Papillary thyroid microcarcinoma: Does management differ based on facility variables?

PURPOSE: Papillary thyroid carcinoma detection has increased dramatically in the United States. However, the indolent nature of papillary thyroid microcarcinoma (mPTC) has led the American Thyroid Association (ATA) to advocate for more conservative management. The 2015 ATA recommendations advocated for observation or lobectomy for mPTC. However, the majority of mPTCs continue to be treated with more aggressive surgical management. In this study, we aim to understand the management of mPTC based on facility variables. MATERIALS AND METHODS: A retrospective observational study of patients diagnosed with mPTC between 2004 and 2018 was performed using the National Cancer Database incidence data. We collected data on patient sex, age, tumor size, race, ethnicity, geographic location, thyroid surgical volume at the facility, and treatment modality for mPTC were collected. Conservative and non-conservative treatment modalities based on patient and facility characteristics were compared both longitudinally and cross-sectionally between pre- and post-2015 ATA recommendations. RESULTS: Total thyroidectomy with or without radioactive iodine ablation (RAI) remains the treatment of choice regardless of patient and facility characteristics. Patients treated at low-volume facilities were actually more likely to be treated conservatively. CONCLUSIONS: Despite 2015 ATA recommendations advocating for observation or lobectomy for mPTC, patients with mPTC are still more likely to be treated with total thyroidectomy with or without RAI, especially at high-volume facilities.

Impact of a History of COVID-19 Infection on Postoperative Outcomes for Free Flap Patients.

Objectives: This study examines the impact of a history of coronavirus disease 2019 (COVID-19) infection on patients' outcomes after microvascular free flap surgery and to examine the recommendations on when to perform microvascular surgery after a COVID-19 infection. Methods: A retrospective chart review using the TriNetX database was completed on March 5, 2023. Two cohorts were created: (1) patients who had a positive COVID-19 diagnosis within 1 year before microvascular free flap surgery, and (2) patients with no history of COVID-19 who underwent free flap surgery. Current Procedural Terminology codes were used to identify procedures and International Classification of Diseases-10 codes were used to identify outcomes. Results: There was a total of 31,505 patients who underwent microvascular free flap surgery, 500 of whom had a diagnosis of COVID-19 within 1 year of free flap surgery and 31,005 without history of COVID-19. There was increased risk of sepsis, surgical site infection (SSI), generalized infection, gangrene, dehiscence, hematoma, seroma, intensive care unit admission, and death in patients who underwent free flap surgery within a year of COVID-19 infection. After propensity score matching, there were 498 patients in both groups. Increased risk remained for SSI and gangrene in patients with a history of COVID-19 after matching. When comparing surgical timing between 0 to 2 months after COVID-19 infection and 2 to 12 months after COVID-19 infection, there were no significant differences between groups. Conclusions: After propensity score matching, patients with a history of COVID-19 infection were at increased risk for SSI and gangrene. However, many flap surgeries cannot be delayed. This study may help counsel patients regarding the possible complications after surgery and provide a heightened awareness in the surgical team of a possible increase in infectious complications in this population. Additional studies should investigate optimal timing of free flap surgery after COVID-19 infection and ways to mitigate the risk of infectious complications.

Utility of Antibiotic Use in Pediatric Facial Fractures: A Systematic Review.

Background: In regard to antibiotic stewardship, it is important to understand the appropriate time to prescribe antibiotics in pediatric facial fracture management. Objective: To evaluate the utility of antibiotics in pediatric facial fractures and determine situational variables influencing appropriate antibiotic prescription. Methods: A comprehensive literature search was conducted in PubMed, Cochrane, and Web of Science databases for articles published from 2000 to 2022. Inclusion criteria consisted of all studies assessing pediatric facial fractures that mentioned antibiotic use. Results: A total of 13 studies were included in the full review. The reviewed studies comprised 31 pediatric patients ranging from 6 months to 18 years old. Most studies were case reports and case series (N = 9). Antibiotics were prescribed for the majority (96.7%) of patients. Antibiotic regimens varied by timing of administration, antibiotic used, and dosage. Fracture locations also varied widely, including orbital, zygomatic, nasal, mandibular, and maxillary fractures. Conclusions: Additional studies with more substantial evidence are needed to fully understand the situational appropriateness of antibiotic use in pediatric facial fractures.

