Reconceptualizing cannabis use risks in the context of health and social inequities: Insights from a qualitative study with young people in Canada.

BACKGROUND: Cannabis became legal in Canada in 2018. Since then, calls for research to evaluate the impact of legalization on youth have been at the forefront of public and academic discussions. Research addressing these calls has largely focused on issues of risk and harm, with limited attention to the role of social context in shaping youth cannabis use. This paper presents the findings of a study that centered youth perspectives on cannabis use in the context of health and social inequities. METHODS: Between 2021 and 2022, we undertook an exploratory and critical qualitative interview study with 56 youth from across Canada who use cannabis and who reported experiences with health or social struggles, broadly self-defined. Our analysis followed a reflexive thematic approach and leveraged theoretical perspectives from critical drug studies to interrogate youths' variegated cannabis use risks and risk environments, whilst facilitating inquiry into their interface with overlapping forms of hardship and inequity. FINDINGS: We developed three interconnected themes: (i) cannabis use risks as contextually situated; (ii) cannabis use as a practice of care; and (iii) cannabis use as a survival tool in connection with trauma and violence. Findings within and across these themes centre on the nexus of intentionality and agency in youth narratives of using cannabis and situates their cannabis use in connection with, and in response to, intersecting health and social inequities. CONCLUSION: This study underscores opportunities for a reconsideration or reconceptualization of risks in the context of youth cannabis use, so that approaches to supporting youth who use cannabis are more resonant and credible with those who experience health and social inequities. Findings offer direction for youth cannabis policy and programming, including to decenter individual pathology, support harm reduction goals, and further consider relationships between cannabis use and context, marginalization, and oppression.

The Phenomenology of the Face-to-Facetime: A Levinasian Critique of the Virtual Clinic.

In order to promote social distancing during the recent COVID-19 pandemic, physicians and healthcare systems have made efforts to replace in-person with virtual clinic visits when feasible. While these efforts have been well received and seem compatible with sound clinical practice, they do not perfectly replicate the experience of a face-to-face exchange between doctor and patient. This essay attempts to describe features of the virtual visit that distinguish it from its face-to-face analog and considers the phenomenological work of Emmanuel Levinas in arguing that these differences may limit the force of the ethical summons a provider would otherwise experience before the face of a patient. The diminishment of this signal therapeutic experience may engender vocational as well as clinical consequences, which should be weighed against the practical benefits of the virtual visit as we consider whether our enthusiasm for this mode of practice should continue.

Factors Affecting Medical Residents' Decisions to Work After Call.

BACKGROUND: Accreditation Council for Graduate Medical Education (ACGME) work-hour restrictions (WHRs) are intended to improve patient safety by reducing resident fatigue. Compliance with ACGME WHRs is not universal. PURPOSE: The purpose of this study was to identify factors that influence residents' decisions to take a postcall day (PCD) off according to ACGME WHRs. METHODS: Residents (N = 433) at one university were emailed a link to a survey in 2019. The survey included demographic details and a Discrete Choice Experiment examining influences on resident decisions to take a PCD off. RESULTS: One hundred seventy-five residents (40.4%) responded to the survey; 113 residents (26%) completed the survey. Positive feedback from attending physicians about taking PCDs off in the past had the greatest impact on respondents' decisions to take a PCD off, increasing the probability by 27.3%, followed by chief resident comments about the resident looking tired (16.6% increase), and having never heard their attendings comment about PCDs off as either positive or negative (13.9% increase). Factors that had the largest effect on decreasing the probability of taking a PCD were negative feedback about taking PCDs off (14.3% decrease), continuity of care concerns (10.8% decrease), and whether the resident was looking forward to an assignment (7.9% decrease). CONCLUSIONS: The most important influencer of residents' decisions to take a PCD off was related to feedback from their attending physicians, suggesting that compliance with WHRs can be improved by focusing on the residency program's safety culture.

Systemic Steroids for Otolaryngology-Head and Neck Surgery Disorders: An Evidence-Based Primer for Clinicians.

