Workforce perspective on racial and ethnic equity in early childhood autism evaluation and treatment: "The cornerstone of everything we do".

LAY ABSTRACT: Black and non-White Latinx children tend to receive autism diagnoses later in life and with a higher degree of impairment than White children. The purpose of this study was to learn what is currently helping as well as preventing Black and non-White Latinx children from getting access to autism evaluation and services. We held virtual interviews with 26 experts who work with autistic children and their families, including clinical providers, researchers, advocates, and policymakers/government representatives. From these interviews, we identified four themes that have an impact on equity in autism services: (1) who makes up the workforce, (2) workforce capacity and accessibility, (3) workforce payment structure, and (4) changes due to the COVID-19 pandemic. These findings show the need for improved workforce diversity, autism-specific education, payment structures, and additional support for workforce members to avoid burnout. To make childhood autism services more equitable, diversity in recruitment across training levels, cultural awareness, increased autism education for all pediatric providers, and partnerships with caregivers as experts must be prioritized. These investments in the autism workforce will allow professionals in the field to better meet the needs of children and families from Black and non-White Latinx communities and achieve equity in early childhood autism services.

New Medical Device and Therapeutic Approvals in Otolaryngology: State of the Art Review of 2022.

Objective: To review new drugs and devices relevant to otolaryngology approved by the Food and Drug Administration (FDA) in 2022. Data Sources: Publicly available FDA data on drugs and devices approved in 2022. Review Methods: A preliminary screen was conducted to identify drugs and devices relevant to otolaryngology. A secondary screen by members of the American Academy of Otolaryngology-Head and Neck Surgery's (AAO-HNS) Medical Devices and Drugs Committee differentiated between minor updates and new approvals. The final list of drugs and devices was sent to members of each subspecialty for review and analysis. Conclusion: A total of 1251 devices and 37 drugs were identified on preliminary screening. Of these, 329 devices and 5 drugs were sent to subspecialists for further review, from which 37 devices and 2 novel drugs were selected for further analysis. The newly approved devices spanned all subspecialties within otolaryngology. Many of the newly approved devices aimed to enhance patient experience, including over-the-counter hearing aids, sleep monitoring devices, and refined CPAP devices. Other advances aimed to improve surgical access, convenience, or comfort in the operating room and clinic. Implications for Practice: Many new devices and drugs are approved each year to improve patient care and care delivery. By staying up to date with these advances, otolaryngologists can leverage new innovations to improve the safety and quality of care. Given the recent approval of these devices, further studies are needed to assess long-term impact within the field of otolaryngology.

Escalating costs of self-injury mortality in the 21st century United States: an interstate observational study.

BACKGROUND: Estimating the economic costs of self-injury mortality (SIM) can inform health planning and clinical and public health interventions, serve as a basis for their evaluation, and provide the foundation for broadly disseminating evidence-based policies and practices. SIM is operationalized as a composite of all registered suicides at any age, and 80% of drug overdose (intoxication) deaths medicolegally classified as 'accidents,' and 90% of corresponding undetermined (intent) deaths in the age group 15 years and older. It is the long-term practice of the United States (US) Centers for Disease Control and Prevention (CDC) to subsume poisoning (drug and nondrug) deaths under the injury rubric. This study aimed to estimate magnitude and change in SIM and suicide costs in 2019 dollars for the United States (US), including the 50 states and the District of Columbia. METHODS: Cost estimates were generated from underlying cause-of-death data for 1999/2000 and 2018/2019 from the US Centers for Disease Control and Prevention's (CDC's) Wide-ranging ONline Data for Epidemiologic Research (WONDER). Estimation utilized the updated version of Medical and Work Loss Cost Estimation Methods for CDC's Web-based Injury Statistics Query and Reporting System (WISQARS). Exposures were medical expenditures, lost work productivity, and future quality of life loss. Main outcome measures were disaggregated, annual-averaged total and per capita costs of SIM and suicide for the nation and states in 1999/2000 and 2018/2019. RESULTS: 40,834 annual-averaged self-injury deaths in 1999/2000 and 101,325 in 2018/2019 were identified. Estimated national costs of SIM rose by 143% from $0.46 trillion to $1.12 trillion. Ratios of quality of life and work losses to medical spending in 2019 US dollars in 2018/2019 were 1,476 and 526, respectively, versus 1,419 and 526 in 1999/2000. Total national suicide costs increased 58%-from $318.6 billion to $502.7 billion. National per capita costs of SIM doubled from $1,638 to $3,413 over the observation period; costs of the suicide component rose from $1,137 to $1,534. States in the top quintile for per capita SIM, those whose cost increases exceeded 152%, concentrated in the Great Lakes, Southeast, Mideast and New England. States in the bottom quintile, those with per capita cost increases below 70%, were located in the Far West, Southwest, Plains, and Rocky Mountain regions. West Virginia exhibited the largest increase at 263% and Nevada the smallest at 22%. Percentage per capita cost increases for suicide were smaller than for SIM. Only the Far West, Southwest and Mideast were not represented in the top quintile, which comprised states with increases of 50% or greater. The bottom quintile comprised states with per capita suicide cost increases below 24%. Regions represented were the Far West, Southeast, Mideast and New England. North Dakota and Nevada occupied the extremes on the cost change continuum at 75% and - 1%, respectively. CONCLUSION: The scale and surge in the economic costs of SIM to society are large. Federal and state prevention and intervention programs should be financed with a clear understanding of the total costs-fiscal, social, and personal-incurred by deaths due to self-injurious behaviors.