Elucidating survival and functional outcomes in patients with primary head and neck malignancies treated in academic versus community settings.

BACKGROUND: Differences in treatment outcomes between community or academic centers are incompletely understood. METHODS: Retrospective review of head and neck cancer patients between 2010 and 2020 in a rural health region. Kaplan-Meier curves and log-rank tests were used to evaluate survival outcomes, along with bivariate and multivariable Cox proportional hazards models. Linear regression was used for functional outcomes of tracheotomy and gastrostomy tube dependence. RESULTS: Two hundred and forty-eight patients treated at an academic center were compared with 94 patients treated in community centers. In multivariable analysis, the risk of death (HR = 0.60, p = 0.019), and risk of recurrence were lower (HR = 0.29, p < 0.001) for patients treated in academic centers. Patients treated in community centers had longer gastrostomy tube dependence (p = 0.002). CONCLUSION: Our findings suggest that treatment at an academic center was associated with a lower risk of recurrence and shorter gastrostomy tube dependence compared to treatment in the community.

Telemedicine in Otolaryngology in the Context of the End of the COVID-19 Public Health Emergency.

At the onset of the COVID-19 pandemic, the US Department of Health and Human Services implemented a range of flexibilities to expedite the adoption of telehealth. As our specialty moved past the height of the pandemic and the use of telehealth transitioned from a necessity to a convenience, numerous health care providers (physicians, advanced practice providers, speech-language pathologists, and audiologists) recognized its benefits and continued to offer these services. In May 2023, the current administration terminated the COVID-19 public health emergency declaration, with some telehealth guidelines in effect until December 31, 2023, and others extended through December 31, 2024. Amidst the changing telehealth landscape, the objective of this commentary is to explain policy implications on Otolaryngology-Head and Neck Surgery and provide insight into how to best implement telehealth under these new guidelines.

Limited Efficacy of Empiric Antibiotics for Pediatric Facial Fractures.

BACKGROUND: Controversies exist regarding the role of perioperative antibiotic use in pediatric craniomaxillofacial fracture repair. PURPOSE: This study aims to identify factors associated with antibiotic prescribing patterns and measures the association between antibiotic exposure and postoperative infections. STUDY DESIGN, SETTING, SAMPLE: In this retrospective cohort study, TriNetX, a research database, was used to gather data on patients under 18 years of age who underwent repair of facial fractures. The records were obtained from 2003 to 2021. Current Procedural Terminology codes for facial fracture procedures were used to identify patients. PREDICTOR/EXPOSURE/INDEPENDENT VARIABLE: Antibiotic use, defined as a binary categorical variable of whether or not patients received perioperative antibiotics. The secondary predictor variable was timing of antibiotic administration, categorized by pre, intra, and postoperative administration. MAIN OUTCOME VARIABLES: Postoperative infection, determined by International Classification of Diseases, 9th and 10th Revision codes within patient charts. COVARIATES: Covariates included demographic variables such as age, sex, race, ethnicity, geographic location, and fracture characteristics, such as number of fractures and location of fracture. ANALYSES: χ2 analyses were used for categorical variables and two sample t tests for quantitative variables. Multivariable logistic regression was used to evaluate patient infection and antibiotic use with adjustment for covariates. P-values were 2-tailed and statistical significance was defined as P < .05. RESULTS: This cohort included 5,413 patients of which 70.4% were male, 74.4% identified as white, and 83.3% identified as non-Hispanic or Latino. There were no differences in postoperative infections in patients who received antibiotics compared to those who did not (0.9 vs 0.5%, respectively, P = .12). Nevertheless, antibiotic prescriptions have increased over the years. After controlling for relevant covariates, antibiotic use did not decrease the odds of infection (adjusted odds ratio 1.1, 95% CI 0.53 to 2.34, P = .79). There was a significant association between the timing of antibiotic use and infection (P = .044), with increased odds of infection when antibiotics were given postoperatively (adjusted odds ratio 3.8, 95% CI 1.2 to 12.07, P = .023). CONCLUSION AND RELEVANCE: While antibiotic prescriptions have increased over the years, this study demonstrates there is no difference in postoperative infection rates for pediatric patients prescribed antibiotics and those where were not.