OBJECTIVE: To offer pragmatic, evidence-informed guidance on the use of systemic corticosteroids (SCS) for common otolaryngologic disorders. DATA SOURCES: PubMed, Cochrane Library, and American Academy of Otolaryngology-Head and Neck Surgery Foundation clinical practice guidelines. REVIEW METHODS: A comprehensive search of published literature through November 2021 was conducted on the efficacy of SCS, alone or in combination with other treatments, for managing disorders in otolaryngology and the subdisciplines. Clinical practice guidelines, systematic reviews, and randomized controlled trials, when available, were preferentially retrieved. Interventions and outcomes of SCS use were compiled to generate summary tables and narrative synthesis of findings. CONCLUSIONS: Evidence on the effectiveness of SCS varies widely across otolaryngology disorders. High-level evidence supports SCS use for Bell's palsy, sinonasal polyposis, and lower airway disease. Conversely, evidence is weak or absent for upper respiratory tract infection, eustachian tube dysfunction, benign paroxysmal positional vertigo, adenotonsillar hypertrophy, or nonallergic rhinitis. Evidence is indeterminate for acute laryngitis, acute pharyngitis, acute sinusitis, angioedema, chronic rhinosinusitis without polyps, Ménière's disease, postviral olfactory loss, postoperative nerve paresis/paralysis, facial pain, and sudden sensorineural hearing loss. IMPLICATIONS FOR PRACTICE: Clinicians should bring an evidence-informed lens to SCS prescribing to best counsel patients regarding the risks, anticipated benefits, and limited data on long-term effects. Alternate routes of corticosteroid administration-such as sprays, drops, inhalers, and intralesional injections-may be preferable for many disorders, particularly those that are self-limited or require a prolonged duration of therapy. Prudent use of SCS reduces the risk of medication-related adverse effects. Clinicians who are conversant with high-level evidence can achieve optimal outcomes and stewardship when prescribing SCS.

Medical Ethics as Taught and as Practiced: Principlism, Narrative Ethics, and the Case of Living Donor Liver Transplantation.

The dominant model for bioethical inquiry taught in medical schools is that of principlism. The heritage of this methodology can be traced to the Enlightenment project of generating a universalizable justification for normative morality arising from within the individual, rational agent. This project has been criticized by Alasdair MacIntyre who suggests that its failure has resulted in a fragmented and incoherent contemporary ethical framework characterized by fundamental intractability in moral debate. This incoherence implicates principlist conceptions of bioethics. Medical ethics as practiced, though, is partially in keeping with teleological alternatives to principlism. Nonetheless, the hegemony of principlism threatens to harm the practice of good medicine whenever it is used to provide justification for the sanction or prohibition of practices, despite not being equipped to grant moral authority to such justifications. An example of this failure and its resulting harm is expressed in the growing obsolescence of living donor liver transplantation.

Perceptions of Safety Climate and Fatigue Related to ACGME Residency Duty Hour Restrictions in Otolaryngology Residents.

OBJECTIVE: To compare otolaryngology residents' perceptions of safety climate with respect to duty hour compliance and self-perceived fatigue. STUDY DESIGN: Cross-sectional study. SETTING: Forty-one otolaryngology residencies distributed across the United States. METHODS: A national sample of otolaryngology residents was surveyed electronically in 2019. The survey included demographic details, on-call descriptors, an 18-point Safety Climate Survey (SCS) modified to measure perceptions of program attitudes and practices around resident duty hour compliance, and the 33-point Chalder Fatigue Questionnaire (CFQ). RESULTS: Of 397 surveyed residents, 205 (51.6%) responded. The mean modified SCS score was 11.29 out of 18 (95% CI, 10.76-11.81). Respondents were most likely to disagree with "Residents are told when they are at risk of working beyond ACGME [Accreditation Council for Graduate Medical Education] duty hour restrictions," where 100 (48.8%) disagreed or strongly disagreed. The mean CFQ score was 15.99 of 33 (95% CI, 15.17-16.81). As the modified SCS score improved, CFQ scores decreased, indicating an inverse relationship between duty hour safety climate and fatigue. Having a protected postcall day off and having the program director, chief resident, or senior resident decide that a resident should take a postcall day off were all associated with higher modified SCS scores. CONCLUSION: Otolaryngology residents perceived a safety climate that is suboptimal with regard to duty hour restriction issues. Additionally, an inverse relationship between fatigue and modified SCS scores suggests that fatigue among residents may be lower in programs where residents perceive that ACGME duty hour compliance is more important.

