Complications of Corticosteroid Therapy: A Comprehensive Literature Review.

Relevance to Patient Care and Clinical Practice: Corticosteroids are among the most prescribed medications, particularly during the COVID-19 era. The literature has clearly highlighted the dangers of prolonged, high-dose corticosteroid use, which is important for clinicians to consider before treating patients in their clinical practices. Objective: The objective of this article is to review the literature on complications of corticosteroid use, review corticosteroid pharmacokinetics, and provide an updated reference on risks associated with corticosteroid therapy, especially at higher doses. Data Sources: A conventional literature search of PubMed was conducted without restrictions on publication date. Search terms included "corticosteroids," "avascular necrosis," "gastrointestinal bleeding," and "complications." Study Selection and Data Extraction: Pertinent systematic review/meta-analyses and randomized controlled trials were reviewed for study inclusion. Data Synthesis: Corticosteroids were associated with complications including avascular necrosis, gastrointestinal bleeding, myocardial infarction, heart failure, cerebrovascular events, diabetes mellitus, psychiatric syndromes, ophthalmic complications, tuberculosis reactivation, and bacterial sepsis. Increased daily and cumulative doses were associated with increased excess risk of complications. Cumulative doses greater than 430 mg prednisone equivalent were shown to increase the excess risk of avascular necrosis, with progressively higher rates with higher doses. Risk of gastrointestinal bleeding was significantly increased with corticosteroid usage in the in-patient but not out-patient setting. Conclusion: Since corticosteroids have been associated with the aforementioned severe complications and frequent medicolegal malpractice claims, counseling and informed consent should be performed when prescribing moderate-high dosages of corticosteroids. Further research is needed to characterize the long-term effects of corticosteroid usage in COVID-19 patients.

Medicolegal Considerations Regarding Steroid Use in Otolaryngology: A Review of the Literature.

OBJECTIVE: To review the literature on corticosteroid use and provide recommendations on patient counseling and/or consent to promote judicious prescribing and reduce the incidence of corticosteroid-related lawsuits. METHOD: A conventional literature search of PubMed on corticosteroid-related medicolegal cases was undertaken. Search terms included "medicolegal," "otolaryngology," and "adrenocorticosteroids." A medical subjects headings search with the keywords "adrenal cortex hormones" and "jurisprudence" was also performed. RESULTS: Corticosteroids have been reported as the third most frequent medication involved in malpractice claims, oftentimes leading to disproportionately costly payments. The most common specialties found to be involved in corticosteroid related medicolegal cases included dermatology (12%), primary care (10%), and neurologists or neurosurgeons (6%). The most common complications encountered were avascular necrosis (39%), changes in mood (16%), infection (14%), and vision changes (14%). Only a few cases corticosteroid-related litigation regarding otolaryngologists were identified. More frequent causes for otolaryngology claims were intraoperative complications, deficits in diagnoses, and failures or delays in treatment. Three medicolegal pitfalls regarding corticosteroid use were identified from this review included: (1) insufficient advising, (2) lack of or incomplete informed consent, and (3) the significance of the patient-physician relationship. CONCLUSION: Despite the scarcity of corticosteroid-related medicolegal literature pertaining to otolaryngologists, corticosteroids are one of the most widely prescribed medications in the field of otolaryngology and have been shown to have a high rate of medical malpractice claims in medicine. Counseling and consenting the patient, as well as developing a strong physician-patient relationship, are integral processes in addressing any adverse effects occurring during therapy, and may also help to decrease the incidence and success of litigation against otolaryngologists.

Oral and intratympanic steroid therapy for idiopathic sudden sensorineural hearing loss.

