Proposed Quality Indicators for Aspects of Pediatric Acute Otitis Media Management.

BACKGROUND: The high incidence of pediatric acute otitis media (AOM) makes the implications of overdiagnosis and overtreatment far-reaching. Quality indicators (QIs) for AOM are limited, drawing from generalized upper respiratory infection QIs, or locally developed benchmarks. Recognizing this, we sought to develop pediatric AOM QIs to build a foundation for future quality improvement efforts. METHODS: Candidate indicators (CIs) were extracted from existing guidelines and position statements. The modified RAND Corporation/University of California, Los Angeles (RAND/UCLA) appropriateness methodology was used to select the final QIs by an 11-member expert panel consisting of otolaryngology-head and neck surgeons, a pediatrician and family physician. RESULTS: Twenty-seven CIs were identified after literature review, with an additional CI developed by the expert panel. After the first round of evaluations, the panel agreed on 4 CIs as appropriate QIs. After an expert panel meeting and subsequent second round of evaluations, the panel agreed on 8 final QIs as appropriate measures of high-quality care. The 8 final QIs focus on topics of antimicrobial management, specialty referral, and tympanostomy tube counseling. CONCLUSIONS: Evidence of variable and substandard care persists in the diagnosis and management of pediatric AOM despite the existence of high-quality guidelines. This study proposes 8 QIs which compliment guideline recommendations and are meant to facilitate future quality improvement initiatives that can improve patient outcomes.

The Impact of COVID-19 Restrictions on Hospital Admissions of Common Head and Neck Infections.

INTRODUCTION: Following the emergence of COVID-19, multiple preventative measures were implemented to limit the spread of the disease. This study aims to elucidate the impact of COVID-19 restrictions on hospital admissions of otolaryngology-related infections. MATERIALS AND METHODS: A retrospective chart review was conducted to capture all admissions for otolaryngology-related infections in the 2 years pre- and post-COVID-19 at the Health Sciences Centre in Winnipeg, Manitoba. These infections included croup, tracheitis, neck abscess, peritonsillar abscess, otitis media, mastoiditis, sinus infection, orbital infection, pharyngotonsillitis, retro/parapharyngeal abscess, and acute epiglottitis. Demographic information and admission details were collected and analyzed to compare pre- and post-COVID-19 admissions. Further analysis was conducted to compare hospital admissions of patients from rural/remote regions. RESULTS: Between March 2018 and March 2022, 253 pediatric patients and 197 adults were admitted for otolaryngology-related infections. Total pediatric admissions decreased post-COVID-19 (154 pre-COVID-19, 99 post-COVID-19; p < 0.001) whereas adult admissions remained stable (107 pre-COVID-19, 90 post-COVID-19; p = 0.25). No significant difference in mean patient age, admission duration, surgical rates or in the proportion of admissions from patients from rural/remote regions was observed in the pediatric or adult cohort when comparing pre-COVID-19 data to post-COVID-19 data. Diagnosis-specific changes in admissions were observed in pediatric croup (40 pre-COVID-19, 15 post-COVID-19; p < 0.001) and in adult orbital infections (30 pre-COVID-19, six post-COVID-19; p < 0.001). CONCLUSION: Following the implementation of COVID-19 restrictions, there was a decrease in admissions due to pediatric croup and adult orbital infections with an overall decrease in pediatric Otolaryngology-infection related admissions. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:3542-3547, 2024.

A systematic review and meta-analysis of computed tomography in the diagnosis of pediatric foreign body aspiration.

INTRODUCTION: Rigid bronchoscopy remains the gold standard for the diagnosis of foreign body aspiration (FBA) despite high rates of negative bronchoscopies. The use of computed tomography (CT) imaging in the assessment of FBA has recently emerged and could help obviate unnecessary bronchoscopy in these patients. The aim of this study is to assess the diagnostic accuracy of CT in the diagnosis of pediatric FBA. METHODS: A systematic literature review was conducted to identify studies reporting the use of CT imaging in suspected pediatric FBA. The search included published articles in Ovid MEDLINE, Ovid EMBASE, PubMed MEDLINE and Web of Science. The search strategy included all articles from inception of the database to January 2021. Manuscripts were reviewed and graded for quality using the QUADAS-2 tool. Subgroup analyses based on the use of virtual bronchoscopy (VB) and sedation was conducted. A meta-analysis evaluating the use of VB in the diagnosis of FBA was also conducted. RESULTS: Sixteen manuscripts met all inclusion criteria. In total, 2056 pediatric patients ranging from 0.3 to 15 years underwent CT for suspected FBA. The sensitivity and specificity of CT were 98.8% and 96.6%, respectively. VB was used in 71.4% (1391/1948) of patients while sedation during CT was required in 70.2% (1263/1800) of patients. Radiation dosing ranged from 0.04 to 2 mSv, 0.99-59.1 mGy-cm and 0.03-16.99 mGy. CONCLUSION: CT can accurately diagnose pediatric FBA and can help decrease the rate of unnecessary bronchoscopies with an acceptable dose of radiation.

Factors Affecting the Use of Medical Articles for Citation and Academic Reference.

