Analysis of Postoperative Outcomes and Economic Behavior Trends of Tympanoplasty and Mastoidectomy With Expansion of High Deductible Health Plans.

HYPOTHESIS: With rising deductibles, patients will delay ear surgeries toward the end of the year, and there will be an increase in postoperative complications. BACKGROUND: The Affordable Care Act (ACA), passed on March 23, 2010, expanded high deductible health plans. The deductible can provide support for patients with high medical costs, but high deductibles deter patients from seeking necessary preventive health care and having elective procedures. Patients may defer care toward the end of the year until the deductible is met. The purpose of this study is to evaluate the relationship between expanding high deductible health plans and the repeal of the ACA's individual mandate on December 22, 2017, with the economic behavior trends of tympanoplasty and mastoidectomy in the fiscal year and surgical outcomes. METHODS: TriNetX was used to obtain summary statistics of patients who had tympanoplasty and/or mastoidectomy from 58 health care organizations. TriNetX is a global federated database that contains de-identified patient data from the electronic medical records of participating health care institutions. This study evaluated the trends in ear surgeries from 2005 to 2021 in the fiscal quarters 1 and 4. Relative risk of developing postoperative complications was statistically interrogated. RESULTS: The average rate of ear surgeries measured in cases/year was higher in Quarter 4 than in Quarter 1 after the expansion of higher deductible health plans (180; 124; p < 0.0001). After the repeal of the ACA's individual mandate, the rate of ear surgeries in Quarter 4 significantly decreased compared to post-ACA (-3.7; 287; p = 0.0002). No statistically significant differences were notable in postoperative complications. CONCLUSIONS: The expansion of high deductible health plans with a rise in deductibles is associated with an increase in ear surgeries toward the end of the year. The repeal of the ACA's individual mandate is associated with a decreased rate of ear surgeries compared to post-ACA implementation. Despite financial concern, there was no increase in postoperative complications toward the end of the year.

Evaluation of Disturbances in Hearing, Tinnitus, and Dizziness as Signs of COVID-19 Infection.

BACKGROUND: There have been reports and studies indicating audiovestibular disturbances in COVID-19 patients with variations in the percentage of sensorineural hearing loss (SNHL). The purpose of this study is to compare the incidence of newly diagnosed SNHL, sudden idiopathic hearing loss (SIHL), tinnitus, and vestibular disturbances between infected and uninfected patients, as well as to identify population groups at risk. METHODS: This study used TriNetX to obtain statistics on COVID-19 (+) and COVID-19 (-) patients from 61 healthcare organizations. Propensity score with 1:1 matching was used to control confounding variables. This study evaluated the relative risk of developing audiovestibular disturbances up to 1 month after a COVID-19 test and further investigated the incidence in COVID-19 (+) subset groups. RESULTS: Between COVID-19 (+) and COVID-19 (-) patients who had an audiogram, there was no statistically significant difference in SNHL or SIHL (SNHL: relative risk [RR] = 0.69, 95% confidence interval [CI] = 0.46-1.04; SIHL: RR = 1.00, 95% CI = 0.42-2.40). Race/ethnicity or specified comorbidity did not affect the incidence of SNHL or SIHL. There was a statistically significant difference in tinnitus and vestibular disturbances between the COVID-19 (+) and the COVID-19 (-) groups (RR = 1.29, 95% CI = 1.01-1.66; RR = 2.33, 95% CI = 2.19-2.48). CONCLUSION: New onset hearing loss is not more common in patients with a positive COVID-19 test than those with a negative COVID-19 test. Audiologic evaluation is needed to verify reported hearing disturbances. Although statistically significant in specific population groups, tinnitus and vestibular disturbances may not be clinically significant due to the low incidence.

Bisphosphonate therapy in otosclerosis: A scoping review.

OBJECTIVE: Otosclerosis, a leading cause of deafness in adults, results from defective bone remodeling of the otic capsule. Bisphosphonates have been used to decrease bone remolding in many diseases, including otosclerosis. This study analyzes whether current literature supports bisphosphonate therapy as an effective treatment for otosclerosis. DESIGN: Scoping review. METHODS: A search was performed in three electronic databases; PubMed, Scopus, and Cochrane Control Trials. Articles were screened independently by two masked reviewers based on prespecified inclusion and exclusion criteria. After unmasking, the two reviewers resolved discrepancies through discussion. RESULTS: From the search, 35 unique articles were identified for analysis. The dates of these publications range from 1982 to 2018. Further title and full-text review identified six articles for inclusion in this review. Three of the studies included are randomized controlled trials (RCT)s, and three are retrospective case reviews. These studies analyzed bisphosphonate therapy regimens, but dose and study length varied, making direct comparisons difficult. Only one RCT study was able to show a statistically significant change between patients treated with bisphosphonates compared to a control group. CONCLUSIONS: The efficacy of bisphosphonates for halting bone remodeling in otosclerosis remains unclear. Reviewing the literature, we found significant variations in experimental design and few studies of high-level evidence. Future RCTs investigating therapies for otosclerosis are needed before a firm conclusion about bisphosphonates efficacy as a pharmacological treatment of otosclerosis.Level of Evidence: 3a.

Gamification in otolaryngology: A narrative review.