Geographic Variation in Otolaryngologist Intranasal Steroid Prescribing Patterns Among Medicare Beneficiaries.

BACKGROUND: Intranasal corticosteroids (INCS) are a commonly prescribed medication to treat various rhinological conditions. However, no prior studies have looked at factors and patterns that influence the rates of INCS prescriptions among Medicare beneficiaries in the United States. OBJECTIVE: This study aims to describe the patterns of INCS prescriptions by otolaryngologists for Medicare beneficiaries in the United States between 2013 and 2017. METHODS: Data on the most common INCS prescriptions by otolaryngologists for Medicare beneficiaries were obtained from the 2013 to 2017 Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use File (PUF) and the Part D Public Use Files from the Centers for Medicare and Medicaid Services (CMS). INCS prescriptions were analyzed by cost, state, provider, and regional temperature. State temperature data was collected through the National Centers for Environmental Information. RESULTS: From 2013 to 2017, the total claims per beneficiary for fluticasone, mometasone, and triamcinolone combined increased from 2.31 to 2.39. Combined cost/beneficiary was similar for mometasone and triamcinolone at 102.47 and 103.60 respectively, while it was much lower for fluticasone at 39.12. There was a strong correlation between otolaryngology providers per beneficiary in each state and total claims per state with a correlation coefficient of .79. Additionally, comparing the average state temperature to the claims/beneficiary yielded a moderately strong correlation coefficient of .44, suggesting that temperature was a possible factor for INCS prescription patterns. CONCLUSIONS: INCS prescriptions by otolaryngologists and the number of INCS beneficiaries have increased between 2013 and 2017. Over the same time period, the costs of fluticasone and triamcinolone have decreased while the cost of mometasone increased. Total providers by state correlated with claims per state. Additionally, average annual temperature was positively correlated with INCS claims per beneficiary in each state.

Virtual Versus In-Person Head and Neck Physical Examination Training in Medical Students: A Pilot Assessment.

OBJECTIVE: To compare the effect of virtual and in-person head and neck physical examination training events on medical student confidence in performing examination maneuvers and seeking mentorship from otolaryngology faculty and residents. METHODS: Training events were held with first-year medical student volunteers in 2020 (in-person) and 2021 (virtual). Participants in both cohorts were given didactics on head and neck cancer, trained to perform a head and neck physical examination, and demonstrated their clinical skills to otolaryngology faculty and residents. Pre- and post-training surveys were utilized to assess the following outcomes: participant head and neck cancer knowledge, confidence in performing examination maneuvers, and confidence in seeking mentorship in otolaryngology. Differences in outcomes between training settings were assessed by comparing participant survey responses pre- and post- training. RESULTS: Both in-person and virtual training modalities improved participant confidence in performing the physical examination. There was no significant difference in the degree of improvement between training types. In-person training significantly increased participant confidence in seeking mentorship from otolaryngology faculty and residents (P = .003), while virtual training did not (P = .194). CONCLUSION: Virtual training modalities are feasible methods of teaching the head and neck physical examination. Instruction through a video conferencing platform has the potential to be incorporated into traditional in-person medical education in a permanent fashion. This pilot study can inform future studies directly comparing in-person and virtual physical examination training modalities.