OBJECTIVE: To investigate the role of intratympanic (IT) therapy in the treatment of idiopathic sudden sensorineural hearing loss (ISSNHL). METHODS: This study was a retrospective review. Patients were treated for ISSNHL from January 1, 2011 to April 12, 2015 with the following: pre/posttreatment audios, treatment initiated ≤90 days and idiopathic etiology. Fifty-three ISSNHL patients were analyzed in the following subgroups: oral steroids (n = 8), combination oral+IT (n = 39), and IT (n = 6). Main outcomes measured were pre/posttreatment pure tone average (PTA) scores. RESULTS: The PTA changes for all treatment groups improved by 8.0 ± 19.5 dB (P = .004); for 31 patients treated ≤2 weeks after onset, PTA improved by 13.8 ± 16.6 dB (P < .001). Multivariable generalized linear model for repeated measures was conducted to investigate the association between PTA changes for treatment groups adjusted for age, gender, time-to-treatment, and vertigo. Earlier time-to-treatment and older age were statistically correlated towards improved outcomes. As time-to-treatment increased by each day, change in PTA decreased by 0.324 (95% CI [0.12, 0.52], P = .002). As age increased by each year, PTA changes increased by 0.802 (95% CI [0.36, 1.24], P < .001). For the oral+IT group, PTA changes for concurrent oral+IT (n = 20, 7.10 dB) and delayed/salvage oral+IT (n = 19, 5.43 dB) were not statistically different (P = .79); earlier time-to-treatment (P = .001), and older age (P = .006) remained statistically correlated towards improved outcomes. CONCLUSION: Results suggest outcomes can be improved with early identification and oral steroid therapy by primary care providers. Poorer prognosis for younger patients potentially suggests a need for more aggressive diagnostic and therapeutic management for this subgroup. LEVEL OF EVIDENCE: 3b.

Developing next-generation telehealth tools and technologies: patients, systems, and data perspectives.

The major goals of telemedicine today are to develop next-generation telehealth tools and technologies to enhance healthcare delivery to medically underserved populations using telecommunication technology, to increase access to medical specialty services while decreasing healthcare costs, and to provide training of healthcare providers, clinical trainees, and students in health-related fields. Key drivers for these tools and technologies are the need and interest to collaborate among telehealth stakeholders, including patients, patient communities, research funders, researchers, healthcare services providers, professional societies, industry, healthcare management/economists, and healthcare policy makers. In the development, marketing, adoption, and implementation of these tools and technologies, communication, training, cultural sensitivity, and end-user customization are critical pieces to the process. Next-generation tools and technologies are vehicles toward personalized medicine, extending the telemedicine model to include cell phones and Internet-based telecommunications tools for remote and home health management with video assessment, remote bedside monitoring, and patient-specific care tools with event logs, patient electronic profile, and physician note-writing capability. Telehealth is ultimately a system of systems in scale and complexity. To cover the full spectrum of dynamic and evolving needs of end-users, we must appreciate system complexity as telehealth moves toward increasing functionality, integration, interoperability, outreach, and quality of service. Toward that end, our group addressed three overarching questions: (1) What are the high-impact topics? (2) What are the barriers to progress? and (3) What roles can the National Institutes of Health and its various institutes and centers play in fostering the future development of telehealth?

Alarm limit settings for early warning systems to identify at-risk patients.

AIM: This paper is a report of a study conducted to provide objective data to assist with setting alarm limits for early warning systems. BACKGROUND: Early warning systems are used to provide timely detection of patient deterioration outside of critical care areas, but with little data from the general ward population to guide alarm limit settings. Monitoring systems used in critical care areas are known for excellent sensitivity in detecting signs of deterioration, but give high false positive alarm rates, which are managed with nurses caring for two or fewer patients. On general wards, nurses caring for four or more patients will be unable to manage a high number of false alarms. Physiological data from a general ward population would help to guide alarm limit settings. METHODS: A dataset of continuous heart rate and respiratory rate data from a general ward population, previously collected from July 2003-January 2006, was analyzed for adult patients with no severe adverse events. Dataset modeling was constructed to analyze alarm frequency at varying heart rate and respiratory rate alarm limits. RESULTS: A total of 317 patients satisfied the inclusion criteria, with 780.71 days of total monitoring. Sample alarm settings appeared to optimize false positive alarm rates for the following settings: heart rate high 130-135, low 40-45; respiratory rate high 30-35, low 7-8. Rates for each selected limit can be added to calculate the total alarm frequency, which can be used to judge the impact on nurse workflow. CONCLUSION: Alarm frequency data will assist with evidence-based configuration of alarm limits for early warning systems.

Impact of continuous vigilance monitoring on nursing workflow.