Introduction: Increases in publication quantity and the onset of open access have increased the complexity of conducting a literature search. Bibliometric markers, like impact factor (IF), have traditionally been used to help identify high-quality research. These markers exist amongst a variety of other factors, which poses the following question: what factors are examined when considering articles for clinical and academic research? Objective: To determine what factors are involved when authors choose citations to include in their publications. Methods: A voluntary and anonymous questionnaire-based survey was distributed to medical students, residents, and faculty from multiple medical schools across Canada during the 2020/2021 academic year. Survey ratings were scored on a 5-point Likert scale and open word response. Results: The study collected 156 complete sets of responses including 78 trainees (61 medical students and 17 residents), and 78 faculty. Language of the article (3.93) and availability on PubMed/Medline (3.77) were found more important than country of origin (2.14), institution (2.26), and IF (2.97). Trainees found the following factors more important than faculty: year of publication (3.94 vs 3.47, p = 0.0016), availability on Google/Google Scholar (2.51 vs 1.88, p = 0.0013), Open-access (2.46 vs 1.87, p = 0.0011), and Free access (2.73 vs 2.31, p = 0.049). Conclusion: Our study identified differences in faculty and trainee literature search preferences, bias towards English language publications, and the movement towards online literature sources. This knowledge provides insight into what biases individuals may be exposed to based on their language and literature search preferences. Future areas of research include how trainees' opinions change over time, identifying trainee ability to recognize predatory journals, and the need for better online journal article translators to mitigate the language bias. We believe this will lead to higher quality evidence and optimal patient care amongst healthcare workers.

Quality indicators for the diagnosis and management of pediatric tonsillitis.

INTRODUCTION: Pediatric tonsillitis is encountered frequently across specialties, and while high quality guidelines exist, there is persistent evidence of care which is not evidence based, including antibiotic overprescribing and surgical practice variability. Quality indicators (QIs) can be utilized for initiatives to improve the quality of care and subsequent patient outcomes. We sought to develop pediatric tonsillitis QIs that are applicable across specialties and that cover aspects of both diagnosis and the spectrum of management options. METHODS: A guideline-based approach to QI development was employed. Candidate indicators (CIs) were extracted from international guidelines deemed high quality by two reviewers and evaluated by an eleven-member expert panel consisting of otolaryngology - head & neck surgeons, a pediatrician and a family physician. The final QIs were selected utilizing a modified RAND/UCLA appropriateness methodology. RESULTS: Twenty-six CIs were identified after initial literature review. After the first round of evaluations, the panel agreed on thirteen candidate indicators as appropriate QIs. A subsequent expert panel meeting provided a platform to discuss areas of disagreement, discuss any recently published research, and to brainstorm additional CIs not identified from the guideline extraction. Following the second round of evaluations, the expert panel agreed upon sixteen QIs as appropriate measures of high-quality care. CONCLUSIONS: This study proposes sixteen QIs developed through a multidisciplinary lens to guide practitioners in the diagnosis and management of pediatric tonsillitis. These QIs can be used to improve transparency, accountability, and provide objective data to assist future quality improvement initiatives.

Pediatric rigid bronchoscopy and foreign body removal during the COVID-19 pandemic: case report.

We present the case of an eight year old boy who presented with foreign body aspiration during the COVID-19 pandemic. The patient was taken the operating room for rigid bronchoscopy and foreign body removal. The details of the operation, steps taken for protection of health care workers, and lessons learned are discussed. Bronchoscopy was performed using N95 respirators and Stryker Flyte Hood garments, combined with a streamlined instrument set-up. Simulation in advance of these cases improves communication and operative planning. Surgeons should have equipment to retrieve foreign bodies from the oropharynx available. Techniques that reduce surgical time and thus exposure risk should be considered.

Mobile Audience Response Systems at a Continuing Medical Education Conference.

BACKGROUND: Mobile audience response systems (mARS) are electronic systems allowing speakers to ask questions and audience members to respond anonymously and immediately on a screen which enables learners to view their peers' responses as well as their own. mARS encourages increased interaction and active learning. OBJECTIVES: This study aims to examine the perceptions of audience members and speakers towards the implementation of mARS at a national medical conference. METHODS: mARS was implemented at the CSO Annual Meeting in Winnipeg 2015. Eleven presenters agreed to participate in the mARS trial. Both audience and presenters received instructions. Five-point Likert questions and short answer questions were emailed to all conference attendees and the data was evaluated. RESULTS: Twenty-seven participants responded, 23 audience members and 4 instructors. Overall, responders indicated improved attention, involvement, engagement and recognition of audience's understanding of topics with the use of mARS. mARS was perceived as easy to use, with clear instructions, and the majority of respondents expressed an interest in using mARS in more presentations and in future national medical conferences. Most respondents preferred lectures with mARS over lectures without mARS. Some negative feedback on mARS involved dissatisfaction with how some presenters implemented mARS into the workshops. CONCLUSION: Overall mARS was perceived positively with the majority of respondents wanting mARS implemented in more national medical conferences. Future studies should look at how mARS can be used as an educational tool to help improve patient outcomes.