Spatio-temporal variation of nitrate based on Landsat 8 in Playa Colorada bay, Sinaloa, Mexico.

Characterizing water quality in coastal waters through spatial observations is challenging, due to spatial and temporal variations in water composition. Nitrate, an important compound for water quality assessment, has received little attention in estimates made from satellite measurements, even though it can be estimated using models generated from multispectral images. Since nitrate is a non-optically active parameter that can be correlated with optically active parameters, it was related to bands of the visible and infrared spectrum, captured in Landsat-8 images, and used to generate empirical models to estimate the spatio-temporal variation of nitrate concentration in the Playa Colorada Bay, in the state of Sinaloa Northwest Mexico. Four sampling campaigns were performed, two in spring and two in fall. Nitrate nitrogen (NO3-N) concentration ranged between 0.69 and 1.80 mg/L, values higher than those recommended in the Mexican ecological criteria of water quality for the protection of marine aquatic life in coastal areas. Generated models showed a significant relationship (P < 0.05) between NO3-N and band reflectance in the infrared (band 5) and short-wave infrared (band 6 and band 7) spectra of Landsat-8 imagery. The B6 band appeared in all models selected to estimate NO3-N in the bay. These results evidence the potential of Landsat-8 images for the estimation of nitrate in the coastal waters of Sinaloa, México.

Human papillomavirus detection in oral rinses and history of tonsillectomy in U.S. adults.

PURPOSE: This study aims to elucidate any relationship between prior tonsillectomy and the presence of oropharyngeal HPV DNA found in screening mouth rinses. MATERIALS AND METHODS: A cross sectional study was conducted using the 2011-2014 National Health and Nutrition Examination Survey (NHANES). Participants between 40 and 69 were included in the study and medical, surgical, and sexual health history were recorded. Multivariable analyses were conducted to examine factors associated with HPV prevalence in oral rinse samples. RESULTS: A total of 4825 participants were recorded with 21.1 % having a history of tonsillectomy. In the no tonsillectomy group, 8.6 % of respondents had a positive oral rinse for HPV, while 7.2 % of those with a tonsillectomy had a positive rinse sample. There was no association between age and HPV prevalence (OR = 1.04, 95 % CI: [1.00-1.07]). When controlling for demographics, medical history, and sexual behaviors, tonsillectomy history was not shown to have an association with HPV (OR = 0.86, 95 % CI: [0.53-1.40]). However, men, Hispanics, smokers, and those with higher lifetime sexual partners had increased odds of having a positive HPV oral rinse sample which was statistically significant. CONCLUSION: Our data showed that a history of tonsillectomy was not significantly associated with the presence of HPV in an oral rinse. However, a significant relationship was seen between the presence of HPV in oral rinses and certain demographic factors such as male gender, Hispanic race, smoking history, and increased sexual partners.

Spatial Variation in Humidity and the Onset of Seasonal Influenza Across the Contiguous United States.

In recent years, environmental factors, particularly humidity, have been used to inform influenza prediction models. This study aims to quantify the relationship between humidity and influenza incidence at the state-level in the contiguous United States. Piecewise segmented regressions were performed on specific humidity data from NASA's Atmospheric Infrared Sounder (AIRS) and incident influenza estimates from Google Flu Trends to identify threshold values of humidity that signal the onset of an influenza outbreak. Our results suggest that influenza incidence increases after reaching a humidity threshold that is state-specific. A linear regression showed that the state-specific thresholds were associated with annual average humidity conditions (R 2 = 0.9). Threshold values statistically significantly varied by region (F-statistic = 8.274, p < 0.001) and of their 36 pairwise combinations, 13 pairs had at least marginally statistically significant differences in their means. All of the significant comparisons included either the South or Southeast region, which had higher humidity threshold values. Results from this study improve our understanding of the significance of humidity in the transmission of influenza and reinforce the need for local and regional conditions to be considered in this relationship. Ultimately this could help researchers to produce more accurate forecasts of seasonal influenza onset and provide health officials with better information prior to outbreaks.