BACKGROUND: Increasing nursing time in patient care is beneficial in improving patient outcomes, but this is proving increasingly difficult with the nursing shortage, budgetary constraints, and higher patient acuity. OBJECTIVE: Nursing workflow was evaluated after the implementation of a continuous vigilance monitoring system to determine if the system enhanced patient-centric nursing care. METHODS: Work sampling observations were conducted at 3 hospitals for 6 categories of nursing activities (direct and indirect nursing, documentation, administrative, housekeeping, and miscellaneous) at baseline and at 3 and 9 months. RESULTS: Statistically significant increases in direct (3 months) and indirect nursing care (3 and 9 months) were found, with variability between sites. Statistically significant increases at 3 and 9 months for documentation of patient care activities and decreases in administrative activities were the most consistent findings for all sites. CONCLUSION: Continuous vigilance monitoring enhanced patient-centric care with increases in direct and indirect nursing care and documentation of those activities.

The effect of dynamic intermittent hypoxic conditioning on arterial oxygen saturation.

BACKGROUND: Increases in arterial oxygen saturation (SaO2) in response to intermittent hypoxic exposure (IHE) are well established. However, IHE protocols have historically involved static hypoxic environments. The effect of a dynamic hypoxic environment on SaO2 is not known. OBJECTIVE: The purpose of this study was to examine the effect of dynamic IHE conditioning on SaO2 using the Cyclical Variable Altitude Conditioning Unit. METHODS: Thirteen trained participants (9 males, age 30.1 +/- 9.2 years; 4 females, age 30.3 +/- 8.9 years) residing at or near sea level were exposed to a 7-week IHE conditioning protocol (mean total exposure time = 30.8 hours). Participants were exposed to a constantly varying series of hypobaric pressures simulating altitudes from sea level to 6858 m (22 500 feet) in progressive conditioning tiers, creating a dynamic hypoxic environment. SaO2 was evaluated using pulse oximetry (SpO2) 4 times: at 2740, 3360, and 4570 m, prior to and following the first 3 weeks of IHE, and at 4570, 5490, and 6400 m at the start and end of the final 4 weeks. RESULTS: SpO2 improved 3.5%, 3.8%, and 4.1% at 2470, 3360, and 4570 m, respectively (P < .05), and 3.3%, 3.4%, and 5.9% at 4570, 5490, and 6400 m, respectively (P < .05). At 4570 m, SpO2 increased from 81.7% +/- 6.5% to 89.1% +/- 3.2% over the entire 7-week conditioning period. DISCUSSION: The dynamic intermittent hypoxic conditioning protocol used in the present study resulted in an acclimation response, such that SpO2 was significantly increased at all altitudes tested, with shorter exposure times than generally reported.

Distance learning on the Internet: web-based archived curriculum.

Web-based education through archived educational modules offers a significant opportunity to provide didactic education. By archiving lectures and teaching materials, it reduces the educators' time of preparation, especially when many students will need to take the same curriculum over a long period of time. The site can package educational material in multiple formats including audio, video, and readable text, allowing the student to tailor the educational experience to his/her learning preferences. This can be a stand-alone program, or integrated into a program combining distance and in-person education. Assessment through on-line tests can also be conducted, but these must be considered open-book assessments where collaboration cannot be prevented. As such, this vehicle can be utilized effectively for continuing education programs in health care, where open book is permitted and credits are generally awarded on the honor system. However, tests for certificate courses should only be given with a proctor in attendance. In this instance, on-line tests can be used as pre-tests for the student, while being structured to enhance further learning.

Telehealth: voice therapy using telecommunications technology.

Telehealth offers the potential to meet the needs of underserved populations in remote regions. The purpose of this study was a proof-of-concept to determine whether voice therapy can be delivered effectively remotely. Treatment outcomes were evaluated for a vocal rehabilitation protocol delivered under 2 conditions: with the patient and clinician interacting within the same room (conventional group) and with the patient and clinician in separate rooms, interacting in real time via a hard-wired video camera and monitor (video teleconference group). Seventy-two patients with voice disorders served as participants. Based on evaluation by otolaryngologists, 31 participants were diagnosed with vocal nodules, 29 were diagnosed with edema, 9 were diagnosed with unilateral vocal fold paralysis, and 3 presented with vocal hyperfunction with no laryngeal pathology. Fifty-one participants (71%) completed the vocal rehabilitation protocol. Outcome measures included perceptual judgments of voice quality, acoustic analyses of voice, patient satisfaction ratings, and fiber-optic laryngoscopy. There were no differences in outcome measures between the conventional group and the remote video teleconference group. Participants in both groups showed positive changes on all outcome measures after completing the vocal rehabilitation protocol. Reasons for participants discontinuing therapy prematurely provided support for the telehealth model of service delivery.

