The influence of perioperative enoxaparin on bleeding after TORS oropharyngectomy.

Perioperative enoxaparin is often avoided in patients undergoing transoral robotic (TORS) oropharyngectomy. Our goal was to quantify the risk of postoperative hemorrhage (POH) in patients receiving enoxaparin after TORS oropharyngectomy. This was a retrospective database cohort study set up in 89 separate healthcare organizations. The TriNetX electronic database was queried for patients with OPSCC who underwent TORS oropharyngectomy. Propensity-score matching was used to create two cohorts, one receiving and one not receiving perioperative enoxaparin. Outcome measures were the POH rate within 1 day of surgery ("primary") and POH rate within 2-30 days of surgery ("secondary"). 1109 patients undergoing TORS for OPSCC were identified, 400 of which received perioperative enoxaparin. One-to-one propensity score matching resulted in 310 patients per cohort. After matching, the primary POH rates between patients receiving and not receiving enoxaparin were 3.23% for both cohorts (OR 1.000, 95% CI 0.410 to 2.438). The secondary POH rates between those receiving and not receiving enoxaparin were 5.47% vs. 3.54% (OR 1.577, 95% CI 0.726 to 3.424). The number needed to harm (NNH) with perioperative enoxaparin use for secondary POH after TORS was 53; no difference was found in primary POH rates. While not statistically significant, the use of perioperative enoxaparin after TORS is associated with increased odds of secondary POH with a NNH of 53; no difference was found in rates of primary POH. For patients undergoing TORS, enoxaparin use requires careful weighing of the risks and benefits.

Effect of perioperative ketorolac on postoperative bleeding after pediatric tonsillectomy.

INTRODUCTION: Ketorolac is a frequently used anesthetic pain agent which is traditionally avoided during tonsillectomy due to concern for postoperative hemorrhage. Our goal was to assess the degree of risk associated with the use of Ketorolac following pediatric tonsillectomy. METHODS: The TriNetX electronic health records research database was queried in January 2024 for patients undergoing tonsillectomy with or without adenoidectomy under the age of 18 years and without a diagnosed bleeding disorder. Patients were separated into two cohorts either having received or not having received ketorolac the same day as surgery. Propensity score matching was performed for age at the time of surgery, sex, race, ethnicity, and preoperative diagnoses. The outcomes assessed were postoperative hemorrhage requiring operative control within the first day (primary hemorrhage) and within the first month after surgery (secondary hemorrhage). RESULTS: 17,434 patients were identified who had undergone pediatric tonsillectomy with or without adenoidectomy and had received ketorolac the same day as surgery. 290,373 patients were identified who had undergone pediatric tonsillectomy with or without adenoidectomy and had not received ketorolac the same day as surgery. 1:1 propensity score matching resulted in 17,434 patients within each cohort. Receipt of ketorolac the same day as surgery resulted in an increased risk of primary hemorrhage OR 2.158 (95 % CI 1.354, 3.437) and secondary hemorrhage OR 1.374 (95 % CI 1.057, 1.787) requiring operative control. CONCLUSION: Ketorolac use during pediatric tonsillectomy with or without adenoidectomy was associated with an increased risk of postoperative primary and secondary bleeding requiring surgery.

Feelings of responsibility and temporal binding: A comparison of two measures of the sense of agency.

Temporal binding refers to a subjective shortening of the interval between an action and its perceptual consequences. Temporal binding has often been used by researchers to indirectly measure participants' sense of agency (SoA), or the subjective sense of causing something to happen. Other studies have proposed links between temporal binding and feelings of moral responsibility. The present study compared subjective interval estimates to feelings of responsibility in a between-subjects design (Exp 1) and a within-subjects design (Exp 2). Participants either estimated the interval between two events (two tones in the passive condition, or a keypress followed by a tone in active conditions) or rated their feeling of responsibility for the tone(s). Manipulations of participant involvement and choice impacted feelings of responsibility more than temporal estimates. Overall, the two dependent variables followed different patterns, suggesting subjective interval estimates may not be a reliable proxy for feelings of responsibility.

The Development of Head and Neck Cancer in Patients with the Isolated Complaint of Globus Pharyngeus.