Association of State Social and Environmental Factors With Rates of Self-injury Mortality and Suicide in the United States.

Importance: Self-injury mortality (SIM) combines suicides and the preponderance of drug misuse-related overdose fatalities. Identifying social and environmental factors associated with SIM and suicide may inform etiologic understanding and intervention design. Objective: To identify factors associated with interstate SIM and suicide rate variation and to assess potential for differential suicide misclassification. Design, Setting, and Participants: This cross-sectional study used a partial panel time series with underlying cause-of-death data from 50 US states and the District of Columbia for 1999-2000, 2007-2008, 2013-2014 and 2018-2019. Applying data from the Centers for Disease Control and Prevention, SIM includes all suicides and the preponderance of unintentional and undetermined drug intoxication deaths, reflecting self-harm behaviors. Data were analyzed from February to June 2021. Exposures: Exposures included inequity, isolation, demographic characteristics, injury mechanism, health care access, and medicolegal death investigation system type. Main Outcomes and Measures: The main outcome, SIM, was assessed using unstandardized regression coefficients of interstate variation associations, identified by the least absolute shrinkage and selection operator; ratios of crude SIM to suicide rates per 100 000 population were assessed for potential differential suicide misclassification. Results: A total of 101 325 SIMs were identified, including 74 506 (73.5%) among males and 26 819 (26.5%) among females. SIM to suicide rate ratios trended upwards, with an accelerating increase in overdose fatalities classified as unintentional or undetermined (SIM to suicide rate ratio, 1999-2000: 1.39; 95% CI, 1.38-1.41; 2018-2019: 2.12; 95% CI, 2.11-2.14). Eight states recorded a SIM to suicide rate ratio less than 1.50 in 2018-2019 vs 39 states in 1999-2000. Northeastern states concentrated in the highest category (range, 2.10-6.00); only the West remained unrepresented. Least absolute shrinkage and selection operator identified 8 factors associated with the SIM rate in 2018-2019: centralized medical examiner system (ß = 4.362), labor underutilization rate (ß = 0.728), manufacturing employment (ß = -0.056), homelessness rate (ß = -0.125), percentage nonreligious (ß = 0.041), non-Hispanic White race and ethnicity (ß = 0.087), prescribed opioids for 30 days or more (ß = 0.117), and percentage without health insurance (ß = -0.013) and 5 factors associated with the suicide rate: percentage male (ß = 1.046), military veteran (ß = 0.747), rural (ß = 0.031), firearm ownership (ß = 0.030), and pain reliever misuse (ß = 1.131). Conclusions and Relevance: These findings suggest that SIM rates were associated with modifiable, upstream factors. Although embedded in SIM, suicide unexpectedly deviated in proposed social and environmental determinants. Heterogeneity in medicolegal death investigation processes and data assurance needs further characterization, with the goal of providing the highest-quality reports for developing and tracking public health policies and practices.

Length and colonization rates of roots associated with arbuscular or ectomycorrhizal fungi decline differentially with depth in two northern hardwood forests.

Ectomycorrhizal (EM) and arbuscular mycorrhizal (AM) fungi are often studied independently, and thus little is known regarding differences in vertical distribution of these two groups in forests where they co-occur. We sampled roots at two soil depths in two northern hardwood stands in Bartlett, New Hampshire, co-dominated by tree species that associate with AM or EM fungi. Root length of both groups declined with depth. More importantly, root length of EM plant species exceeded that of AM plants at 0-10-cm depth, while AM exceeded EM root length at 30-50-cm depth. Colonization rates were similar between mineral and organic portions of the shallow (0-10 cm) samples for EM and AM fungi and declined dramatically with depth (30-50 cm). The ratio of EM to AM fungal colonization declined with depth, but not as much as the decline in root length with depth, resulting in greater dominance by EM fungi near the surface and by AM fungi at depth. The depth distribution of EM and AM roots may have implications for soil carbon accumulation as well as for the success of the associated tree species.

