Systematic review of submental artery island flap versus free flap in head and neck reconstruction.

PURPOSE: The aim of this systematic review is to compare the perioperative characteristics and outcomes of submental artery island flap (SAIF) to free tissue transfer (FTT) in head and neck reconstruction. MATERIALS AND METHODS: Screening and data extraction were done with Pubmed, Embase, and Web of Science databases by two independent authors to identify randomized and observational studies that compared patient outcomes for SAIF vs. FTT for reconstruction head and neck cancer ablative surgery. Data were pooled with random-effects meta-analysis to determine pooled difference in means (DM), absolute risk differences, and 95% confidence intervals (CI). Heterogeneity was assessed with the I-squared statistic. RESULTS: Initial query yielded 997 results, of which 7 studies met inclusion criteria. The pooled sample sizes for the SAIF and FTT cohorts were 155 and 198, respectively. SAIF reduced mean operative time by 193 min (95% CI -160 to -227), reduced hospital stay by 2.1 days (95% CI -0.9 to -3.4), and had a smaller flap area of 22.5cm2 (95% CI 6.5 to 38.4). SAIF had a 5% higher incidence of partial flap necrosis than FTT (95% CI, 1 to 10), but all other perioperative complications, including recurrence rate in malignant cases, were statistically comparable. CONCLUSIONS: The SAIF requires less operative time, hospital stay, and has comparable perioperative outcomes to FTT, but the area of flap harvest is significantly smaller. The findings of this study add to the growing body of evidence demonstrating the safety and reliability of SAIF in head and neck reconstruction.

Enforcement trends in the city of St. Louis from 2007 to 2017: Exploring variability in arrests and criminal summonses over time and across communities.

The goal of this study is twofold: (a) to describe trends in enforcement activity in the city of St. Louis from 2007 through 2017 and (b) to document community variation in these trends. Five types of enforcement actions are examined: felony, misdemeanor, municipal, and bench warrant arrests and criminal summonses-in-lieu of arrest. Results indicate that enforcement activity decreased over the study period, particularly for nonfelony arrests among Blacks. City-wide trends obscure some variability in neighborhood enforcement. Neighborhood trends in enforcement varied by type of action, but in all cases, trends were conditioned by racial composition. For example, misdemeanor and bench warrant arrests exhibited steeper declines in neighborhoods with a higher percentage of Black residents, resulting in a narrowing of the race gap. In contrast, differences in criminal summonses across neighborhoods of varying racial compositions increased. The effects persisted net of measures of economic disadvantage, community location, residential mobility, household composition, calls for service, and population size. The findings highlight the importance of disaggregating enforcement trends by race and place and documenting changes in less serious, but more prevalent, types of law enforcement activity.

The intersection of aggregate-level lead exposure and crime.

CONTEXT: Childhood lead exposure has been associated with criminal behavior later in life. The current study aimed to analyze the association between elevated blood lead levels (n=59,645) and crime occurrence (n=90,433) across census tracts within St. Louis, Missouri. DESIGN: Longitudinal ecological study. SETTING: Saint Louis, Missouri. EXPOSURE MEASURE: Blood lead levels. MAIN OUTCOME MEASURE: Violent, Non-violent, and total crime at the census tract level. RESULTS: Spatial statistical models were used to account for the spatial autocorrelation of the data. Greater lead exposure at the census-tract level was associated with increased violent, non-violent, and total crime. In addition, we examined whether non-additive effects existed in the data by testing for an interaction between lead exposure and concentrated disadvantage. Some evidence of a negative interaction emerged, however, it failed to reach traditional levels of statistical significance (supplementary models, however, revealed a similar negative interaction that was significant). CONCLUSIONS: More precise measurements of lead exposure in the aggregate, produced additional evidence that lead is a potent predictor of criminal outcomes.

Childhood lead exposure and sexually transmitted infections: New evidence.