OBJECTIVES: Globus pharyngeus (GP) is a perplexing problem that accounts for 4% of referrals to otolaryngologists. Workup can be extensive and may not be definitive in terms of etiology. The concern that lingers is that of a subtle cancer, which can prolong anxiety and increase testing cost. The aim of this study was to identify the incidence of head and neck cancer (HNC) in patients diagnosed with GP. METHODS: Longitudinal data were captured from two academic institutions, identifying patients with a new diagnosis of globus pharyngeus in 2015. The patient cohort was tracked for at least 4 years to assure follow-up and ability to determine if a HNC developed. Additional demographic data was also collected to determine most common consults, treatments, and testing employed. RESULTS: Excluding patients with previous diagnosis of HNC, 377 patients were identified who presented with GP in 2015 that had at least 4 years of follow-up. Demographics were predominantly women (64.65%), with a mean age of 56.48 years at diagnosis, and the most common provider specialty on the first visit was otolaryngology (39.52%). Four patients ultimately developed HN cancer, for an overall incidence of 1% for the 4-year period of 2015-2019. CONCLUSIONS: Given the long-term follow-up of this population, the overall incidence of developing a head and neck cancer, with a presenting symptom of globus, is low. This is the largest study to date to report the percentage of patients endorsing GP to then subsequently develop HNC. This helps otolaryngologists to reassure patients who have a normal comprehensive exam, flexible endoscopy, and targeted studies. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:1147-1154, 2024.

Impact of recurrent acute rhinosinusitis on quality of life.

KEY POINTS: Quality of life (QoL) in patients with recurrent acute rhinosinusitis (RARS) is understudied. QoL for RARS patients is similar to chronic rhinosinusitis patients, although objective disease severity is lower. QoL of RARS patients is similarly affected during active and inactive infection.

Cognitive load decreases the sense of agency during continuous action.

The sense of agency that normally accompanies voluntary actions depends on a combination of sensory predictions and other inferences. For example, when people manipulate moving objects and rate their degree of control, control ratings are influenced by proximal correlations between motor commands and visual feedback as well as the overall success or failure of the action. The relative importance of sensory predictions vs. post hoc feedback may depend on the availability and perceived reliability of those cues, which is context dependent. The present study investigated how increasing cognitive load during a visuomotor tracking task influences the sense of agency, and whether cognitive load influences the extent to which control ratings depend on sensory predictions vs. post hoc feedback. In Experiments 1 and 2, participants performed a dual task that involved tracking a moving target using a joystick while rehearsing 3, 5, or 7 digits. Control ratings decreased as memory set size increased, even though set size had no significant effect on objective tracking error. Experiment 3 replicated this finding while also manipulating the favorability of feedback presented after each trial. Control ratings were correlated with post hoc feedback, but there was no significant interaction between feedback and cognitive load. These results suggest that sensorimotor predictions, performance feedback, and availability of working memory resources can all influence sense of agency. The hypothesis that people rely more on post hoc feedback to rate control when they are distracted was not supported.

The Impact of Homemade Laparoscopic Box Trainers on Medical Student Surgical Skills: A Randomized Control Pilot Study.

Objective: While instructional videos are commonly used in surgical education, there is a paucity of data on home laparoscopic box trainers. This pilot study evaluated impacts of augmenting instructional videos with these devices. Design: This was a randomized controlled pilot study evaluating laparoscopic surgical performance on the LapSim virtual surgical simulator before and after a 2 week curriculum of instructional videos alone (n = 8, 47.1%) vs videos plus a home laparoscopic box trainer (n = 9, 52.9%). The LapSim recorded mistake number, time, and instrument path length to complete each task. Participants completed surveys about their perceptions of surgery before and after the course. Participants: Preclinical medical students were recruited. Those with extensive surgical experience or did not complete the course were excluded. Results: For the box trainer group vs the videos alone group: mean change in mistakes was -10.0 (standard deviation [SD]:17.1) vs +.5 (SD:21.59) (P = .28); mean change in time was -433.24 (SD:304.67) seconds vs -366.16 (SD:240.10) seconds (P = .62); mean change in instrument path length was -4.27 (SD:4.38) meters vs -3.19 (SD:4.86) meters (P = .64). The box trainer group ranked "I feel as though surgery comes naturally" 1.58 points higher (95% confidence interval [CI]: .85, 2.32; P < .01) and "I am worried about being skilled at surgery" 1.26 points lower (95% CI: 2.29, -.24; P = .02) upon completing the study. The videos alone group reported no significant changes in survey responses. Conclusion: Home laparoscopic box trainers can generate confidence and reduce anxiety regarding surgical fields. This study provides a framework for future larger scale works.