Symptomatic versus asymptomatic primary hyperparathyroidism: A systematic review and meta-analysis.

Purpose: Primary hyperparathyroidism (PHPT) is the underlying etiology for 90% of patients with hypercalcemia. PHPT patients have traditionally been characterized as being symptomatic or asymptomatic. However, we submit that even "asymptomatic" patients may still have clinical features, posing the idea of coining asymptomatic disease as a misnomer. This paper presents a systematic review and meta-analysis elucidating the differences between asymptomatic and symptomatic PHPT in the literature. Methods: A comprehensive literature search was conducted in PubMed, Cochrane, and Web of Science databases for articles published from 2012 to 2022. Inclusion criteria consisted of all studies comparing symptomatic and asymptomatic PHPT patients. Two reviewers independently evaluated the literature using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The level of evidence was determined using the Oxford Center for Level of Evidence-Based Medicine. Data were extracted, and a meta-analysis was performed. I2 index was employed for heterogeneity. Results: There were 18 studies included, with a total of 4238 patients. The average age of patients included was 56.37, with 25.7% of the cohort being male. Several studies reported clinical features even for the "asymptomatic" group. Patients in the symptomatic group tended to have higher levels of PTH and calcium. The asymptomatic group had greater levels of vitamin D. There was observed heterogeneity between the studies. Conclusions: More extreme PTH, calcium values, and low vitamin D levels were seen in patients with symptomatic disease. However, asymptomatic patients occasionally exhibited clinical features. Therefore, the terminology of "asymptomatic" disease is likely inappropriate for these patients.

Female Neurosurgery Residency Program Directors in the United States: A Cross-sectional Descriptive Analysis.

BACKGROUND: The residency program director (PD) position is a valued leadership appointment in academic medicine. PDs are responsible for the success of their program and its residents. The objective of this study is to provide a cross-sectional analysis of baseline demographics and academic backgrounds of current neurosurgery program directors. METHODS: Data was compiled on neurosurgery PDs and their residency programs, as of the end of May 2021, using publicly available resources including Doximity, FREIDA, and Healthgrades. The Mann-Whitney and Fisher exact tests were used for statistical analysis. RESULTS: Of 113 PDs identified, 91.15% are male (P < 0.01). The majority of PDs (88.5%) received their medical degrees from U.S. medical schools. The average age of current PDs is 54 years, and the average age at appointment was 48 years. Compared to their male counterparts, female PDs are more likely to be younger at appointment (41 vs. 48 years; P = 0.001) and while holding the same position (45 vs. 55 years; P = 0.001). As a result, female PDs experience less time to appointment after residency (8.6 years vs. 14.7 years, P = 0.013). There are no significant differences regarding the gender of the PD and university affiliation, current appointment, completion of a fellowship, and resident gender ratios. CONCLUSIONS: The position of neurosurgery residency PD is dominated by fellowship-trained men in their late 40s to 50s. The gender ratio of neurosurgery residents is consistent with the underrepresentation of women in this position. With increasing female representation in neurosurgery, more women may assume this leadership position and begin to hasten the gender balance.

Management of compression symptoms of thyroid goiters: Hemithyroidectomy is equally as successful as total thyroidectomy.