Standardization and Reduction of Narcotics After Pediatric Tonsillectomy.

OBJECTIVES: (1) To measure caregiver satisfaction with a nonstandardized postoperative pain regimen after pediatric tonsillectomy. (2) To implement a quality improvement project (QIP) to reduce the number and volume of narcotics prescribed and to describe the effect on caregiver satisfaction. METHODS: A prospective cohort study at a tertiary children's hospital examined postoperative narcotics prescribed to children following adenotonsillectomy. A QIP was implemented 3 months into the observation, with the goal to standardize nonnarcotic analgesics and reduce the volume of narcotics prescribed. Caregivers were called 2 to 3 weeks postoperatively to assess pain control and caregiver satisfaction. RESULTS: Over an 8-month period, 118 patients were recruited (66 before the QIP, 52 after induction). Prior to the QIP, 47% of patients were prescribed postoperative narcotics, as opposed to 27% after the QIP (P < .05). There was a significant reduction in the volume of narcotics prescribed before (mean ± SD, 300 ± 150 mL) versus after (180 ± 111 mL) the initiative (P < .05). The per-kilogram dose did not change over the study time frame. On a 5-point Likert scale, there was no difference in the caregivers' satisfaction regarding pain control before (4.37 ± 0.85) versus after (4.35 ± 1.0) the project started. DISCUSSION: A system shift was identified with the establishment of a posttonsillectomy pain control protocol associated with a reduction in prescribed narcotics without a significant change in caregiver satisfaction. IMPLICATIONS FOR PRACTICE: Implementing a standardized plan for the use of nonnarcotic medications was associated with reduced frequency and volume of narcotics prescribed. Future work will further standardize our postoperative pain regimen.

Incisional Hernia After Orthotopic Liver Transplantation: A Systematic Review and Meta-analysis.

BACKGROUND: Incisional hernia (IH) is a well-known complication of orthotopic liver transplantation. Despite wide recognition of the impact of this problem, the incidence remains imprecisely known. METHODS: The MEDLINE, EMBASE, Cochrane Central Register of Clinical Trials and Cochrane Database of Systematic Reviews databases were searched from their inception to November 2017 for abstracts documenting IH after orthotropic liver transplantation (OLT). The primary endpoint of this study was incidence of IH, secondary endpoints were time to hernia and recurrence. Three reviewers independently graded abstracts for inclusion in this review. Heterogeneity in combining data was assumed prior to pooling. Random-effects meta-analyses were performed to estimate percentages and 95% CIs. RESULTS: After a review of 77 abstracts, 18 studies were graded as relevant. The methodological quality of studies was assessed with a minimum Oxford Centre for Evidence-Based Medicine level of 2B. These represent a cohort of 981 patients with IH after OLT reported in the literature. A meta-analysis of studies meeting inclusion criteria shows mean incidence of 15.1% (CI 12.1%-18.2%). Aggregate recurrence rate reported in the literature is 12.4% (CI 4.3%-20.5%). Overall reported time to IH after OLT was 42.9 months. CONCLUSIONS: Although reported incidences of IH after OLT vary widely across studies, an overall incidence of 15.1% is reported. This is a relatively late complication after transplantation. Recurrence of hernia after initial repair is 12.4% within this patient population.

Flipping the Classroom in Otolaryngology Residencies.