INTRODUCTION: The medical field has incorporated gamification elements into education platforms over the past decade. The standard definition for gamification that has been adopted by most research studies is the addition of game elements and game mechanics within a platform to enhance user engagement. In this review, seven established, consolidated components, as well as an additional new or novel component, will be evaluated: a point system/leaderboards, question banks or gradable content, social interaction with other participants, leaderboards, progress or levels, immediate feedback, badges/icons or a reward system, and the novel component, a story line. METHODS: Two reviewers searched MEDLINE, Cochrane, PsycINFO, Web of Knowledge, and the Nursing Registry. This review compares the one identified otolaryngology study with current residency education gamification practices within the medical field.The authors searched "residency AND gamification", "residency AND video games", and "residency AND games". After applying exclusion criteria, the 13 remaining studies included a procedure, questions/scenarios, and at least three gamification elements. RESULTS: Across the 13 studies, the average number of included gamification elements was higher than the minimum threshold of three (3.84). Ten of the studies incorporated leaderboards, feedback, and social interaction; eight incorporated a question bank; and four incorporated progress bars, rewards, and story lines. The otolaryngology study incorporated four of the gamification components: a point system, instant feedback/solution after a question was answered, player-to-player communication, and a leaderboard. CONCLUSION: Review of the current literature found that the medical field has limited research regarding the use of gamification in educational platforms. Despite many simulation studies and attempts at gamification, the medical community has not fully embraced gamification within residency education. In closing, the medical education community should establish a definition of "gamification" and survey residency programs to identify desired gamification elements.

A Universal Stress Protein That Controls Bacterial Stress Survival in Micrococcus luteus.

Bacteria have remarkable mechanisms to survive severe external stresses, and one of the most enigmatic is the nonreplicative persistent (NRP) state. Practically, NRP bacteria are difficult to treat, and so inhibiting the proteins underlying this survival state may render such bacteria more susceptible to external stresses, including antibiotics. Unfortunately, we know little about the proteins and mechanisms conferring survival through the NRP state. Here, we report that a universal stress protein (Usp) is a primary regulator of bacterial survival through the NRP state in Micrococcus luteus NCTC 2665, a biosafety level 1 (BSL1) mycobacterial relative. Usps are widely conserved, and bacteria, including Mycobacterium tuberculosis, Mycobacterium smegmatis, and Escherichia coli, have multiple paralogs with overlapping functions that have obscured their functional roles. A kanamycin resistance cassette inserted into the M. luteus universal stress protein A 616 gene (ΔuspA616::kanM. luteus) ablates the UspA616 protein and drastically impairs M. luteus survival under even short-term starvation (survival, 83% wild type versus 32% ΔuspA616::kanM. luteus) and hypoxia (survival, 96% wild type versus 48% ΔuspA616::kanM. luteus). We observed no detrimental UspA616 knockout phenotype in logarithmic growth. Proteomics demonstrated statistically significant log-phase upregulation of glyoxylate pathway enzymes isocitrate lyase and malate synthase in ΔuspA616::kanM. luteus We note that these enzymes and the M. tuberculosis UspA616 homolog (Rv2623) are important in M. tuberculosis virulence and chronic infection, suggesting that Usps are important stress proteins across diverse bacterial species. We propose that UspA616 is a metabolic switch that controls survival by regulating the glyoxylate shunt.IMPORTANCE Bacteria tolerate severe external stresses, including antibiotics, through a nonreplicative persistent (NRP) survival state, yet the proteins regulating this survival state are largely unknown. We show a specific universal stress protein (UspA616) controls the NRP state in Micrococcus luteus Usps are widely conserved across bacteria, but their biological function(s) has remained elusive. UspA616 inactivation renders M. luteus susceptible to stress: bacteria die instead of adapting through the NRP state. UspA616 regulates malate synthase and isocitrate lyase, glyoxylate pathway enzymes important for chronic Mycobacterium tuberculosis infection. These data show that UspA616 regulates NRP stress survival in M. luteus and suggest a function for homologous proteins in other bacteria. Importantly, inhibitors of UspA616 and homologs may render NRP bacteria more susceptible to stresses, including current antibiotics.

A color-based competition assay for studying bacterial stress responses in Micrococcus luteus.

Competition assays measure differences between populations of bacteria after stress adaptation, populations of different bacteria and mutations in antibiotic resistance genes. We have developed a competition-based assay to evaluate if genes upregulated under starvation are important for bacterial survival. Stress responses are critical for survival in non-pathogenic and pathogenic bacteria alike including Mycobacterium tuberculosis, Enterococcus fecaelis, Escherichia coli and Staphylococcus aureus. Unfortunately, most stress-survival proteins are poorly understood because suitable model bacteria and techniques are limited. To address this problem, we have engineered Micrococcus luteus NCTC 2665 (M. luteus) for competition assays by inactivating the sarcinaxanthin biosynthesis gene crtE (ΔcrtE), changing M. luteus colonies from yellow to white. This change allows easy identification in mixed cultures. The crtE knockout is relatively neutral for growth in complex and minimal acetate media and shows a measured fitness of one in competition with yellow wild-type bacteria. The ΔcrtE M. luteus competition assay identified a competition defect in a M. luteus strain when a specific universal stress protein was inactivated, suggesting a negative survival phenotype for this protein. We anticipate this competition assay can identify defects in other gene knockouts and mutational studies in M. luteus and will enhance our understanding of bacterial survival mechanisms.