PURPOSE: Patients with thyroid goiters and compressive symptoms are treated with surgery. The adequate extent of this surgery for these cases remains unclear. In the current study, we analyze the effect of surgery, total thyroidectomy versus hemithyroidectomy, on the resolution of various compressive symptoms. MATERIALS AND METHODS: This retrospective analysis utilized the TriNetX Research Network to recognize adults with thyroid goiters treated surgically. International Classification of Diseases 10 (ICD10) was used to identify patients. Two groups were created based on surgical treatment, for either a hemithyroidectomy or total thyroidectomy. The primary outcomes were compression symptoms, including dysphagia, choking/globus sensation, dyspnea, cough, and hoarseness/dysphonia. RESULTS: This retrospective review included 45,539 subjects. Of these, 9293 had a partial thyroidectomy, and 36,246 had a total thyroidectomy. After propensity score matching was done for compression symptoms before surgery, there were 8280 patients in each group. There were no differences in symptoms between the matched groups, except for increased hoarseness and dysphonia after total thyroidectomy (RR, 95 % CI) (0.781, 0.67-0.91). Compression symptoms significantly decreased after surgical treatment in both the hemithyroidectomy and total thyroidectomy groups. CONCLUSIONS: Hemithyroidectomy is associated with efficacy similar to total thyroidectomy in reducing compression symptoms postoperatively. Hemithyroidectomy may be able to alleviate compressive symptoms with less surgical risk.

Discharge destination and readmissions among patients with head and neck cancer.

Objective: Lowering hospital readmission rates is a national goal, and presents an opportunity to lower health care costs, improve quality, and increase patient satisfaction. We aim to assess whether discharge disposition is associated with readmission. Methods: A retrospective cohort study using logistic regression to quantify risk factors of hospital readmission in patients with confirmed head and neck cancer (HNC) who underwent surgery from 2010 to 2018 contained in the Pennsylvania Health Care Cost Containment Council database, which includes patients treated in Pennsylvania hospitals. Results: The readmission rate in this study was 18.1%. Cancers of the hypopharynx had the highest rates of readmission (29.2%). Male sex (odds ratio [OR]: 0.87, 95% CI: 0.75-1.00), emergent admission (vs. elective admission: OR = 1.33, 95% CI: 1.02-1.74), discharge to home health (vs. home: OR = 1.85, 95% CI: 1.59-2.16), discharge to skilled nursing facility (SNF) (vs. home: OR = 2.21, 95% CI: 1.80-2.72), and having 4+ comorbidities (vs. 0-1: OR = 1.39, 95% CI: 1.09-1.76) were significant risk factors for hospital readmission. Conclusion: It is necessary to consider the readmission risk associated with HNC patients. Reasons for readmission are multifactorial and can be related to demographics, hospital course, comorbidities, or discharge disposition-this requires further assessment. There is importance in increasing HNC awareness and staff education about the unique needs of this population. Level of Evidence: 4.

Quality tracheotomy care can be maintained for non-COVID patients during the COVID-19 pandemic.

Objectives: To analyze changes in tracheotomy practices at the onset of the COVID-19 pandemic, and determine if quality patient care was maintained. Methods: This was a single institution retrospective study that included patients undergoing tracheotomy from May 2019 to January 2021. Patients were divided into two groups, pre-COVID and post-COVID. Only three patients tested positive for COVID-19, and they were excluded from the study. Data were collected from the electronic medical record. Statistical analyses were performed using 2-tailed independent t tests, Wilcoxon Rank Sum tests, Chi-Square tests, and Kaplan-Meier curves. Results: There were 118 patients in the pre-COVID group and 91 patients in the post-COVID group. The main indication for tracheotomy in both groups was prolonged intubation. There were no significant differences in overall length of stay, time to tracheotomy, duration of tracheotomy procedure, or time to initial tracheotomy change between the two groups. Due to protocols implemented at our institution to limit viral transmission, there were significant increases in the percent of tracheotomies performed in the OR (p = .02), and those performed via open technique (p = .04). Additionally, the median time to decannulation significantly decreased in the post-COVID group (p = .02). Conclusion: Several variables regarding the timing of patient care showed no significant differences between groups which demonstrates that quality patient care was maintained. It is important to note that this data was collected early in the Pandemic, and additional trends may become apparent over time. Level of evidence: 4.