Objective To understand the use of the flipped classroom (FC) - learning core content prior to an academic session, with class time devoted to applying this content - in otolaryngology residency education. Methods An electronic survey of 107 otolaryngology program directors (PDs), including demographic details, the flipped classroom perception instrument (FCPI), and the otolaryngology programs' current use of FC. Results Forty-four (41%) PDs completed the FCPI. Seventy-one point one (71.1%) of respondents were male, 60% were 30-49 years, and the remainder were older. Sixty-two percent (62%) had fellowships associated with their program, 21.7% of programs used the FC model Very Often, 17.4% Somewhat Often, 28.3% Sometimes, 17.4% Somewhat Rarely, 8.7% Very Rarely, and 6.5% Never. Attitudes toward FC principles were positive with modes "strongly agree" for all, except for "online modules enhance learning" where the mode was "slightly agree" with significantly higher scores for PDs over age 50 than for those younger (4.17 vs. 3.63, p=0.033). There were no other significant differences comparing male vs. female PDs, younger vs. older PDs, smaller vs. larger programs, programs with or without fellowships, programs with 100% vs. <100% board exam pass rates, or programs in different geographical regions. The pre-class activity mean score was 4.34 (95% CI 4.12-4.56) and the in-class mean score was 4.18 (95% CI 3.99-4.37). There was no significant correlation between the likelihood of using a flipped classroom and attitude scores. Conclusion PDs value both the pre-class and interactive in-class principles of FCs but only 37.8% of programs use FC often, suggesting that practical approaches to implementation in this group could improve education in this population.

Surgical Team Exposure to Cautery Smoke and Its Mitigation during Tonsillectomy.

OBJECTIVES: To assess the exposure of surgical personnel to known carcinogens during pediatric tonsillectomy and adenoidectomy (T&A) and compare the efficacy of surgical smoke evacuation systems during T&A. STUDY DESIGN: Prospective, case series. SETTING: Tertiary children's hospital. SUBJECTS AND METHODS: The present study assessed operating room workers' exposure to chemical compounds and aerosolized particulates generated during T&A. We also investigated the effect of 3 different smoke-controlling methods: smoke-evacuator pencil cautery (SE), cautery with suction held by an assistant (SA), and cautery without suction (NS). RESULTS: Thirty cases were included: 12 in the SE group, 9 in SA, and 9 in NS. The chemical exposure levels were lower than or similar to baseline background concentrations, with the exception of methylene chloride and acetaldehyde. Within the surgical plume, none of the chemical compounds exceeded the corresponding occupational exposure limit (OEL). The mean particulate number concentration in the breathing zone during tonsillectomy was 508 particles/cm3 for SE compared to 1661 particles/cm3 for SA and 8208 particles/cm3 for NS cases. NS was significantly different compared to the other two methods (P = .0009). CONCLUSIONS: Although the exposure levels to chemicals were considerably lower than the OELs, continuous exposures to these chemicals could cause adverse health effects to surgical personnel. These findings suggest that the use of a smoke-evacuator pencil cautery or an attentive assistant with handheld suction would reduce exposure levels to the aerosolized particles during routine T&A, compared to the use of cautery without suction.

Balloon Catheter Dilation in Pediatric Chronic Rhinosinusitis: A Meta-analysis.

BACKGROUND: Paranasal sinus balloon catheter dilation (BCD) represents a tool that has been shown to be safe in the management of pediatric chronic rhinosinusitis (pCRS); however, its efficacy compared to standard treatment regimens has not been well established. OBJECTIVE: The purpose of this meta-analysis was to evaluate the clinical utility of BCD in pCRS. METHODS: Articles reporting BCD for pCRS in patients under 18 years of age were identified via the following search terms: sinusitis OR rhinosinusitis AND balloon dilatation OR balloon dilation OR balloon sinuplasty OR sinuplasty AND adolescent OR children OR infant OR pediatric OR toddler. The primary outcome analyzed includes quality of life improvement as measured via Sinus and Nasal Quality of Life Survey (SN-5) or Sino-nasal Outcome Test (SNOT-22) scores. RESULTS: Eighty studies were abstracted; 10 studies were included for final qualitative analysis after dual investigator screening. Three studies described BCD with surgical controls, including adenoidectomy, saline irrigation, or maxillary antrostomy. Noninferiority was not demonstrated (ie, BCD is inferior) in 2 of 3 studies. Pooled analysis utilizing a random effects model revealed a decreased effect size yet no statistically significant difference between BCD and standard operative techniques as measured by quality of life measures (g = -0.04, I2 = 41%). CONCLUSION: This work highlights a lack of published evidence regarding the role of BCD in pCRS. Two of the 3 included studies demonstrated the inferiority of BCD when compared to other standard surgical interventions, whereas meta-analysis was unable to detect any statistically significant difference between standard treatment regimens. Future scientific investigations are necessary to assess the comparative effectiveness of BCD in pCRS.

