Validation of a Novel Mobile Application for Assessing Pediatric Tracheostomy Emergency Simulations.

Objective: Pediatric tracheostomy is associated with high morbidity and mortality, yet clinician knowledge and quality of tracheostomy care may vary widely. In situ simulation is effective at detecting and mitigating related latent safety threats, but evaluation via retrospective video review has disadvantages (eg, delayed analysis, and potential data loss). We evaluated whether a novel mobile application is accurate and reliable for assessment of in situ tracheostomy emergency simulations. Methods: A novel mobile application was developed for assessment of tracheostomy emergency in situ simulation team performance. After 1.25 hours of training, 6 raters scored 10 tracheostomy emergency simulation videos for the occurrence and timing of 12 critical steps. To assess accuracy, rater scores were compared to a reference standard to determine agreement for occurrence or absence of critical steps and a timestamp within ±5 seconds. Interrater reliability was determined through Cohen's and Fleiss' kappa and intraclass correlation coefficient. Results: Raters had 86.0% agreement with the reference standard when considering step occurrence and timing, and 92.8% agreement when considering only occurrence. The average timestamp difference from the reference standard was 1.3 ± 18.5 seconds. Overall interrater reliability was almost perfect for both step occurrence (Fleiss' kappa of 0.81) and timing of step (intraclass correlation coefficient of 0.99). Discussion: Using our novel mobile application, raters with minimal training accurately and reliably assessed videos of tracheostomy emergency simulations and identified areas for future refinement. Implications for Practice: With refinements, this innovative mobile application is an effective tool for real-time data capture of time-critical steps in in situ tracheostomy emergency simulations.

Long-Term Water Vapor Thermal Therapy Outcomes Across a Broad Range of Prostate Volumes.

INTRODUCTION: Water vapor thermal therapy (WVTT) is a minimally invasive therapy designed to treat lower urinary tract symptoms associated with benign prostatic hyperplasia. Long-term outcomes with large (>80 cc) and small (<30 cc) prostate volumes (PVs) remain limited. We report 48-month outcomes for a multiethnic cohort of WVTT-treated men, stratified by PV. METHODS: In this single-center retrospective study, patients were stratified by PV: < 30 cc, 30 to 80 cc, or > 80 cc. Outcome measures, including International Prostate Symptom Score, quality of life, International Index of Erectile Function, medication usage, and adverse events, were analyzed at baseline and at 1-, 3-, 6-, 12-, 24-, 36-, and/or 48-month follow-up. RESULTS: Two hundred fifty-two patients met inclusion; 35 (13.9%) had PVs < 30 cc, 196 (77.8%) had PVs 30 to 80 cc, and 21 (8.3%) had PVs > 80 cc. Most patients were Asian (33.7%) or non-Hispanic Black (29.4%). International Prostate Symptom Score and quality of life improved in all cohorts from baseline at all follow-ups (all P < .05), with no differences between cohorts. International Index of Erectile Function-Orgasmic Function and -Erectile Function domains improved in 30 to 80 cc patients at 48 months. Alpha blocker and/or 5-alpha reductase inhibitor usage decreased at all follow-ups in < 30 cc and 30 to 80 cc patients and remained durable to only 6 months for > 80 cc patients. No significant differences in adverse events or reoperation rates were observed between cohorts. CONCLUSIONS: Our study suggests WVTT to be efficacious, durable, and safe in managing lower urinary tract symptoms across PVs, although PV > 80 cc patients may require benign prostatic hyperplasia medication at long-term follow-up. Further research is desired to clarify WVTT's role regarding sexual function and in treating men with larger PVs.

Harnessing In Situ Simulation to Identify Human Errors and Latent Safety Threats in Adult Tracheostomy Care.

