Hospital Admissions Associated With Head and Neck Injuries From Olympic-style Sports and Activities Between 2010 and 2022.

The objective of this study was to evaluate which Olympic-style sports and activities are most likely to result in hospitalizations relating to head and neck injuries. This was a cross-sectional study using the National Electronic Injury Surveillance System (NEISS) database. Subjects with head and neck injuries from selected Olympic-style sports and activities between 2010 and 2022 were included. Independent variables were demographics and injury characteristics (injury location and sport). The primary outcome variable was hospitalization (yes/no). Survey-weighted descriptive, bivariate, and logistic regression statistics were computed to measure the association between demographic/injury variables and hospitalization. There were 175,995 subjects (national estimate, 5,922,584) meeting inclusion criteria. After adjusting for demographic and injury characteristics, head injuries (odds ratio [OR] = 2.17; 95% CI, 1.83-2.56; P<0.001) demonstrated higher odds of hospitalization compared with facial injuries. Injuries from cycling (OR = 2.52; 95% CI, 2.16-2.95; P<0.001), mountain biking (OR = 2.56; 95% CI, 1.80-3.65; P<0.001), and horseback riding (OR = 4.01; 95% CI, 2.76-5.83; P<0.001) demonstrated higher odds of hospitalization relative to baseball injuries. In conclusion, head and neck injuries associated with high velocity Olympic-style sports and activities such as cycling, mountain biking, and horseback riding had the highest odds of hospitalization.

Virtual Surgical Planning of Superior Orbital Rim Fractures in Calvarial and Maxillofacial Trauma.

BACKGROUND: Superior orbital rim fractures are challenging fractures as they often concomitantly occur with additional calvaria fractures. Virtual surgical planning (VSP) has been underutilized in this area of craniomaxillofacial trauma for reconstruction. PURPOSE: The purpose of this study is to qualitatively describe the use of VSP and anatomically perfected stereolithic models in treatment of superior orbital rim fractures in combined neurosurgery/oral and maxillofacial surgery cases. STUDY DESIGN, SETTING, SAMPLE: This study is a retrospective case series of subjects who were treated at the Massachusetts General Hospital (July 2022 to November 2022). Inclusion criteria include subjects who had both calvaria and maxillofacial injuries requiring concurrent operative intervention on their superior orbital rim fractures and the use of VSP. PREDICTOR/EXPOSURE/INDEPENDENT VARIABLE: Not applicable. MAIN OUTCOME VARIABLE: The outcome variable of interest is the difference in the planned position of the orbital rim repair compared to the actual position achieved. COVARIATES: None. ANALYSES: Heat map analysis was used to compare the difference in the planned position versus the actual position achieved. RESULTS: There were six orbits (five subjects, mean age 33.8 ± 21.49 years) that met the criteria. The mean difference in planned versus actual orbital volume achieved was 2.52 ± 2.48 cm3. The superimposition of the postoperative scan to the planned simulation revealed 84% ± 3.27% of the voxel surface was within +2 and -2 millimeters of its planned position. CONCLUSION AND RELEVANCE: This study has demonstrated the use of VSP in combined neurosurgery and oral and maxillofacial surgery procedures in the fixation of superior orbital rim fractures. This case series highlights that the postoperative position achieved in the six orbits was within 84% of the planned position.

Understanding Health Policy and Its Importance in Residency Education for Oral and Maxillofacial Surgery.

Health policy shapes the delivery of surgical care and the reimbursement of oral and maxillofacial surgeons (OMSs). Understanding broad principles of health policy will better allow surgeons to develop policies that will ultimately affect surgical practice. The growing presence of corporate and private equity investments in OMS practice management as well as expanding interests in value-based reimbursement models has innumerable implications for OMSs and patients. A standardized health policy curriculum for educating OMS trainees in key health policy principles may encourage OMSs to actively participate in health care advocacy efforts and shape the policies that may affect their future scope of practice.

Pulmonary manifestations of chronic HPV infection in patients with recurrent respiratory papillomatosis.