INTRODUCTION: The adverse health effects of lead exposure in children are well documented and include intellectual and behavioral maladies. Childhood lead exposure has also been linked to impulsive behaviors, which, in turn, are associated with a host of negative health outcomes including an increased risk for sexually transmitted infections (STI). The purpose of this study was to assess the association of lead exposure with STI rates across census tracts in St. Louis City, Missouri. METHODS: Incident cases of gonorrhea and chlamydia (GC) during 2011 were identified from the Missouri Department of Health and Senior Services and aggregated by census tract. We also geocoded the home address of 59,645 children >72 months in age who had blood lead level tests performed in St. Louis City from 1996 to 2007. Traditional regression and Bayesian spatial models were used to determine the relationship between GC and lead exposure while accounting for confounders (condom and alcohol availability, crime, and an index of concentrated disadvantage). RESULTS: Incident GC rates were found to cluster across census tracts (Moran's I=0.13, p=0.006). After accounting for confounders and their spatial dependence, a linear relationship existed between lead exposure and GC incidence across census tracts, with higher GC rates occurring in the northern part of St. Louis City CONCLUSIONS: At the census-tract level, higher lead exposure is associated with higher STI rates. Visualizing these patterns through maps may help deliver targeted interventions to reduce geographic disparities in GC rates.

"The Pedagogical Legacy of Dr. Chevalier Jackson: An Archival Visit to the John Q. Adams History Center at the American Academy of Otolaryngology-Head and Neck Surgery".

This article explores the historic records of the American Academy of Otolaryngology-Head and Neck Surgery's (AAO-HNS) John Q. Adams Center for the History of Otolaryngology-Head and Neck Surgery, with particular attention paid to the Dr. Chevalier Jackson Collection. The library houses diverse materials that would be of interest to medical historians seeking to understand the early innovations in our specialty. With a repository of over 2200 items chronicling over 200-years of otolaryngological history, the library contains special collections dedicated to Drs. Maurice H. Cottle, Samuel Rosen, Adam Politzer, and Chevalier Jackson. An original aim of this visit sought to understand Dr. Jackson's early contributions to the fields of laryngology, bronchology, and esophagology; yet, an intimate review of his works, including autobiographical material, reveals a fascinating pedagogical legacy.

Assessment of Swallowing Function in Healthy Adults While Using High-Flow Nasal Cannula.

OBJECTIVE: Despite widespread use of high flow nasal cannula (HFNC) for respiratory support, the effect of HFNC on swallowing physiology is poorly understood. Flow rates that permit safe swallowing have not been established. We aim to assess if healthy individuals have diminished swallowing function and safety at high flow rates. STUDY DESIGN: Repeated measures with planned data collection. SETTING: Outpatient dysphagia clinic. METHODS: Swallowing function in a cohort of healthy individuals was assessed using Flexible Endoscopic Evaluation of Swallowing (FEES). Participants' safety of swallowing was assessed with different textures under randomized rates of HFNC (0, 30, 40, 50, and 60 LPM). Swallowing trials included quantities of thin liquids, mildly-thick liquids, and purees. Trials were scored using the Penetration-Aspiration Scale (PAS). Pearson chi-square tests were used to test for correlation between PAS result, flow rate, and consistency across each quantity of material. RESULTS: Twenty-seven subjects were enrolled. Forty-one percent were male with mean age of 34 years (11 standard deviation). Ninety-nine percent (267/270), 97% (n = 263/270), and 99% (399/405) of 1 sip swallows, 3 sip swallows, and 5 mL swallows, respectively, were safe. There was no significant correlation between swallow safety and flow rate using Pearson Chi-Square test across all consistencies and across all quantities of materials (P > 0.05). Of note, out of all subtrials, the thin liquid, 3 sips trial at 60 LPM, had the largest percent of unsafe swallows (14%). CONCLUSION: Our results suggest rate of aspiration is not significantly affected by high flow nasal cannula in healthy individuals.

Foundations of Lifestyle Medicine and its Evolution.