BACKGROUND: Tracheostomies are associated with high rates of complications and preventable harm. Safe tracheostomy management requires highly functioning teams and systems, but health care providers are poorly equipped with tracheostomy knowledge and resources. In situ simulation has been used as a quality improvement tool to audit multidisciplinary team emergency response in the actual clinical environment where care is delivered but has been underexplored for tracheostomy care. METHODS: From July 2021 to May 2022, the study team conducted in situ simulations of a tracheostomy emergency scenario at Montefiore Medical Center to identify human errors and latent safety threats (LSTs). Simulations included structured debriefs as well as audiovisual recording that allowed for blind rating of these human errors and LSTs. Provider knowledge deficits were further characterized using pre-simulation quizzes. RESULTS: Twelve human errors and 15 LSTs were identified over 20 simulations with 88 participants overall. LSTs were divided into the following categories: communication, equipment, and infection control. Only 50.0% of teams successfully replaced the tracheostomy tube within the scenario's five-minute time limit. In addition, knowledge gaps were highly prevalent, with a median pre-simulation quiz score of 46% (interquartile range 36-64) among participants. CONCLUSION: An in situ simulation-based quality improvement approach shed light on human errors and LSTs associated with tracheostomy care across multiple settings in one health system. This method of engaging frontline health care provider key stakeholders will inform the development, adaptation, and implementation of interventions.

Real-world four-year functional and surgical outcomes of Rezum therapy in younger versus elderly men.

BACKGROUND: Management of urinary symptoms in elderly patients with benign prostatic hyperplasia (BPH) is complex given challenges with medications and invasive surgeries. Rezum, a minimally invasive water vapor therapy, is an emerging alternative. We compare real-world Rezum outcomes between young and elderly patients over 4 years. METHODS: We retrospectively analyzed a multiethnic population treated with Rezum at a single center between 2017-2019. Patients were stratified into young (<65 years) or elderly (≥65 years) cohorts. International Prostate Symptom Score (IPSS), Quality of Life (QoL), maximum urinary flow rate (Qmax), decisional regret scores, and adverse events (AEs) were assessed at baseline, 1-, 3-, 6-, 12-, and/or 48-months. Descriptive statistics were compared using t-tests, Chi-squared, or Mann-Whitney U tests. Changes in outcomes were assessed using Wilcoxon signed-rank tests, stratified by age. RESULTS: 256 patients - 146 (57%) young and 110 (43%) elderly - were included. The majority were Asian (33.2%) or non-Hispanic Black (28.9%). Significant improvements were observed in the combined cohort at 4-years in IPSS, QoL, and Qmax when compared to baseline (all p < 0.05). Between the age cohorts, there were no significant differences in IPSS, QoL, or Qmax at any follow-up. Within both cohorts, significant improvements in IPSS and QoL were found from baseline to all follow-ups. In the young cohort, Qmax was significantly improved from baseline to all follow-ups while in the elderly cohort, this was observed only at the 3-month follow-up. No significant differences in AEs or regret was found between cohorts. There was no significant difference in 4-year surgical retreatment rates between cohorts (elderly 4.0% vs young 4.4%, p = 0.86). CONCLUSIONS: There were no significant differences in IPSS, QoL, or AEs between elderly and younger men over 4 years following Rezum, suggesting comparable benefits and risks. Future research is warranted to clarify the impact of Rezum on Qmax in elderly men.

Teaching Tracheostomy Tube Changes: Comparison of Operant Learning Versus Traditional Demonstration.