Human papillomavirus (HPV) types 6 and 11 can infect the squamous epithelium of the respiratory tract. Up to 8·9% of patients with HPV-associated recurrent respiratory papillomatosis (RRP) have pulmonary involvement. Pulmonary manifestations of HPV infection are associated with considerable morbidity, in part because treatment options and management guidelines are lacking. Patients with pulmonary RRP have a 32-times increased lifetime risk of malignant transformation compared with the overall RRP population. We review the clinical and radiographic presentation, pathological features, and genetics of pulmonary RRP, and we provide management algorithms based on our clinical experience with this complex patient population. In patients with suspected pulmonary involvement, tissue-sparing procedures to address growing lesions might be warranted given the chronicity and multifocality of the disease over a patient's lifetime. However, malignant transformation of pulmonary lesion(s) warrants standard-of-care treatment for primary lung squamous cell carcinoma. Large cohort studies are needed to understand the clinical course of pulmonary RRP and to identify molecular markers of increased risk of malignant transformation in order to develop guidelines for optimal and standardised surveillance and treatment.

Direct application of ropivacaine-soaked gauze to sciatic nerve after necrotizing fasciitis exposes underlying muscles and nerves.

Background: Necrotizing fasciitis is a rapidly progressive infection of the subcutaneous tissue and fascia with significant morbidity and mortality. There is a paucity of literature published on the benefits of regional anaesthesia in patients with necrotizing fasciitis of the extremities. Case Presentation: This study demonstrates novel approaches to management of pain in a patient with necrotizing fasciitis of the lower extremity. A 47-year-old male with polysubstance use disorder was found to have necrotizing fasciitis of the lower extremity. Surgical debridement included 15% of his total body surface area and resultant exposure of his sciatic nerve. A ropivacaine-soaked gauze was applied directly to the exposed sciatic nerve. Femoral and lateral cutaneous nerve blocks were performed to facilitate necessary surgical dressing changes and physical therapy. Conclusion: This report details techniques used in postoperative pain management to facilitate surgical dressing changes after extensive debridement of an extremity for necrotizing fasciitis. The use of local anaesthetic-soaked gauze may be a useful adjunct in certain scenarios.

Operating Room Staff Perceptions of Medical Students.

OBJECTIVE: While the operating room (OR) is a keystone experience, medical students often report negative experiences and intimidation in the OR. The purpose of this study is to describe the perceived role of medical students in the OR by registered nurses and certified surgical technologists to improve medical student education. DESIGN: A cross-sectional survey of select Massachusetts General Hospital perioperative staff in surgery was conducted through an anonymous survey in March 2021. Statistical analysis included inductive thematic analysis, descriptive statistics, and Mann-Whitney U tests, with a p-value of <0.05. The survey instrument characterized the perception of medical student preparedness for OR-related tasks and free-text responses on the role of medical students in the OR and opportunities for improvement. SETTING: The study was conducted at the Massachusetts General Hospital, Boston, MA. PARTICIPANTS: Participants included Massachusetts General Hospital perioperative staff in the Department of Surgery, with 262 registered nurses and 90 certified surgical technologists receiving the survey. RESULTS: There were 86 completed responses (24.4% response rate). A total of 71.23% of respondents believe medical students should be observational learners in the OR. Areas for improvement include OR etiquette (37.5%), awareness of the surgical field (26.79%), and scrubbing skills (26.79%). A total of 48.8% of staff agreed they enjoy working with medical students, followed by 20.9% who somewhat agree. A total of 27.91% of respondents somewhat agreed that medical students were knowledgeable about OR sterility and scrubbing procedures, followed by 25.58% who somewhat disagreed. CONCLUSIONS: Operating room staff enjoy working with medical students. The majority of staff believe medical students' role in the OR is that of observational learning. Areas of improvement for medical students include OR etiquette, awareness of the surgical field, scrubbing and gowning skills, and assisting staff whenever needed. Possible solutions include incorporating nursing staff as surgery clerkship stakeholders to optimize medical student experiences in the OR.