Perioperative Acetaminophen and Dexmedetomidine Eliminate Post-Operative Opioid Requirement following Pediatric Tonsillectomy.

Administration of post-operative opioids following pediatric tonsillectomy can elicit respiratory events in this patient population that often arise as central and obstructive sleep apnea. The primary objective of this study was to determine whether a perioperative combination of dexmedetomidine and acetaminophen could eliminate post-operative (in recovery and at home) opioid requirements. Following IRB approval and a waiver for informed consent, the medical records of 681 patients who underwent tonsillectomy between 1 January 2013 and 31 December 2018 were evaluated. Between 1 January 2013 and 31 December 2015, all patients received a fentanyl-sevoflurane-based anesthetic, without acetaminophen or dexmedetomidine, and received opioids in recovery and for discharge home. On 1 January 2016, an institution-wide practice change replaced this protocol with a multimodal perioperative regimen of acetaminophen (intravenous or enteral) and dexmedetomidine and eliminated post-operative opioids. This is the first time that the effect of an acetaminophen and dexmedetomidine combination on the perioperative and home opioid requirement has been reported. Primarily, we compared the need for rescue opioids in the post-anesthesia care period and after discharge. The multi-modal protocol eliminated the need for post-tonsillectomy opioid administration. Dexmedetomidine in combination with acetaminophen eliminated the need for post-operative opioids in the recovery period.

The Role of Educational Podcast Use Among Otolaryngology Residents.

OBJECTIVE: Medical podcasts are becoming increasingly available; however, it is unclear how these new resources are being used by trainees or whether they influence clinical practice. This study explores the preferences and experiences of otolaryngology residents with otolaryngology-specific podcasts, and the impact of these podcasts on resident education and clinical practice. METHODS: An 18-question survey was distributed anonymously to a representative junior (up to post-graduate year 3) and senior (post-graduate year 4 or greater) otolaryngology residents at most programs across the US. Along with demographic information, the survey was designed to explore the preferences of educational materials, podcast listening habits and motivations, and influence of podcasts on medical practice. Descriptive statistics and student t-tests were used to analyze the results. RESULTS: The survey was distributed to 198 current otolaryngology residents representing 94% of eligible residency programs and was completed by 73 residents (37% response rate). Nearly 3-quarters of respondents reported previous use of otolaryngology podcasts, among which 83% listen at least monthly. Over half of residents changed their overall clinical (53%) and consult (51%) practice based on podcast use. Residents rank-ordered listening to podcasts last among traditional options for asynchronous learning, including reading textbooks and watching online videos. CONCLUSIONS: While other asynchronous learning tools remain popular, most residents responding to this survey use podcasts and report that podcasts influence their clinical practice. This study reveals how podcasts are currently used as a supplement to formal otolaryngology education. Results from the survey may inform how medical podcasts could be implemented into resident education in the future.

Intractable Bleeding Following an Awake Bedside Injection Laryngoplasty in a Patient on KVAD ECMO.

INTRODUCTION: Awake injection laryngoplasty (IL) is becoming increasingly utilized in the inpatient setting, especially as a therapeutic option for patients with vocal fold immobility immediately following cardiothoracic surgery. While prior studies consistently demonstrate complication rates below 3%, significant bleeding has not been reported as a major complication in any awake IL case series. The objective of this report is to highlight a case of intractable bleeding following awake inpatient bedside IL in a patient on KVAD (Koji Takeda Ventricular Assist Device) extracorporeal membrane oxygenation (ECMO). METHODS: Case Report. RESULTS: A 24-year-old female admitted to the cardiac ICU for asystole was placed on KVAD ECMO for heart failure of unknown etiology. She was extubated and listed for cardiac transplant. On postoperative day 14, she underwent a left vocal fold injection at bedside to treat fold paralysis with a large glottic gap causing her complete aphonia, dysphagia, and chronic aspiration. Seven hours post procedure, the patient had to be reintubated due to intractable bleeding. A direct laryngoscopy was performed at bedside and continuous trickle of blood from the injection site at the superior posterior lateral surface of the vocal fold was stopped using a combination of epi-pledgets and hemostatic matrix. The same procedure had to be performed again due to further bleeding 2 days later and permanent hemostasis was achieved. During the week post injection, the patient required transfusion of 5 units of pRBC's. One month later the patient underwent successful orthotopic heart transplantation and was transferred from the ICU to a stepdown unit, and then a rehabilitation unit. No further IL hemorrhage occurred. CONCLUSION: Although a few studies have discussed the safety of IL in patients receiving anticoagulation, this case report demonstrates intractable bleeding requiring intubation and intervention to achieve hemostasis in a patient on KVAD ECMO. This report highlights the importance of weighing the risks and benefits of vocal fold injection in this patient population.