Lifestyle Medicine (LM) is a rapidly growing discipline that focuses on the role of lifestyle factors in preventing, managing, and reversing chronic disease. At this point in the field's evolution, there is strong evidence that the 6 pillars of LM-a whole-food, plant-predominant eating pattern, physical activity, restorative sleep, stress management, avoidance of risky substances, and positive social connections-are central in the creation and maintenance of health. Previous publications, many of them randomized controlled studies and meta-analyses, have solidified the evidence base for the use of the 6 pillars within the field of LM. As data emerged, so did its governing body, the American College of Lifestyle Medicine (ACLM), and with it a rich history began to unfold. Several articles have been written on the early history of the ACLM and the growth of the field; however, this review article explores the history and foundation of LM, aiming to provide a comprehensive understanding of its relevance and impact on health care. It underscores landmark studies that have defined the field and provides a road map detailing national and global barriers and areas of potential future growth.

American College of Lifestyle Medicine Expert Consensus Statement: Lifestyle Medicine for Optimal Outcomes in Primary Care.

OBJECTIVE: Identify areas of consensus on integrating lifestyle medicine (LM) into primary care to achieve optimal outcomes. METHODS: Experts in both LM and primary care followed an a priori protocol for developing consensus statements. Using an iterative, online process, panel members expressed levels of agreement with statements, resulting in classification as consensus, near consensus, or no consensus. RESULTS: The panel identified 124 candidate statements addressing: (1) Integration into Primary Care, (2) Delivery Models, (3) Provider Education, (4) Evidence-base for LM, (5) Vital Signs, (6) Treatment, (7) Resource Referral and Reimbursement, (8) Patient, Family, and Community Involvement; Shared Decision-Making, (9) Social Determinants of Health and Health Equity, and (10) Barriers to LM. After three iterations of an online Delphi survey, statement revisions, and removal of duplicative statements, 65 statements met criteria for consensus, 24 for near consensus, and 35 for no consensus. Consensus was reached on key topics that included LM being recognized as an essential component of primary care in patients of all ages, including LM as a foundational element of health professional education. CONCLUSION: The practice of LM in primary care can be strengthened by applying these statements to improve quality of care, inform policy, and identify areas for future research.

The Case for Physician Training and Certification in Lifestyle Medicine.

Certification in lifestyle medicine demonstrates that a physician has achieved a high level of knowledge, abilities, and skills in this area of specialization. Since the American Board of Lifestyle Medicine (ABLM) began certifying physicians in 2017 through January 2022, about 1850 U.S. diplomates have emerged, with an additional 1375 physicians certified in 72 countries in partnership with the International Board of Lifestyle Medicine. Certification by the ABLM is not only a source of personal pride and accomplishment, but facilitates practice growth, employment opportunities, leadership roles, career satisfaction, and credibility among consumers, the public, payors, and within health systems. In this commentary, we make the case for certification as an integral, and logical, corollary to the explosive growth of the lifestyle medicine as an increasingly relevant, and essential, part of mainstream medical practice.

Scoping review of the association of plant-based diet quality with health outcomes.