Room-temperature valence transition in a strain-tuned perovskite oxide.

Cobalt oxides have long been understood to display intriguing phenomena known as spin-state crossovers, where the cobalt ion spin changes vs. temperature, pressure, etc. A very different situation was recently uncovered in praseodymium-containing cobalt oxides, where a first-order coupled spin-state/structural/metal-insulator transition occurs, driven by a remarkable praseodymium valence transition. Such valence transitions, particularly when triggering spin-state and metal-insulator transitions, offer highly appealing functionality, but have thus far been confined to cryogenic temperatures in bulk materials (e.g., 90 K in Pr1-xCaxCoO3). Here, we show that in thin films of the complex perovskite (Pr1-yYy)1-xCaxCoO3-δ, heteroepitaxial strain tuning enables stabilization of valence-driven spin-state/structural/metal-insulator transitions to at least 291 K, i.e., around room temperature. The technological implications of this result are accompanied by fundamental prospects, as complete strain control of the electronic ground state is demonstrated, from ferromagnetic metal under tension to nonmagnetic insulator under compression, thereby exposing a potential novel quantum critical point.

Acute colonic pseudo-obstruction (Ogilvie syndrome) leading to respiratory compromise and death.

Here, we present an unusual case of acute colonic pseudo-obstruction (ACPO), also known as Ogilvie syndrome, which resulted in respiratory failure and sudden death. The patient was a 19-year-old man with a history of cerebral palsy (CP) and severe autism who experienced marked abdominal distension that progressed over several days in his skilled nursing facility. He developed shortness of breath and episodic diarrhea, before having an unwitnessed cardiac arrest and subsequently expiring after prehospital and emergency department care. Autopsy revealed developmental deformities consistent with CP, rectal prolapse, and significant abdominal distension. Postmortem radiography showed diffuse bowel distension with bilateral upward displacement of the diaphragm and consequent lung compression. Thorough examination of the gastrointestinal tract failed to reveal any perforation or obstruction. The cause of death was determined to be respiratory compromise secondary to diaphragmatic compression as a result of ACPO, a condition defined as colonic distension without a mechanical explanation for obstruction. This case highlights the challenges that ACPO can pose to a forensic pathologist at autopsy, and serves as a teaching point to clinicians on the warning signs and treatment measures for ACPO.

Empiric treatment for peritonsillar abscess: A single-center experience with medical therapy alone.

PURPOSE: Compare the use of medical therapy alone (MTA) with surgical therapy (ST) for the empiric treatment of peritonsillar abscess (PTA). MATERIALS AND METHODS: A consecutive cohort of patients treated for PTA at our institution from May 2013 to February 2019 was analyzed. Demographics, disease characteristics, management strategies, and treatment outcomes were compared between treatment groups. Primary outcomes included treatment failure, defined as the need for follow-up surgical intervention, and complications within 2-weeks of empiric treatment. RESULTS: 306 patients (72.7%) received MTA while 115 (27.3%) underwent ST. There was no significant difference in the rate of treatment failure between the MTA (7.2%) and ST (6.1%) groups (p = 0.879). Complications were rare in both groups (1.6% with MTA versus 0.9% with ST; p = 0.898). Dysphagia (p = 0.011), trismus (p = 0.045), larger abscesses (p < 0.001), and hospital admission (p < 0.001) were more common in the ST group. Corticosteroid prescriptions were a common component of MTA (53.3%) and less often used with ST (33.9%; p = 0.001). After adjusting for abscess size, there remained no significant difference in the rate of treatment failure between groups. Univariate analyses demonstrated no significant independent predictors of treatment failure including age, sex, race, tonsillitis history, smoking history, presenting signs and symptoms, abscess size, hospital admission, and corticosteroid prescriptions. CONCLUSIONS: MTA may be a safe and effective alternative to surgical drainage for the empiric treatment of PTA, warranting larger-scale prospective analyses. Abscess size did not appear to influence treatment failure; however, careful patient selection is likely to optimize treatment outcomes.