Same day discharge for pectus excavatum-is it possible?

PURPOSE: The use of intercostal nerve cryoablation (INC) has been an effective modality for treating pain in patients undergoing pectus excavatum (PE) repair. This study sought to evaluate if PE patients undergoing Nuss procedures with INC and intercostal nerve block (INB) could safely be discharged the same day of surgery. METHODS: A prospective study with IRB approval of 15 consecutive patients undergoing PE Nuss repair with INC, INB, and an enhanced recovery after surgery (ERAS) protocol was conducted. The primary outcome measure was hospital length of stay (LOS) in hours. Secondary variables included same day discharge, postoperative complications, emergency department (ED) visits, urgent care (UC) visits, opioid use, and return to the operating room (OR). RESULTS: LOS averaged 11.9 h amongst 15 patients. Ten patients (66.7%) went home on postoperative day (POD) 0, and the rest went home on POD 1. No patients stayed in the hospital due to pain. Reasons for failure to discharge included urinary retention, drowsiness, vomiting, and anxiety, but not pain. No patients were readmitted to the ED. One patient visited UC for constipation. One patient had bar migration requiring return to the OR for revision. Ten (66.7%) patients did not use opioids after discharge. CONCLUSIONS: Same day discharge is feasible and safe in PE patients undergoing Nuss procedure with INC and INB. INC with INB can adequately control pain without significant complications. Same day discharge can be safely considered for PE patients undergoing Nuss procedure with INC with INB. TYPE OF STUDY: Prognosis study LEVEL-OF-EVIDENCE RATING: Level II.

Same-day discharge following the Nuss repair: A comparison.

PURPOSE: Intercostal Nerve Cryoablation (INC) has significantly improved pain control following the Nuss repair of pectus excavatum (PE). This study sought to evaluate patients undergoing the Nuss repair with INC compared to the Nuss repair with an ERAS protocol, INC, and intercostal nerve blocks (INB). METHODS: In June 2020, a new protocol was implemented involving surgery, anesthesia, nursing, physical therapy, and child life with the goal of safe same day discharge for patients undergoing the Nuss repair. They were compared to a control group who underwent the Nuss repair with INC alone in 2017-2019. The primary outcome measure was hospital length of stay (LOS) in hours, secondary outcomes were number of patients discharged on postoperative day (POD) 0, and returns to the emergency department (ED), urgent care (UC), and operating room (OR). RESULTS: The characteristics between the groups were the same (Table 1). The mean LOS was 11.8 h in the INB group versus 58.2 h in the INC group, p < 0.01. 10 of 15 patients in the INB group went home on POD 0 (average of 5.5 h postop), versus 0 patients in the INC only group, p < 0.01. Five patients in the INB stayed overnight. Two patients stayed owing to anxiety, one owing to urinary retention, one owing to nausea, and one owing to drowsiness. None stayed for pain control. Four patients in the INC group returned to the ED for pain control, versus 0 in the INB group, and 1 patient in the INB returned to UC for constipation. CONCLUSIONS: The majority of patients undergoing the Nuss repair of PE with a multidisciplinary regimen of pre and postoperative nursing education, precise intraoperative anesthesia care, performance of direct vision INB and INC, as well as careful surgery can go home on the day of surgery without adverse outcomes or unanticipated returns to the hospital. LEVEL-OF-EVIDENCE: Level II.

High Prevalence of Asymptomatic Malarial Anemia and Association with Early Conversion from Asymptomatic to Symptomatic Infection in a Plasmodium falciparum Hyperendemic Setting in Cameroon.