Effects of racial residential segregation on oral squamous cell carcinoma prognosis and survival.

OBJECTIVES: The objective of this study is to evaluate the impact of racial residential segregation on disease prognosis and overall survival in Black patients diagnosed with oral squamous cell carcinoma (OSCC), relative to White patients. MATERIALS AND METHODS: This retrospective cohort study identified individuals diagnosed with OSCC between 2005 and 2015 using the Surveillance, Epidemiology and End Results Database. Patients were included with cancers diagnosed in the following locations: lip, tongue, gum, floor of mouth, palate, and other/unspecified. Tumors located at the base of tongue, tonsils, and oropharynx were excluded. The primary predictor variable was the degree of residential segregation. The primary outcome was overall survival. A Kaplan Meier survival analysis and univariate/multivariate analyses were performed to account for potential confounders of survival. RESULTS: A total of 35,769 patients met inclusion criteria. At the time of initial diagnosis, Black patients presented with OSCC of higher grades and more advanced stages (p < 0.001). A greater number of Black subjects were dead by the time of last follow-up compared to White subjects (p < 0.001). Across the entire spectrum of residential segregation, cumulative survival was worse among Black patients compared to Whites (p < 0.001). Multivariate analysis identified highly segregated counties, advanced age, higher grade/advanced stage at time of diagnosis, lack of surgery, and no chemotherapy treatment as poor prognostic factors for survival among Black individuals. CONCLUSION: Racial residential segregation results in poorer long-term cancer survival among Black patients. Understanding the links between residential segregation and inequities in cancer outcomes will allow policymakers to better implement targeted, population-based interventions in treating various cancers.

Perioperative considerations in the management of cold agglutinin disease in laparoscopic surgery.

An 80-year-old man with idiopathic cold agglutinin disease presented with acute cholecystitis. We describe operating room and anaesthetic considerations for patients with cold agglutinin disease and measures that can be taken to prevent disease exacerbation in this case report. Multidisciplinary collaboration and planning between the operative room staff, anaesthesia team and surgical team are needed to ensure safe surgery and optimal patient outcomes.

The Efficacy of Liposomal Bupivacaine for Opioid and Pain Reduction: A Systematic Review of Randomized Clinical Trials.

Background The opioid crisis has prompted surgeons to search for alternative postoperative methods of analgesia. Liposomal bupivacaine is a long-acting local anesthetic formulation used for pain, potentially reducing opioid use. Evaluation of liposomal bupivacaine as a viable alternative for pain management is needed. The objective was to assess the efficacy of randomized clinical trials (RCTs) of liposomal bupivacaine in postoperative pain management and opioid consumption. Material and Methods The authors extracted RCTs comparing liposomal bupivacaine versus placebo or active comparators for postoperative pain or opioid reduction from PubMED/MEDLINE, Cochrane Library, and ClinicalTrials.gov. Exclusion criteria included nonhuman studies, non-RCTs, pooled studies, and inability to access full text. The following variables were abstracted: surgical specialty, number of subjects, pain and opioid outcomes, and authors' financial conflicts of interest. Results We identified 77 published RCTs, of which 63 studies with a total of 6770 subjects met inclusion criteria. Liposomal bupivacaine did not demonstrate significant pain relief compared to placebo or active agents in 74.58% of RCTs. Of the studies evaluating narcotic use, liposomal bupivacaine did not show a reduction in opioid consumption in 85.71% of RCTs. Liposomal bupivacaine, when compared to standard bupivacaine or another active agent, yielded no reduction in opioid use in 83.33% and 100.00% of studies, respectively. Clinical trials with a financial conflict of interest relating to the manufacturer of liposomal bupivacaine were significantly more likely to show pain relief (OR: 14.31 [95% CI, 2.8, 73.10], P = 0.0001) and decreased opioid consumption (OR: 12.35 [95% CI 1.40, 109.07], P = 0.0237). Of the 265 unpublished RCTs on ClinicalTrials.gov, 47.54% were withdrawn, terminated, suspended, or completed without study results available. Conclusions The efficacy of liposomal bupivacaine for providing superior postoperative pain control relative to placebo or another active agent is not supported by a majority of RCTs. Underreporting of trial results and bias due to underlying financial relationships amongst authors are two major concerns that should be considered when evaluating the available evidence.