The effect of cigarette smoke versus vaporized nicotine on healing of a rat femur.

INTRODUCTION: Little data exists regarding the effects of vaporized nicotine on healing. Our goal was to compare vaporized nicotine, combusted nicotine and control with respect to bone healing in a rat femur fracture model. MATERIALS AND METHODS: Forty-five male Sprague Dawley rats were divided into three equal cohorts. Rats were exposed to two cigarettes daily, an equivalent dose of vaporized nicotine, or control, six days a week. Exposures occurred for 4 weeks prior to iatrogenic femur fracture and intramedullary repair. Four additional weeks of exposure occurred prior to sacrifice. Radiographic, biomechanical and histologic analysis was conducted. RESULTS: No significant difference between the three groups was identified for total mineralized bone volume (p = 0.14), total volume of mature bone (p = 0.12) or immature bone (p = 0.15). Importantly, less total mineralized bone volume and immature bone volume was seen in the vaporized nicotine group compared to combusted tobacco, but results were not significant. Biomechanical testing revealed no significant difference in group torsional stiffness (p = 0.92) or maximum torque (p = 0.31) between the three groups. On histologic analysis, chi-square testing showed no significant difference in any category. CONCLUSIONS: This exploratory study compared combusted nicotine, vaporized nicotine and a control on rat femur fractures. While no statistically significant differences were identified, there were trends showing less total mineralized bone volume and immature bone volume in the vaporized nicotine group compared to the other groups. Additional study is warranted based on our findings.

Hypocalcemia After Thyroidectomy in Patients with Prior Bariatric Surgery: A Propensity Score Matched Analysis from a National Administrative Database.

Background: Studies have suggested that patients with prior gastric bypass may be at increased risk for hypocalcemia following thyroidectomy. Unfortunately, most of these studies are limited to case reports and small series. This study represents the largest sample size to date to assess the incidence of post-thyroidectomy hypocalcemia in patients with a history of bariatric surgery. Methods: The TriNetX Research Network was queried to retrospectively identify patients with prior bariatric surgery who underwent total thyroidectomy between 2011 and 2021. The incidence of hypocalcemia following surgery was compared with patients who underwent total thyroidectomy, and hemithyroidectomy with no history of bariatric surgery. Results: We identified 446 patients with a history of bariatric surgery and subsequent thyroidectomy, 29,346 patients with total thyroidectomy, and 19,603 patients with hemithyroidectomy alone. The one-month incidence of hypocalcemia was 54.7% in those with a history of bariatric surgery who underwent thyroidectomy, 43.9% in those with thyroidectomy alone (relative risk, RR = 1.2 [confidence interval, CI 1.1-1.4], p < 0.001), and 8.1% in those with hemithyroidectomy only (RR = 6.8 [CI 6.1-7.4], p < 0.001). Permanent hypocalcemia was documented in 11.4% of patients with prior bariatric surgery who underwent thyroidectomy, 7.7% of those with thyroidectomy only (RR = 1.5 [CI 1.1-1.9], p = 0.003), and 2.9% of patients with hemithyroidectomy alone (RR = 3.9 [CI 3.0-5.2], p < 0.001). Significant differences persisted after matching demographics, prior need for supplementation, and risk factors for hypocalcemia after thyroidectomy. When stratified by bariatric procedure, patients with a history of Roux-en-Y gastric bypass (RYGB) (n = 35) had a greater, although not statistically significant, risk of short-term hypocalcemia (51.4%; RR = 1.2 [CI 0.8-1.6], p = 0.37), and a significantly increased risk of permanent hypocalcemia (20.0%; RR = 2.6 [CI 1.3-5.1], p = 0.005) compared with thyroidectomy alone. Sleeve gastrectomy (SG) (n = 40) was not associated with an increased risk of short-term (40.0%; RR = 0.9 [CI 0.6-1.3], p = 0.62) or permanent (7.5%; RR = 1.0 [CI 0.3-2.9], p = 0.96) hypocalcemia. Conclusions: Prior RYGB, but not SG, may increase the risk of permanent hypocalcemia after thyroidectomy. Additional research is necessary to determine optimal prevention and treatment strategies to reduce morbidity in this population.