Asymptomatic malarial parasitemia is highly prevalent in Plasmodium falciparum endemic areas and often associated with increased prevalence of mild to moderate anemia. The aim of this study was to assess the prevalence of anemia during asymptomatic malaria parasitemia and its interplay with persistent infection in highly exposed individuals. A household-based longitudinal survey was undertaken in a malaria hyperendemic area in Cameroon using multiplex nested polymerase chain reaction to detect plasmodial infections. Residents with P. falciparum asymptomatic parasitemia were monitored over a 3-week period with the aid of structured questionnaires and weekly measurements of axillary temperatures. Of the 353 individuals included (median age: 26 years, range 2-86 years, male/female sex ratio 0.9), 328 (92.9%) were positive for malaria parasitemia of whom 266 (81.1%) were asymptomatic carriers. The prevalence of anemia in the study population was 38.6%, of which 69.2% were asymptomatic. Multivariate analyses identified high parasitemia (> 327 parasites/µL) and female gender as associated risk factors of asymptomatic malarial anemia in the population. Furthermore, risk analyses revealed female gender and anemia at the time of enrolment as key predictors of early development of febrile illness (< 3 weeks post enrolment) among the asymptomatic individuals. Together, the data reveal an extremely high prevalence of asymptomatic malaria parasitemia and anemia in the study area, unveiling for the first time the association of asymptomatic malarial anemia with early clinical conversion from asymptomatic to symptomatic infection. Furthermore, these findings underscore the negative impact of asymptomatic malaria parasitemia on individual health, necessitating the development of appropriate control and preventive measures.

Fatal self-injury in the United States, 1999-2018: Unmasking a national mental health crisis.

BACKGROUND: Suicides by any method, plus 'nonsuicide' fatalities from drug self-intoxication (estimated from selected forensically undetermined and 'accidental' deaths), together represent self-injury mortality (SIM)-fatalities due to mental disorders or distress. SIM is especially important to examine given frequent undercounting of suicides amongst drug overdose deaths. We report suicide and SIM trends in the United States of America (US) during 1999-2018, portray interstate rate trends, and examine spatiotemporal (spacetime) diffusion or spread of the drug self-intoxication component of SIM, with attention to potential for differential suicide misclassification. METHODS: For this state-based, cross-sectional, panel time series, we used de-identified manner and underlying cause-of-death data for the 50 states and District of Columbia (DC) from CDC's Wide-ranging Online Data for Epidemiologic Research. Procedures comprised joinpoint regression to describe national trends; Spearman's rank-order correlation coefficient to assess interstate SIM and suicide rate congruence; and spacetime hierarchical modelling of the 'nonsuicide' SIM component. FINDINGS: The national annual average percentage change over the observation period in the SIM rate was 4.3% (95% CI: 3.3%, 5.4%; p<0.001) versus 1.8% (95% CI: 1.6%, 2.0%; p<0.001) for the suicide rate. By 2017/2018, all states except Nebraska (19.9) posted a SIM rate of at least 21.0 deaths per 100,000 population-the floor of the rate range for the top 5 ranking states in 1999/2000. The rank-order correlation coefficient for SIM and suicide rates was 0.82 (p<0.001) in 1999/2000 versus 0.34 (p = 0.02) by 2017/2018. Seven states in the West posted a ≥ 5.0% reduction in their standardised mortality ratios of 'nonsuicide' drug fatalities, relative to the national ratio, and 6 states from the other 3 major regions a >6.0% increase (p<0.05). INTERPRETATION: Depiction of rising SIM trends across states and major regions unmasks a burgeoning national mental health crisis. Geographic variation is plausibly a partial product of local heterogeneity in toxic drug availability and the quality of medicolegal death investigations. Like COVID-19, the nation will only be able to prevent SIM by responding with collective, comprehensive, systemic approaches. Injury surveillance and prevention, mental health, and societal well-being are poorly served by the continuing segregation of substance use disorders from other mental disorders in clinical medicine and public health practice. FUNDING: This study was partially funded by the National Centre for Injury Prevention and Control, US Centers for Disease Control and Prevention (R49CE002093) and the US National Institute on Drug Abuse (1UM1DA049412-01; 1R21DA046521-01A1).