Introduction: The association of plant-based dietary patterns with health outcomes has traditionally been assessed without considering nutritional value. The plant-based dietary index (PDI), first published in 2016, overcomes this limitation with both a healthful PDI (hPDI) and an unhealthful PDI (uPDI), based on the quality of plant foods consumed plus the frequency of animal foods. We sought to summarize the breadth of research using the hPDI and uPDI to gain insight into how the quality of plant-based dietary patterns might be associated with health outcomes. Methods: Scoping review of studies that used the PDI, hPDI, or uPDI to report associations with health outcomes. Multiple databases were searched from 2010 through April 2023 with 2 authors independently assessing eligibility and extracting data. In addition to assessing the association of the indices to health outcomes, we determined the frequency of concordant or discordant findings for hPDI versus PDI and for hPDI versus uPDI. Results: We included 95 articles (54% longitudinal, 37% cross-sectional, and 9% case-control) with a median sample size of 3,646. Higher hPDI levels were associated with favorable health outcomes in 36% of comparisons (most often for obesity, mortality, diabetes, cardiovascular disease, and psychiatric disorders), compared to 25% for the PDI and only 2% for the uPDI. Conversely, higher levels of the uPDI were associated with unfavorable health outcomes in 33% of comparisons, in contrast to under 1% for the hPDI and 2% for the PDI. When the hPDI association to an outcome was discordant with the uPDI or PDI, the significance and directionality always favored the hPDI over the uPDI, and nearly always favored the hPDI over the PDI. Discussion: Dietary indices that account for the quality of plant foods can show health benefits that might be missed by a generic plant-based index. A greater focus on the quality of plant foods could improve nutrition guidelines, raise awareness about the benefits of adding unrefined plant foods to the diet, and empower consumers to make incremental additions of such foods to displace unhealthy foods. We anticipate increasing use of indices that address food quality in future research.

The Nasogenital Reflex: Imprudence of the Past as a Lesson for a Wiser Future.

The history of the nasogenital reflex, a theory that purports a bidirectional pathway between the nose and genitalia, reveals a complex and diverse record spanning back to antiquity and across the Eurasian continent. This article examines how an antiquated medical theory made its way into early contemporary medicine, and the lesson this account serves as otolaryngology-head and neck surgery continues to work toward making all its interventions based on a hierarchy of evidence.

Outcomes of in-office versus operating room insertion of tympanostomy tubes in children.

OBJECTIVE: Tympanostomy tube insertion in children is commonly performed under general anesthesia, but there has been increasing interest in office-based alternatives. Although initial research comparing in-office versus operating room (OR) insertion of tubes looks promising, there are scant data available on long-term outcomes. The objective of this study is to compare long-term outcomes of tympanostomy tubes placed in-office versus the OR, with emphasis on the duration of tube function. METHODS: We reviewed electronic medical records in an academic pediatric otolaryngology practice of children under age 13 years who had tubes placed in-office or the OR between 2010 and 2021. Differences in time to unilateral and bilateral tube occlusion/extrusion were compared by Kaplan-Meier survival analysis with log rank comparison. Cox regression modeling was performed to identify predictors of tube occlusion/extrusion. RESULTS: 817 children were included (473 office tubes, 344 OR tubes). Tube placement was equally successful for both groups (98.3% for office and 98.9% for OR). Comparison of Kaplan-Meier plots for time to unilateral and bilateral tube occlusion/extrusion by location showed no significant difference (P = .842 for unilateral and P = .714 for bilateral). However, regression analysis indicated a strong interaction of location with operator status (resident vs attending). Median time to unilateral occlusion/extrusion and bilateral occlusion/extrusion was shorter for OR residents compared to OR attendings (15.0 vs 19.5 months, P = .002, and 22.1 vs 32.0 months, P = .030, respectively). There was no difference in the time to unilateral or bilateral tube occlusion/extrusion between the office attending and OR attending groups (16.8 vs 19.5 months, P = .057 for unilateral, and 23.0 vs 32.0 months, P = .320 for bilateral). There was no significant difference between groups in the need for tube removal, repeat tubes, tube medialization, or post-extrusion tympanic membrane perforation. CONCLUSION: The comparable long-term outcomes found for tubes inserted in-office versus the OR, including time to occlusion/extrusion, suggest that both settings are acceptable for the procedure, with choice based primarily on parental preference, clinician experience, and shared decision making with families.

Office Insertion of Tympanostomy Tubes and the Role of Automated Insertion Devices.