Can a flexible surgical robot be used in the pediatric population: A feasibility study.

OBJECTIVES: Transoral robotic surgery in adults confers excellent results and decreased morbidity. Application of these techniques has not yet been rigorously investigated in children. The goal of this study is to evaluate the feasibility of a flexible robotic surgical system in a pediatric population. METHODS: This was a non-randomized, non-blinded, prospective clinical trial. An Investigational Device Exemption was obtained from the FDA. Patients 8-12 years old scheduled for tonsillectomy and adenoidectomy between February and December 2019 at an academic tertiary care children's hospital were included. Exclusion criteria included pulmonary or vascular conditions posing risks for extended anesthesia, or a smaller mouth opening than the instrumentation (28 mm × 15 mm). Tonsillectomy was completed with standard monopolar cautery. After the surgery was complete, the robot was utilized for evaluation and assessment of exposure. A pediatric anesthesiologist screened patients for tolerance of additional anesthesia (up to 15 min). A flexible robotic surgical system, the MedRobotics Flex® Robotic System, was used to visualize and access the tonsillar fossa, posterior pharynx, base of tongue, epiglottis and false vocal folds. Visualization and access were graded on a five-point Likert scale. RESULTS: A total of ten patients, eight males and two females, with obstructive sleep apnea (OSA) or sleep disordered breathing (SDB) were recruited in 2019. One patient did not complete the study due to equipment malfunction. The average patient demographics were: age 10.1 years (8.6-11.8 years), height 142.4 cm (127-164.9 cm), weight 47.5 kg (24.4-84.5 kg), and BMI 22.6 (13.9-31.0). Study time averaged 10.3 min (5-13 min). The tonsillar fossa, base of tongue, and posterior pharynx were visualized completely and easily accessed with the robotic instruments. The epiglottis and false vocal folds were visualized and accessed in 66% and 55% of patients, respectively. There were no adverse effects. CONCLUSIONS: This study demonstrated that a flexible robotic surgical system is feasible for use in children 8-12 years of age when performing otolaryngology - head and neck surgery procedures of the oropharynx and larynx.

Descriptive Analysis of Otolaryngology Program Directors with a Focus on Gender Disparity.

OBJECTIVE: To describe and analyze the demographics and academic backgrounds of United States otolaryngology program directors (PD) and assess gender disparity in the field. METHODS: This was a cross-sectional study in which an online search using publicly available sources was performed to gather information on PDs for 125 United States otolaryngology programs from May 14, 2021, to May 30, 2021. Data collected included PD appointment year, age, gender, resident gender breakdown, degree, as well as training location and graduation year. RESULTS: There were 69.6% programs with a male PD and 30.4% with a female PD. Ninety percent of PDs have an MD degree and 9.6% have a DO degree. The current average age of PDs was 49.9 years old (range 35-79). Males were older than females PD (51.0 vs 47.1 years, P = 0.045) and have served a longer time as PD (7.1 vs 4.8 years, P = 0.019). There was no significant difference in other variables collected. There were 27.3% of program directors that held the position of professor, 44.5% associate professor, and 28.2% assistant professor. The most common subspecialty practiced by otolaryngology PDs was head and neck oncology. CONCLUSION: Disparity in women's representation in otolaryngology still exists, but the program director leadership position demonstrates better parity. There is an equal percent representation when examining female PDs and female otolaryngologists in academic medicine. Continued efforts to encourage women to enter and become leaders in otolaryngology are necessary moving forward.

Otolaryngology in the face of A pandemic.