Differentiating Pseudohyperkalemia From True Hyperkalemia in a Patient With Chronic Lymphocytic Leukemia and Diverticulitis.

Acute changes in electrolyte levels can result in severe physiologic complications. Rapid treatment of abnormally elevated potassium levels is essential due to the increased risk of potentially fatal cardiac arrhythmias. However, there are a number of circumstances that can lead to falsely elevated serum potassium levels, including fist clenching during phlebotomy and hemolysis of hematocytes during laboratory processing. Here we present a case of an elderly woman with chronic lymphocytic leukemia who presented with lower left quadrant pain and hematochezia. Laboratory tests revealed an elevated serum potassium level (7.5 mmol/L) on initial testing, in the absence of hyperkalemia symptoms, EKG changes, and hemolysis of the blood specimen. Abdominal CT revealed inflammatory changes consistent with diverticulitis. She was treated with intravenous calcium, insulin, glucose, and bicarbonate for her hyperkalemia and admitted for treatment for diverticulitis. A subsequent serum potassium level (3.9 mmol/L) and discussion with the hospitalist suggested a diagnosis of leukolysis-induced pseudohyperkalemia, and further treatment of hyperkalemia was halted. This case serves to remind current and future physicians about the importance of maintaining clinical suspicion and clarifying unexpected laboratory readings when the clinical picture and results do not completely align.

Individual Differences in Sensitivity to Visuomotor Discrepancies.

This study explored whether sensitivity to visuomotor discrepancies, specifically the ability to detect and respond to loss of control over a moving object, is associated with other psychological traits and abilities. College-aged adults performed a computerized tracking task which involved keeping a cursor centered on a moving target using keyboard controls. On some trials, the cursor became unresponsive to participants' keypresses. Participants were instructed to immediately press the space bar if they noticed a loss of control. Response times (RTs) were measured. Additionally, participants completed a battery of behavioral and questionnaire-based tests with hypothesized relationships to the phenomenology of control, including measures of constructs such as locus of control, impulsiveness, need for cognition (NFC), and non-clinical schizotypy. Bivariate correlations between RTs to loss of control and high order cognitive and personality traits were not significant. However, a step-wise regression showed that better performance on the pursuit rotor task predicted faster RTs to loss of control while controlling for age, signal detection, and NFC. Results are discussed in relation to multifactorial models of the sense of agency.

Storm, rogue wave, or tsunami origin for megaclast deposits in western Ireland and North Island, New Zealand?

The origins of boulderite deposits are investigated with reference to the present-day foreshore of Annagh Head, NW Ireland, and the Lower Miocene Matheson Formation, New Zealand, to resolve disputes on their origin and to contrast and compare the deposits of tsunamis and storms. Field data indicate that the Matheson Formation, which contains boulders in excess of 140 tonnes, was produced by a 12- to 13-m-high tsunami with a period in the order of 1 h. The origin of the boulders at Annagh Head, which exceed 50 tonnes, is disputed. We combine oceanographic, historical, and field data to argue that this is a cliff-top storm deposit (CTSD). A numerical model for CTSDs is developed which indicates that boulder shape in addition to density and dimensions should be taken into account when applying hydrodynamic equations to such deposits. The model also predicts that the NE Atlantic storms are capable of producing boulderites that, when size alone is considered, cannot be distinguished from tsunamites. We review the characteristics that identify the origins of these two deposits.

A harbinger of plate tectonics: a commentary on Bullard, Everett and Smith (1965) 'The fit of the continents around the Atlantic'.