Objective: Tracheostomy tube change is a multistep skill that must be performed rapidly and precisely. Despite the critical importance of this skill, there is wide variation in teaching protocols. Methods: An innovative operant conditioning teaching methodology was employed and compared to traditional educational techniques. Medical student volunteers at a tertiary care academic institution (Albert Einstein College of Medicine) were recruited and randomly distributed into 2 groups: operant vs traditional (control). Following the educational session, each group was provided with practice time and then asked to perform 10 tracheostomy tube changes. Performance was recorded and scored by blinded raters using deidentified video recordings. Results: The operant learning group (OLG) demonstrated greater accuracy in performing a tracheostomy tube change than the traditional demonstration group. Twelve of 13 operant learners performed the skill accurately each time compared to 3 of 13 in the traditional group (P = 0.002). The median lesson time was longer for the OLG (535 seconds) than for the traditional group, (200 seconds P < 0.001). The average time per tracheostomy change was not significantly different between the 2 groups (operant learners mean 7.1 seconds, traditional learners mean 7.5 seconds, P = 0.427). Discussion: Although the operant conditioning methodology necessarily requires a greater time to teach, the results support this methodology over traditional learning modalities as it enhances accuracy in the acquired skill. Operant learning methodology is under consideration for other skills and education sessions in our program. Future steps include the application and adaptation of this education model to students and residents in other settings and fields. Implications for Practice: Operant learning is effective for teaching multistep skills such as tracheostomy tube changes with decreased error rates.

Pediatric Tracheostomy Emergency Readiness Assessment Tool: International Consensus Recommendations.

OBJECTIVE: To achieve consensus on critical steps and create an assessment tool for actual and simulated pediatric tracheostomy emergencies that incorporates human and systems factors along with tracheostomy-specific steps. METHODS: A modified Delphi method was used. Using REDCap software, an instrument comprising 29 potential items was circulated to 171 tracheostomy and simulation experts. Consensus criteria were determined a priori with a goal of consolidating and ordering 15 to 25 final items. In the first round, items were rated as "keep" or "remove". In the second and third rounds, experts were asked to rate the importance of each item on a 9-point Likert scale. Items were refined in subsequent iterations based on analysis of results and respondents' comments. RESULTS: The response rates were 125/171 (73.1%) for the first round, 111/125 (88.8%) for the second round, and 109/125 (87.2%) for the third round. 133 comments were incorporated. Consensus (>60% participants scoring ≥8, or mean score >7.5) was reached on 22 items distributed across three domains. There were 12, 4, and 6 items in the domains of tracheostomy-specific steps, team and personnel factors, and equipment respectively. CONCLUSIONS: The resultant assessment tool can be used to assess both tracheostomy-specific steps as well as systems factors affecting hospital team response to simulated and clinical pediatric tracheostomy emergencies. The tool can also be used to guide debriefing discussions of both simulated and clinical emergencies, and to spur quality improvement initiatives. LEVEL OF EVIDENCE: 5 Laryngoscope, 133:3588-3601, 2023.

Should Men Eat More Plants? A Systematic Review of the Literature on the Effect of Plant-Forward Diets on Men's Health.

OBJECTIVE: To perform a systematic review of the literature on plant-based and plant-forward diets and the prevention/treatment of the following common men's health conditions: prostate cancer (PCa), erectile dysfunction (ED), and benign prostatic hyperplasia (BPH). METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses system criteria were utilized to search PubMed and Medline databases for the following search terms: "Diet (Mesh)" OR "Diet Therapy (Mesh)" AND "Prostatic Hyperplasia (Mesh)" OR "Prostatic Neoplasm (Mesh)" OR "Erectile Dysfunction (Mesh)." Articles in English published from 1989 to 2022 using human participants were analyzed, data summarized, and assessed for bias. RESULTS: Studies reporting on plant-based or vegetable-forward diets (Mediterranean) as an intervention were included. Cohort and cross-sectional studies using food frequency questionnaires or diet classification indices to quantify plant-based food intake patterns were included in the study. Ultimately, 12 PCa articles, 4 BPH articles, 6 ED articles, and 2 articles related to both BPH and ED were reviewed. Overall, the literature suggests plant-forward diets confer a protective effect on the men's health conditions reviewed. CONCLUSIONS: Evaluation of the literature on the impact of plant-forward diets on urologic conditions includes a heterogenous range of dietary patterns and study designs. The greatest amount of research has evaluated the application of plant-forward diets for PCa. While there is currently a lack of high-quality evidence for the use of plant-forward diets as prevention and/or treatment for PCa, ED, or BPH, reported outcomes suggest a consistent small beneficial impact alongside well-established benefits for common chronic conditions.