Adding Live-Streaming to Recorded Lectures in a Non-Distributed Pre-Clerkship Medical Education Model.

BACKGROUND: Live-streaming video has had increasing uses in medical education, especially in distributed education models. The literature on the impact of live-streaming in non-distributed education models, however, is scarce. OBJECTIVES: To determine the attitudes towards live-streaming and recorded lectures as a resource to pre-clerkship medical students in a non-distributed medical education model. METHODS: First and second year medical students were sent a voluntary cross-sectional survey by email, and were asked questions on live-streaming, recorded lectures and in person lectures using a 5-point Likert and open answers. RESULTS: Of the 118 responses (54% response rate), the data suggested that both watching recorded lectures (Likert 4.55) and live-streaming lectures (4.09) were perceived to be more educationally valuable than face-to-face attendance of lectures (3.60). While responses indicated a statistically significant increase in anticipated classroom attendance if both live-streaming and recorded lectures were removed (from 63% attendance to 76%, p =0.002), there was no significant difference in attendance if live-streaming lectures were removed but recorded lectures were maintained (from 63% to 66%, p=0.76). CONCLUSION: The addition of live-streaming lectures in the pre-clerkship setting was perceived to be value added to the students. The data also suggests that the removal of live-streaming lectures would not lead to a statistically significant increase in classroom attendance by pre-clerkship students.

Hair barrette induced cochlear implant receiver stimulator site infection with extrusion.

Background. Cochlear implant infections and extrusion are uncommon but potentially devastating complications. Recent literature suggests conservative management can be employed. Local measures inclusive of aggressive surgical debridement with vascularized flaps and parenteral antibiotics represent a viable option and often permit device salvage. However, explantation should be considered if there is evidence of systemic, intracranial, or intractable infection. Method. A Case report and literature review. Case Report. This case illustrates a complicated local wound infection associated with cochlear implantation due to transcutaneous adherence of a ferrous hair barrette to a cochlear implant magnet. Reconstruction of computed tomography (CT) data with 3D volume rendering significantly improved the value of the images and facilitated patient counseling as well as operative planning. Conclusion. Cochlear implant infections can be associated with foreign bodies. CT images are beneficial in the evaluation of cochlear implant complications. 3D CT images provide a comprehensive view of the site of interest, displaying the relationship of the hardware to the skull and soft tissues, while minimizing associated artifacts. Cochlear implant patients should consider use of nonmetallic hair devices.

Role of NQO1 polymorphisms as risk factors for squamous cell carcinoma of the head and neck.

A case: control study was carried out to determine if inactivating polymorphisms of the NQO1 gene at bases 609 and 465 are associated with altered risk of developing squamous cell carcinoma of the head and neck (SCCHN). Genotyping was carried out by PCR RFLP analysis on whole blood samples. The frequency of the inactive 609T and active 609C forms, and the inactive 465T and active 465C forms, of NQO1 were compared in patient and control groups by a logistic regression analysis and odds ratios (ORs) were calculated. Participants were stratified by tobacco and alcohol use, and genotype distributions in these sub-groups were compared. There were no significant differences in genotype distribution between SCCHN patients and the control population for the base 609 or 465 polymorphisms. There were also no significant differences in genotype distributions between patient and control groups for tobacco and/or alcohol users and non-users. Genotype distributions were similar for SCCHN patients at all disease sites with the exception of the nasopharynx where there was a higher incidence of the 609C:609T and 609T:609T genotypes. These results suggest that individuals having either 609T or 465T alleles generally do not have an altered risk of developing SCCHN.

Quantification of sodium thiosulphate protection on cisplatin-induced toxicities.

OBJECTIVE: To quantify the amount of protection from cisplatin (CDDP)-induced mortality and toxicity provided by sodium thiosulphate (STS). DESIGN: Prospective controlled animal study. SETTING: Animal research facility. METHOD: Nephrotoxicity, myelotoxicity, and auditory/neurotoxicity were studied in guinea pigs. Total CDDP doses of 15, 21, 25, 35, and 45 mg/kg were administered to animals in groups of five. In some groups, STS (8000 mg/kg) was given. Animals underwent bloodwork and auditory brainstem response (ABR) testing to estimate toxicity before and 1 month after treatment. MAIN OUTCOME MEASURES: Blood urea nitrogen, creatinine, and white blood cell count were used to assess renal and myelotoxicity. Hearing was assessed with ABR thresholds to click stimuli. Survival was an overall measure of toxicity. RESULTS: Forty guinea pigs in six treatment groups were studied. Animals given 21 mg/kg CDDP all died within 1 month and showed evidence of severe toxicity. Eighty percent of subjects treated with CDDP 15 mg/kg survived and showed evidence of nephrotoxicity and ototoxicity. Subjects treated with STS and CDDP showed survival comparable to the control group treated with CDDP 15 mg/kg. Under STS protection, CDDP was tolerated in doses three times the toxic dose without protection. Without STS, the maximum dose of CDDP tolerated for a month was 15 mg/kg. CONCLUSIONS: STS protects against mortality owing to CDDP by reducing toxicity. Under STS protection, the maximum tolerated dose of CDDP is greatly increased in guinea pigs.