ERAS for Head and Neck Tissue Transfer Reduces Opioid Usage, Peak Pain Scores, and Blood Utilization.

OBJECTIVES: We implement a novel enhanced recovery after surgery (ERAS) protocol with pre-operative non-opioid loading, total intravenous anesthesia, multimodal peri-operative analgesia, and restricted red blood cell (pRBC) transfusions. 1) Compare differences in mean postoperative peak pain scores, opioid usage, and pRBC transfusions. 2) Examine changes in overall length of stay (LOS), intensive care unit LOS, complications, and 30-day readmissions. METHODS: Retrospective cohort study comparing 132 ERAS vs. 66 non-ERAS patients after HNC tissue transfer reconstruction. Data was collected in a double-blind fashion by two teams. RESULTS: Mean postoperative peak pain scores were lower in the ERAS group up to postoperative day (POD) 2. POD0: 4.6 ± 3.6 vs. 6.5 ± 3.5; P = .004) (POD1: 5.2 ± 3.5 vs. 7.3 ± 2.3; P = .002) (POD2: 4.1 ± 3.5 vs. 6.6 ± 2.8; P = .000). Opioid utilization, converted into morphine milligram equivalents, was decreased in the ERAS group (POD0: 6.0 ± 9.8 vs. 10.3 ± 10.8; P = .010) (POD1: 14.1 ± 22.1 vs. 34.2 ± 23.2; P = .000) (POD2: 11.4 ± 19.7 vs. 37.6 ± 31.7; P = .000) (POD3: 13.7 ± 20.5 vs. 37.9 ± 42.3; P = .000) (POD4: 11.7 ± 17.9 vs. 36.2 ± 39.2; P = .000) (POD5: 10.3 ± 17.9 vs. 35.4 ± 45.6; P = .000). Mean pRBC transfusion rate was lower in ERAS patients (2.1 vs. 3.1 units, P = .017). There were no differences between ERAS and non-ERAS patients in hospital LOS, ICU LOS, complication rates, and 30-day readmissions. CONCLUSION: Our ERAS pathway reduced postoperative pain, opioid usage, and pRBC transfusions after HNC reconstruction. These benefits were obtained without an increase in hospital or ICU LOS, complications, or readmission rates. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:E792-E799, 2021.

Development of In-Office Laryngeal Nerve Conduction Studies: Computed Tomography and Cadaveric Study.

OBJECTIVES/HYPOTHESIS: In-office recurrent laryngeal nerve conduction studies (NCSs) are a technique that can potentially provide information about laryngeal innervation. NCS is essential in the management of other neuropathies including carpal tunnel syndrome and spinal cord injury. We hypothesize that laryngeal NCS may have similar utility in managing patients with vocal fold paralysis, atrophy, and neurodegenerative disease. NCSs are technically challenging because they require transcervical stimulation of the recurrent laryngeal nerve (RLN). This study combines radiographic data with cadaveric dissection to describe the anatomic parameters for optimal RLN stimulation. STUDY DESIGN: Radiographic and Cadaveric Study. METHODS: Fifty computed tomography scans were reviewed to determine the dimensions for ideal needle electrode placement. These values were compared to measurements from 12 fresh human cadaveric neck dissections. Ultrasound imaging was utilized in select cases. The neck was dissected to assess the accuracy of electrode placement. RESULTS: Radiographically, the mean transcervical depth to the RLN was 33.2 mm ± 8.3 mm in males versus 29.4 mm ± 9.4 mm in females. The working space between the lateral trachea and carotid artery was 15.3 mm ± 3.6 mm on the right and 14.1 mm ± 2.9 mm on the left. After placement of stimulating electrodes into the cadaveric neck, the electrode tips were consistently within 8 mm of the RLN. Ultrasound guidance improved placement accuracy of the stimulating electrode. CONCLUSIONS: Laryngeal NCSs can provide detailed and objective information about laryngeal innervation that could dramatically improve the management of various neuropathies. In-office NCSs require technical precision, and this study describes anatomic factors that may affect the feasibility of performing this technique. LEVEL OF EVIDENCE: NA Laryngoscope, 131:1566-1569, 2021.