Patient characteristics associated with being offered take home naloxone in a busy, urban emergency department: a retrospective chart review.

BACKGROUND: Overdose deaths can be prevented by distributing take home naloxone (THN) kits. The emergency department (ED) is an opportune setting for overdose prevention, as people who use opioids frequently present for emergency care, and those who have overdosed are at high risk for future overdose death. We evaluated the implementation of an ED-based THN program by measuring the extent to which THN was offered to patients presenting with opioid overdose. We analyzed whether some patients were less likely to be offered THN than others, to identify areas for program improvement. METHODS: We retrospectively reviewed medical records from all ED visits between April 2016 and May 2017 with a primary diagnosis of opioid overdose at a large, urban tertiary hospital located in Alberta, Canada. A wide array of patient data was collected, including demographics, opioid intoxicants, prescription history, overdose severity, and whether a naloxone kit was offered and accepted. Multivariable analyses were used to identify patient characteristics and situational variables associated with being offered THN. RESULTS: Among the 342 ED visits for opioid overdose, THN was offered in 49% (n = 168) of cases. Patients were more likely to be offered THN if they had been found unconscious (Adjusted Odds Ratio 3.70; 95% Confidence Interval [1.63, 8.37]), or if they had smoked or injected an illegal opioid (AOR 6.05 [2.15,17.0] and AOR 3.78 [1.32,10.9], respectively). In contrast, patients were less likely to be offered THN if they had a current prescription for opioids (AOR 0.41 [0.19, 0.88]), if they were admitted to the hospital (AOR 0.46 [0.22,0.97], or if they unexpectedly left the ED without treatment or before completing treatment (AOR 0.16 [0.22, 0.97). CONCLUSIONS: In this real-world evaluation of an ED-based THN program, we observed that only half of patients with opioid overdose were offered THN. ED staff readily identify patients who use illegal opioids or experience a severe overdose as potentially benefitting from THN, but may miss others at high risk for future overdose. We recommend that hospital EDs provide additional guidance to staff to ensure that all eligible patients at risk of overdose have access to THN.

Financial Burden of Liver Transplant vs Resection for Hepatocellular Carcinoma.

BACKGROUND: Liver transplant and liver resection are surgical treatments for hepatocellular carcinoma (HCC) performed with curative intent. While liver transplant provides longer survival when compared to resection, the financial burden on patients and payors is significantly greater. With the increase in health care costs and the emergence of high deductible insurance policies that increase out of pocket deductibles for patients, assessment of value-based treatment is warranted. METHODS: We compiled total billable events from diagnosis of HCC through resection (N = 20) or transplant (N = 24) to death or last reported encounter from January 2011 to December 2012. RESULTS: Patients with HCC receiving resection had a model of end stage liver disease of 10.2 ± 1.2, survival 652 days (3-1, 167 days), and billable encounters of $316,873 ($2904/day). HCC patients receiving a liver transplant had a greater liver injury (model of end stage liver disease of 19.2 ± 3.7), longer survival (1579 days), and higher billable encounters, $740,714 ($2889/day). The surgical procedure represented the largest cost category (28% and 26% resection vs transplant, respectively). The cost effectiveness of treatment was directly proportional to length of survival. In resection, patients who survived >30 days (85%) cost per day dropped to $432. Transplant patients who survived >2 years (75%) saw the cost per day drop to $462. CONCLUSION: The relative financial burdens of liver resection vs liver transplant for treating HCC are comparable in patients who survive beyond a certain threshold. Transplant patients survived longer, and survival beyond 2 years makes this approach cost effective. In a health care climate aiming to contain costs and evaluate value-based treatment paradigms, expected survival and financial burden should be included in the treatment decision analysis.

