which H2 formula is less reliable to use. STUDY DESIGN: This retrospective cohort study included a total of 1220 sonographic fetal weight estimations performed within seven days of delivery and recorded at a single medical center from January 2014 to December 2016. Estimated fetal weight was calculated using H1 and H2 formulas. Their accuracies were compared using percentage error, the proportion of weight estimations falling within ±15% error interval and by Bland-Altman analysis. Multivariate regression was performed to evaluate factors affecting weight estimation by H2 formula. RESULTS: The mean birth weight was 3288.92 ±â€¯641.27gr. The H2 formula presented with statistically significant higher value of systemic mean percent error comparing to H1 (3.19% vs. 1.87%, p < 0.001 respectively). H2 formula had a lower accuracy compared to H1 in predicting fetal weight within ±15% of birth weight (90.49% vs. 93.44%, p < 0.01 respectively). Using Bland-Altman analysis, the 95% limits of agreement between both formulas were (-142.03) to 231.79gr with a mean of 44.88gr. Factors found to influence significantly on H2 formula were long femur length (OR 1.144, p < 0.0001) and low maternal age (OR 0.947, p < 0.01). CONCLUSIONS: H1formula was more accurate than H2 formula in predicting fetal weight at term. However, the accuracy difference was found to be small. Therefore, if ultrasonographic evaluation of HC is technically difficult, Hadlock formula that excludes head circumference can be used with confidence. Caution should be paid with higher values of femur length and lower maternal age.

Neonatal Risk Factors for Colonization with Extended-Spectrum Beta-Lactamase-Producing Bacteria in the Neonatal Intensive Care Unit.

BACKGROUND: Extended-spectrum beta-lactamase (ESBL) production is the most common antimicrobial resistance mechanism in the neonatal intensive care unit (NICU), with colonization and blood stream infections being a major threat to this population. Since 2013, all NICU admissions at our facility were screened twice weekly for ESBL colonization. OBJECTIVES: To determine independent risk factors for colonization of infants with ESBL-producing bacteria in the NICU. METHODS: A retrospective case study of ESBL-colonized infants vs. controls (matched by date of birth and gestational age) was conducted in the NICU of Soroka University Medical Center, Israel, between 2013 and 2014. Epidemiological, laboratory, and clinical data were extracted from medical files. Univariable and multivariable analyses were used to assess associations between ESBL colonization and possible clinical risk factors. RESULTS: Of 639 admissions during the study period, 87 were found to be ESBL-colonized (case infants) and were matched to 87 controls. Five case infants became infected (5.7%) with ESBL strains. Klebsiella pneumoniae was the most common isolated bacteria. The mean time from admission to colonization was 15 days. Univariable analysis showed an association of male gender and highest Apgar score at 1 and 5 minutes with ESBL colonization (P < 0.05). Multivariable analysis yielded only a possible association of higher Apgar score at 1 and 5 minutes (hazard ratio [HR] 1.515, 95% confidence interval [95%CI] 0.993-2.314; HR 1.603, 95%CI 0.958-2.682, respectively) with ESBL colonization. CONCLUSIONS: Future studies should focus on maternal colonization and possible strategies for preventing vertical transmission of ESBL strains to high-risk neonates.