Although infrequent, pandemics are serious public health concerns with unpredictable courses. The COVID-19 pandemic began over 2 years ago and is far from over. This pandemic has spread rapidly throughout the world and led to several million deaths, making it commonly compared to the deadly Spanish influenza pandemic. Policy and safety measures are constantly being adapted to reduce transmission rates. The pandemic places stress on all healthcare workers, but especially otolaryngology providers due to their direct contact with airway connected cavities. This puts them at high risk for infection and has impacted inpatient and outpatient otolaryngology care, as well as education, research, and mental health.

Assessing nonsexual transmission of the human papillomavirus (HPV): Do our current cleaning methods work?

Human papillomavirus (HPV) is thought to be sexually transmitted; however, there have been a few studies investigating a possible iatrogenic source of infection. Therefore, it is important to assess the cleaning methods of reusable medical devices. This study assessed whether cleaning methods of flexible endoscopes in an otolaryngology clinic are effective against HPV. There were 24 patients with a history of head and neck cancer in the study; however, two outliers were excluded. Nine patients were confirmed to have HPV-associated cancer. PCR was used to measure and quantify the viral genomes of samples collected before and after cleaning. After cleaning, few HPV+ samples had endoscopes with less DNA than before cleaning. Additionally, for several patients with non-HPV-associated head and neck cancer, PCR showed more DNA after cleaning than before cleaning, suggesting residual HPV DNA within the cleaning solution. There was no significant difference (p > 0.05) between pre- and post-cleaning in both cohorts. Current cleaning methods of reusable endoscopes may not be effective in completely removing viral DNA.

School Nurses on the Front Lines of Health Care: Clinical Presentations Associated With COVID-19 Infection.

Over the past 2 years, COVID-19 has swept through the United States and our world, infecting millions of people. Due to the high transmissibility of this communicable disease, school-age children are at a unique risk because of close contact with others throughout the day. Many children who contract COVID-19 will go on to have asymptomatic or mild noncomplicated symptomatic infections. However, some children will develop severe or persistent symptoms. Given the unique position of school nurses in seeing a large volume of children and adolescents, it is important that they are familiar with the variable presentations and complications of COVID-19. Throughout this article, we discuss three cases of students presenting to the school nurse's office with signs and symptoms associated with COVID-19 infection.

Inorganic nitrate supplementation and blood flow restricted exercise tolerance in post-menopausal women.

Exercise tolerance appears to benefit most from dietary nitrate (NO3-) supplementation when muscle oxygen (O2) availability is low. Using a double-blind, randomized cross-over design, we tested the hypothesis that acute NO3- supplementation would improve blood flow restricted exercise duration in post-menopausal women, a population with reduced endogenous nitric oxide bioavailability. Thirteen women (57-76 yr) performed rhythmic isometric handgrip contractions (10% MVC, 30 per min) during progressive forearm blood flow restriction (upper arm cuff gradually inflated 20 mmHg each min) on three study visits, with 7-10 days between visits. Approximately one week following the first (familiarization) visit, participants consumed 140 ml of NO3- concentrated (9.7 mmol, 0.6 gm NO3-) or NO3-depleted beetroot juice (placebo) on separate days (≥7 days apart), with handgrip exercise beginning 100 min post-consumption. Handgrip force recordings were analyzed to determine if NO3- supplementation enhanced force development as blood flow restriction progressed. Nitrate supplementation increased plasma NO3- (16.2-fold) and NO2- (4.2-fold) and time to volitional fatigue (61.8 ± 56.5 s longer duration vs. placebo visit; p = 0.03). Nitrate supplementation increased the rate of force development as forearm muscle ischemia progressed (p = 0.023 between 50 and 75% of time to fatigue) with non-significant effects thereafter (p = 0.052). No effects of nitrate supplementation were observed for mean duration of contraction or relaxation rates (all p > 0.150). These results suggest that acute NO3- supplementation prolongs time-to-fatigue and speeds grip force development during progressive forearm muscle ischemia in postmenopausal women.