Experience with key indicator cases among otolaryngology residents.

OBJECTIVE: To describe the resident experience with respect to key indicator cases for each year of training. STUDY DESIGN: Multi-institution, cross-sectional assessment. METHODS: Using an electronic survey, current otolaryngology residents were solicited to complete a survey regarding their experiences with the key indicator cases to that point. The survey was sent to this cohort in the winter of 2017-2018. RESULTS: Three hundred and three residents responded, with 293 completing the survey. Twenty-three percent were PGY1, 19% PGY2, 21% PGY3, 18% PGY4, and 19% PGY5 or higher. The majority of residents progress from resident assistant as a PGY2, to resident surgeon as a PGY3 and self-assessed competent surgeon as a PGY4 for the majority of the key indicator cases. Less than 50% of the surveyed PGY5 residents had reached independent practice in all the key indicator cases, with stapedectomy (16%), rhinoplasty (18%), and paramedian forehead flap (14.5%) being the cases least frequently performed independently. Ninety-five percent of the respondent residents felt their program provided adequate training, but 20% of the respondents were either unsure or believed that they would be unable to perform all the key indicator cases by the completion of their training. CONCLUSIONS: The majority of otolaryngology residents feel confident in their training, but experience with certain cases lags behind and may not currently be taught as resident level cases. These findings raise the question of whether the current key indicator cases are the best option for assessing breadth and depth of residency training. LEVEL OF EVIDENCE: NA.

Effect of intra-op morphine on children with OSA undergoing tonsillectomy.

OBJECTIVES: 1. To compare outcomes after tonsillectomy for pediatric patients with obstructive sleep apnea (OSA) given morphine intra-operatively and post operatively compared to those who were not - specifically Recovery Room (RR) time, length of stay (LOS), Emergency Department (ER) visits. STUDY DESIGN: Retrospective case series with chart review. SETTING: Tertiary care children's hospital. SUBJECTS AND METHODS: All children between 1 and 17 years old who had undergone tonsillectomy in a single institution from 2013 to 2016. Comparison between children who had received morphine intra-operatively was made for outcomes. RESULTS: 556 patients were included, 73 patients had morphine intraoperatively and 483 did not; these latter children were older (8.8 vs 6.5 years, P < 0.001), and had fewer episodes of obstructive apnea and hypopnea (AHI 4.47 vs 10.15, p = 0.003) than children who did not receive intra-op morphine. There were no differences in co-morbidities including asthma, whether they had a sleep study, time in the operating room, emergence time, RR time, airway complications, IMC/PICU admission for respiratory distress, ER visits, readmissions, bleeding or post-discharge nurse phone calls. There was a longer LOS (25.9 vs 21.4 h, P = 0.011) for the group receiving intra-op morphine. CONCLUSION: Children with OSA who receive intra-op morphine have a longer LOS suggesting that its use should be examined more closely in this population.

Uptake into a bedside needle and syringe program for acute care inpatients who inject drugs.

INTRODUCTION AND AIMS: Injection drug use is associated with significant morbidity and mortality worldwide. Needle and syringe programs (NSP) have been shown to reduce negative health outcomes for people who inject drugs. However, NSPs have limited reach in hospitals, and no peer-reviewed research has examined NSP implementation in acute care settings. We describe the implementation of an inpatient NSP offered through an addiction medicine consultation service in a large, urban acute care hospital in Edmonton, Canada, and compared characteristics of inpatients who did versus did not access the NSP. DESIGN AND METHODS: Administrative data were reviewed for all addiction medicine consult service intakes between 11 July 2016 and 14 January 2018. We calculated the proportion of intakes in which patients: (i) were offered syringes; and (ii) accepted syringes. Multivariate analyses were used to examine associations between these outcomes and patient age and sex. RESULTS: Patients reported injecting drugs in 597 (31%) of 1907 intakes during the study period. People who inject drugs were offered syringes in 334 (56%) of these intakes, and accepted syringes in 124 (37%) of them. Female patients were more likely to accept syringes. DISCUSSION AND CONCLUSIONS: In a recently implemented NSP for hospital inpatients, just over half of patients who reported injection drug use were offered syringes, and the rate of patient acceptance was low. Further research is necessary to describe best practice for inpatient NSPs and identify and remove any barriers that prevent some inpatients from either being offered or accepting syringes.