OBJECTIVE: Insertion of tubes in an office setting and automated tube insertion devices were identified as high-priority quality improvement opportunities during the update process for the 2013 clinical practice guideline on tympanostomy tubes from the American Academy of Otolaryngology-Head and Neck Surgery. The guideline update group, however, decided to avoid any recommendations on these topics, based on limited research evidence, and instead selected a subset of group members to author this state of the art review, with the goal of facilitating informed decisions in clinical practice. DATA SOURCES: PubMed through September 2021, Google search of device manufacturer websites, and SmartTots research website for articles on anesthesia neurotoxicity. REVIEW METHODS: A state of the art review format emphasizing evidence from the past 5 years, with manual cross-checks of reference lists of identified articles for additional relevant studies. CONCLUSIONS: The existing literature is too sparse to make recommendations about procedure setting and optimal technique or assess long-term outcomes. The role of automated devices is uncertain, given the increased equipment cost and limited information on characteristics of the proprietary preloaded tubes, including intubation duration and rates of otorrhea, obstruction, medialization, granulation tissue, and persistent perforation. IMPLICATIONS FOR PRACTICE: Whether to undertake in-office tube insertion in awake children should be based on clinician experience, clinician ability to interact with and reassure caregivers, shared decisions with caregivers, and judgment regarding the level of cooperation (or lack thereof) to be expected from a given child. Clinicians should remain alert to new research and expect increasing queries from patients and families.

Otolaryngologists' Attitudes toward In-Office Pediatric Tympanostomy Tube Placement without General Anesthesia.

OBJECTIVES: Our objectives were to assess attitudes regarding office-based insertion of tympanostomy tubes without general anesthesia, to identify barriers that would discourage in-office procedures, and to highlight opportunities that would potentially facilitate this approach in the future. METHODS: Cross-sectional survey administered to members of the American Society of Pediatric Otolaryngology (ASPO) from March to April 2020 using the Research Electronic Data Capture (Redcap), internet-based data capture platform. The brief, 10-item survey required 3 minutes to complete and used a 5-point Likert scale for primary questions. RESULTS: Respondents included 172 fellowship trained, pediatric otolaryngologists with 14 median years of clinical practice and 25 median tympanostomy tube insertions per month (75% >40 per month). Although tubes, in any setting, were most often inserted in children under age 2 years (95% "often" or "very often") and in those aged 3 to 5 years (93%), the likelihoods of doing this in-office for these age groups were only 8% and 6% respectively. For children aged 6 to 12 years, likelihood of in-office insertion was only 15%. Frequent barriers noted were safety concerns, emotional trauma, physical pain, and inability to suction. Opportunities to facilitate this approach include improved topical anesthesia, availability of conscious sedation, conclusive research on adverse effects of general anesthesia, and availability of an automated tube insertion device. CONCLUSION: Office-based insertion of tympanostomy tubes in children without general anesthesia is performed by a small minority of respondents, but there are discernible barriers and opportunities to promote future uptake. Our results should facilitate ongoing discussion and innovation to better accommodate the preferences of families whose children are candidates for tympanostomy tubes.

Systematic Review and Meta-Analysis of Post-Treatment PET/CT in HPV-Associated Oropharyngeal Cancer.

OBJECTIVE: To perform a systematic review with meta-analysis to investigate the utility of post-treatment PET/CT specifically in HPV-associated oropharyngeal squamous cell carcinoma following curative intent treatment. METHODS: Random-effects meta-analysis was used to pool data from 7 observational studies (2013-2019) obtained from a database search of PubMed, Web of Science, and EMBASE using an a priori protocol with dual independent evaluation for inclusion, risk of bias assessment for acceptable methodology, and extraction of data for analysis. PET/CT results, treatment failure, imaging and interventions subsequent to PET/CT findings, and efficacy of salvage therapy were extracted. RESULTS: Of the 907 post-treatment scans, PET/CT results were largely negative (76.2%; 95% CI, 63.4-85.6) and least often positive (11.3%; 95% CI, 8.8-14.4). PET/CT results were equivocal for 22.5% (95% CI, 12.5-36.9) and equivocal/positive for 34.2% of patients (95% CI, 25.1-44.5). Patients with an initial positive scan had the highest treatment failure rates (43.1%; 95% CI, 21.4-67.7) and those with an initial negative scan had the lowest rates (7.4%; 95% CI, 5.7-9.7). The equivocal and equivocal/positive scans had intermediate prevalence of 16.5% (95% CI, 9.4-27.6) and 16.7% (95% CI, 9.1-28.7), respectively. CONCLUSION: The low treatment failure rate following a negative PET/CT scan is reassuring, but the data are consistent with treatment failure rates up to 9.7% suggesting follow-up of these patients is prudent. Additionally, the low positive predictive value for treatment failure observed alludes to use of post-treatment PET/CT in HPV-associated disease frequently leading to unnecessary subsequent imaging and intervention.