In the 1960s, geology was transformed by the paradigm of plate tectonics. The 1965 paper of Bullard, Everett and Smith was a linking transition between the theories of continental drift and plate tectonics. They showed, conclusively, that the continents around the Atlantic were once contiguous and that the Atlantic Ocean had grown at rates of a few centimetres per year since the Early Jurassic, about 160 Ma. They achieved fits of the continental margins at the 500 fathom line (approx. 900 m), not the shorelines, by minimizing misfits between conjugate margins and finding axes, poles and angles of rotation, using Euler's theorem, that defined the unique single finite difference rotation that carried congruent continents from contiguity to their present positions, recognizing that the real motion may have been more complex around a number of finite motion poles. Critically, they were concerned only with kinematic reality and were not restricted by considerations of the mechanism by which continents split and oceans grow. Many of the defining features of plate tectonics were explicit or implicit in their reconstructions, such as the torsional rigidity of continents, Euler's theorem, closure of the Tethyan ocean(s), major continental margin shear zones, the rapid rotation of small continental blocks (Iberia) around nearby poles, the consequent opening of small wedge-shaped oceans (Bay of Biscay), and misfit overlaps (deltas and volcanic piles) and underlaps (stretched continental edges). This commentary was written to celebrate the 350th anniversary of the journal Philosophical Transactions of the Royal Society.

Do implicit and explicit measures of the sense of agency measure the same thing?

The sense of agency (SoA) refers to perceived causality of the self, i.e. the feeling of causing something to happen. The SoA has been probed using a variety of explicit and implicit measures. Explicit measures include rating scales and questionnaires. Implicit measures, which include sensory attenuation and temporal binding, use perceptual differences between self- and externally generated stimuli as measures of the SoA. In the present study, we investigated whether the different measures tap into the same self-attribution processes by determining whether individual differences on implicit and explicit measures of SoA are correlated. Participants performed tasks in which they triggered tones via key presses (operant condition) or passively listened to tones triggered by a computer (observational condition). We replicated previously reported effects of sensory attenuation and temporal binding. Surprisingly the two implicit measures of SoA were not significantly correlated with each other, nor did they correlate with the explicit measures of SoA. Our results suggest that some explicit and implicit measures of the SoA may tap into different processes.

The phenomenology of controlling a moving object with another person.

The phenomenology of controlling what one perceives is influenced by a combination of sensory predictions and inferential processes. While it is known that external perturbations can reduce the sense of control over action effects, there have been few studies investigating the impact of intentional co-actors on the sense of control. In three experiments, we investigated how individuals' judgments of control (JoC) over a moving object were influenced by sharing control with a second person. Participants used joysticks to keep a cursor centered on a moving target either alone or with a co-actor. When both participants' actions had similar perceptual consequences, JoC ratings were highest when self-generated movements were the only influence on the cursor, while the appearance of sharing control with a second person decreased JoC ratings. By contrast, when participants performed complementary actions with perceptually distinctive consequences, JoC ratings were highest when both participants were able to influence the cursor. The phenomenology of control during joint action is influenced by low-level visuomotor correlations, the presence of competing causal influences, and group-level performance.

Predictable and self-initiated visual motion is judged to be slower than computer generated motion.

Self-initiated action effects are often perceived as less intense than identical but externally generated stimuli. It is thought that forward models within the sensorimotor system pre-activate cortical representations of predicted action effects, reducing perceptual sensitivity and attenuating neural responses. As self-agency and predictability are seldom manipulated simultaneously in behavioral experiments, it is unclear if self-other differences depend on predictable action effect contingencies, or if both self- and externally generated stimuli are modulated similarly by predictability. We factorially combined variation in (1) predictability of action effects, (2) spatial congruence, and (3) performance by the self or computer to dissociate these influences on a visual discrimination task. Participants performed 2AFC speed judgments. Self-initiated motion was judged to be slower than computer-initiated motion when action effect contingencies were predictable, while spatial congruence influenced speed judgments only when action effect contingencies were unpredictable. Results are discussed in relation to current theories of sensory attenuation.

When dyads act in parallel, a sense of agency for the auditory consequences depends on the order of the actions.

The sense of agency (SA) is the perception of willfully causing something to happen. Wegner and Wheatley (1999) proposed three prerequisites for SA: temporal contiguity between an action and its effect, congruence between predicted and observed effects, and exclusivity (absence of competing causal explanations). We investigated how temporal contiguity, congruence, and the order of two human agents' actions influenced SA on a task where participants rated feelings of self-agency for producing a tone. SA decreased when tone onsets were delayed, supporting contiguity as important, but the order of the agents' actions (lead, follow, or simultaneous) also mattered. Relative contiguity was the main determinant of SA, as delayed tones were usually attributed to the most recent action. This was unaffected by contingencies between the two actors' actions (Experiment 2), showing that contiguity has a powerful influence on SA, even during joint action in the presence of other cues.