The Inequitable Global Burden of Lip and Oral Cancers: Widening Disparities Across Countries.

PURPOSE: In light of continued innovation in cancer immunotherapy regimens and surgical management, no studies currently exist assessing the effect of these advances on global disparities in lip and oral cavity cancer disease burden. The purpose of this study is to characterize longitudinal trends in disease burden caused by lip and oral cavity cancers globally. MATERIALS AND METHODS: This retrospective, longitudinal cohort study extracted data on lip and oral cavity cancer disease burden from The Global Health Data Exchange for 1990-2017. The primary predictor variable was country human development index (HDI). The primary outcome variable was disease burden, measured by age-standardized disability-adjusted life years (DALYs) per 100,000 population, listed for each individual country. Additional variables assessed include country-level data on alcohol consumption and tobacco smoking. Concentration indices were also calculated. Mann-Whitney U and Kruskal-Wallis one-way analysis of variance tests with Bonferroni correction were utilized with a significance threshold of 0.008. RESULTS: A total of 185 countries met inclusion criteria. Global age-standardized DALYs increased from 44.5 ± 35.7 to 51.1 ± 41.1 from 1990 to 2017. High HDI and medium HDI countries showed a +37.6% and +22.4% median increase in DALYs, respectively, which is significantly greater than very-high HDI (+3.8%) and low HDI countries (-0.5%) (P < .001). The concentration index for lip and oral cavity cancer became increasingly negative from -0.064 to -0.077 from 1990 to 2015. In 2017, disease burden was concentrated in South Asia and Eastern Europe. CONCLUSIONS: High and medium HDI countries experienced a disproportionate growth in lip and oral cavity cancer disease burden. These findings may have resulted from increased life expectancy among these countries. Global and public health policy initiatives should focus on understanding the mechanisms driving these disparities with the goal of reducing disease burden globally.

Assessment of Intraoperative Time for Head and Neck Cancer Surgeries Compared With Medicare Work Time.

PURPOSE: Surgeon reimbursement is dictated in part by the operative time necessary to complete a procedure. The purpose of this study is to compare insurer-set time to true intraoperative time for common head and neck cancer procedures. METHODS: This retrospective cohort study compares intraoperative times between the 2019 Center for Medicare and Medicaid Services (CMS) work-time estimates and the 2017 to 2018 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) data sets for 10 commonly billed head and neck cancer procedures. The primary predictor variable was common head and neck oncologic and reconstructive procedures with corresponding Current Procedural Terminology (CPT) code. The primary outcome variable includes the computed difference between CMS and NSQIP times. Additional variables collected include patient demographics (gender, age, race, and inpatient/outpatient) and work relative value unit (wRVU) per CPT code. Analysis of variance was used to evaluate differences in intraoperative times across CPT codes. Linear regression using standardized coefficients were calculated between CMS time and NSQIP time; CMS time and wRVUs; and NSQIP time and wRVUs. RESULTS: There were 8,330 subjects (44% female, 57.7% inpatient) across 10 CPT codes. Analysis of variance revealed intercode variability in median intraoperative times between CMS and NSQIP (P < .001). CMS underestimated the time necessary to complete excision of malignant tumor mandible (CPT 21045) by 315 minutes. CMS overestimated the time necessary for excision of tongue lesion (CPT 41112) by 5 minutes. Overall, CMS intraoperative time estimates were neither invariably longer nor consistently shorter than NSQIP procedural times (ß, 0.85; 95% confidence interval, 0.43 to 1.26). CONCLUSIONS: CMS estimates of time needed to complete head and neck cancer surgeries varies from national intraoperative times. No consistent trend in underestimation or overestimation of procedure time was found. Improving the accuracy of CMS time estimates used in determining surgeon reimbursement for head and neck cancer procedures may be warranted.