Tonsil Riots and Vaccine Hesitancy: A 100-Year Legacy of Medical Mistrust.

The "tonsil riots" of 1906 were panics that developed at several public schools in historically immigrant-dominated neighborhoods of New York City (NYC). Per archived newspaper articles, several NYC public schools asked for parental consent to have Board of Health physicians come and perform tonsillectomy and adenoidectomy on their students. When children subsequently returned home from school "drooling mouthfuls of blood and barely able to speak," mothers reacted with panic and flocked to the schools demanding the safe return of their children. Police, ultimately, had to be called in to manage the crowds, and the events of 1906 largely faded from the public eye. However, these events can offer important lessons in communication and cultural humility as the United States continues its mass vaccination against coronavirus disease 2019.

Diet and Health in Otolaryngology.

Diet is essential to health and can modulate inflammatory markers, the microbiota, and epigenetic outcomes. Proper nutrition is also key to good postsurgical outcomes. Diet is challenging to study, resulting in a relative dearth of influential studies. There is substantial evidence regarding the benefits of a whole food plant-predominant diet on health and longevity, in general, but limited evidence regarding otolaryngologic disorders. Diet may be associated with the risk of head and neck cancer, hearing loss, laryngopharyngeal reflux, and sinonasal symptoms. Evidence, however, is heterogenous and often insufficient for treatment recommendations. Many opportunities exist for future research and expansion..

Autoinflation compared to ventilation tubes for treating chronic otitis media with effusion.

BACKGROUND: Otitis media with effusion (OME) is the most common cause of acquired hearing loss and surgery in children. Autoinflation has been suggested as an alternative treatment for OME. OBJECTIVES: The aim of the study was to compare treatment outcome with a new autoinflation device versus ventilation tube (VT) surgery or watchful waiting in children with chronic bilateral OME from the waiting list for surgery. METHODS: Forty-five children performed autoinflation during four weeks, forty-five were submitted to VT surgery, and twenty-three were enrolled as control group. Tympanometry was performed in the autoinflation and the control groups and audiometry in all groups. RESULTS: An equivalent hearing improvement was achieved in the autoinflation and the VT group at one (p=.19), six (p=.23) and twelve (p=.31) months with no significant alteration in the control group. In the autoinflation group 80% of the children avoided surgery and no complications were reported compared to 34% complication rate in the VT group. CONCLUSION: Autoinflation achieved an equivalent improvement in hearing thresholds compared to VT surgery for treating OME. SIGNIFICANCE: Autoinflation may be a reasonable first-line treatment for children with OME to potentially avoid surgery.Article Summary: The Moniri autoinflation device is well tolerated and an effective alternative to ventilation tubes for treatment of chronic otitis media with effusion in young children.What's known on this subject: Previous studies have shown that autoinflation may reduce effusion in children with otitis media with effusion; however limited compliance to treatment, lack of adequate hearing evaluation, short follow-up time and also lack of comparative data to ventilation tube surgery have been reported.What this study adds: A new device was developed to allow for the performance of autoinflation in young children. The effect is compared to ventilation tube surgery and equivalent improvement in hearing is achieved in the short and the long-term follow-up.