Telemedicine: teleproctored endoscopic sinus surgery.

OBJECTIVE/HYPOTHESIS: Teleproctored surgery projects a surgeon's expertise to remote locations. The objective of the present study was to evaluate the safety and feasibility of this technique as compared with the current standard of care. STUDY DESIGN: Prospective. METHODS: A study was conducted in a residency training program comparing conventionally proctored endoscopic sinus surgery cases with teleproctored cases, with the faculty surgeon supervising through audiovisual teleconferencing (VTC) in a control room 15 seconds from the operating room. RESULTS: Forty-two control patients (83 sides) and 45 teleproctored patients (83 sides) were evaluated. There were no internal differences between groups regarding extent of polypoid disease, revision status, procedures per case, degree of difficulty, general or local anesthesia, or microdebrider use. There were no cases of visual disturbance, orbital ecchymosis or hematoma, or cerebrospinal fluid leak. Orbital fat herniation and blood loss were equal between groups. Three teleproctored cases required faculty intervention: two for surgical difficulty, one for VTC problems. Teleproctored cases took 3.87 minutes longer per side (28.54 vs. 24.67 min, P <.024), a 16% increase. This was thought to be a result of nuances of VTC proctoring. Residents had a positive learning experience, with nearly full control of the operating suite combined with remote supervision through telepresence. Faculty thought such supervision was safe but had concerns regarding personal skills maintenance. CONCLUSIONS: Teleproctored endoscopic sinus surgery can be safely performed on selected cases with an acceptable increase in time. Teleproctored surgery with remote sites may continue to be safely investigated. Incorporating remote supervision through telepresence into the curriculum of surgical residency training requires further study.

Telemedicine in otolaryngology.

More research is needed in otolaryngology telemedicine, but it would be a mistake to stop at only determining if telemedicine is as good as an in-person exam. The digital image recorded in a telemedicine encounter can be manipulated to increase diagnostic information not currently available. Radiologists currently take a chest radiograph in which a chest mass or the tip of an nasogastric tube is difficult to visualize, and by inverting the gray scale or viewing other digital manipulations of that image, the mass or tube tip becomes obvious. Examples in otolaryngology might include images of the larynx manipulated to better demonstrate the inflamed tissue of reflux, or images of the tympanic membrane manipulated to better demonstrate early retraction. Despite dramatic and likely continued decreases, equipment cost is still an issue. Current research points to good consumer acceptance, and certainly with each new generation the technology is more readily accepted. As Nesbitt [4] points out, it is certainly not difficult to look to the future and see ubiquitous broadband with video as common as telephone, or even extreme broadband enabling robotics and virtual reality TV with three-dimensional touch. Robotics and genomics will eventually play a greater role in telemedicine and our lives in general. Applications for remote diagnosis in biologic warfare defense and homeland security are currently raising interest in telemedicine. Telemedicine will be combined with new technological advances such as virtual "fly-through" computerized axial tomography examinations. Instead of performing an exploratory tympanotomy, surgeons will use computer programs to "fly through" and examine all aspects of a patient's middle or even inner ear. Spectral imaging of the eardrum, larynx, or oropharynx will immediately identify bacteria without cultures, or gram stain, and potential malignancy without biopsy. By measuring fluorescence emitted from an oropharynx illuminated with a specific visible or nonvisible light spectrum, spectral imaging will be able to provide instant identification of bacteria or evidence of malignant changes. The underlying principles of a successful business model must continue to be applied, with the most critical ingredient for telemedicine's success being the filling of specific health care needs. As long as the need is there, telemedicine in otolaryngology will advance.