Transdermal lidocaine as treatment for chronic subjective tinnitus: A pilot study.

OBJECTIVE: To assess the efficacy of transdermal lidocaine as a treatment for chronic subjective tinnitus as measured by the Tinnitus Functional Index (TFI). STUDY DESIGN: Pilot, prospective efficacy trial. SETTING: Tertiary care hospital. PATIENTS: Men and women, over the age of 18 with chronic subjective tinnitus for >6 months. INTERVENTION: Daily application of commercially available transdermal lidocaine patch. OUTCOME MEASURE: Change in the TFI. RESULTS: The average pre-treatment TFI score was 56.2. After 1 month the average TFI decreased to 41 (p < 0.05). The scores dropped to 34 and 35 after 2 and 3 months of treatment respectively. Despite improvement in symptoms of tinnitus, most patients did not continue the study after the first month, dropping out due to the size, discomfort, and appearance of the lidocaine patch, failure to follow-up and lack of perceived benefit from treatment. CONCLUSIONS: In this preliminary study, 5% transdermal lidocaine appears to be a potential treatment for chronic subjective tinnitus. The majority of subjects who completed 1 month of treatment had clinically significantly improved tinnitus. These findings are confounded however by the small sample size and significant drop out rate.

Postoperative renal impairment is associated with increased length of stay for incisional hernia repair after liver transplantation.

BACKGROUND: Incisional hernia repair is the most common procedure after orthotopic liver transplantation. Although enhanced recovery protocols are increasingly employed, the post-orthotopic liver transplantation patient may not benefit from all aspects of these models. The aim of the present study is to assess which perioperative interventions and patient factors affect hospital length of stay in a cohort of post-orthotopic liver transplantation patients undergoing incisional hernia repair. METHODS: We conducted a retrospective review of a series of adult patients undergoing incisional hernia repair after orthotopic liver transplantation. The primary endpoint was length of stay. Results were stratified by demographic, intraoperative, and postoperative variables. RESULTS: Eleven percent (172/1523) of patients who received orthotopic liver transplantation during the study period underwent subsequent incisional hernia repair. Median length of stay was 5 days (range 2-50). The strongest predictor of length of stay was postoperative renal function. Despite liberal intraoperative administration of volume (median 642 mL/h) and brisk intraoperative urine output (median 72 mL/h), postoperative acute kidney injury occurred in 48% of patients. Those that developed acute kidney injury received less intraoperative volume (6 vs 8.5 mL/kg/h; P = .031) and the severity of postoperative renal injury was inversely related to the amount intraoperative volume given. CONCLUSIONS: In patients undergoing incisional hernia repair after orthotopic liver transplantation, postoperative renal function is frequently impaired. Although many aspects of current ERAS protocols may be applied to post-transplant patients, restrictive intraoperative fluid administration strategies should be employed with caution given a high propensity for the development of post-operative acute kidney injury in this complex population.

Bilateral spontaneous temporomandibular joint herniation: A case report and literature review.

In this article we report the case of a 41-year-old man with bilateral aural fullness and hearing loss. On examination he was found to have bilateral, dehiscent anterior canal walls with herniation of the mandibular condyle. This herniation partially obstructed the canals and contributed to his symptoms. To the best of our knowledge, this is only the third reported case of bilateral spontaneous temporomandibular joint herniation, and only 28 cases of unilateral spontaneous herniation can be found in the English language literature. While it is a rare phenomenon, it should be considered when evaluating a patient with fluctuating ear symptoms.