Factors Associated with Safe Extubation in the Operating Room After On-Pump Cardiac Valve Surgery.

BACKGROUND: Extubation in the operating room (OR) after cardiac surgery remains controversial due to safety concerns. Its feasibility had been suggested in select patients after off-pump surgery. AIM: To review the outcomes of patients extubated in the OR after on-pump cardiac valve surgery (cohort of interest) in comparison with patients extubated conventionally in the intensive care unit (ICU) (control). We hypothesized that the timing of extubation was not associated with postoperative complications. METHODS: Retrospective review of 272 consecutive patients who had undergone cardiac valve surgery at Jackson Memorial Hospital, Miami, Florida between January 1, 2009 and December 30, 2013. RESULTS: Compared with the control group, patients extubated in the OR had shorter cardiopulmonary bypass (CPB) (87 vs. 113 min, p < 0.0001) and aortic cross-clamp times (60 vs. 78 min, p < 0.0001), lower transfusion requirements (41.38% vs. 57.01%, p = 0.0342), shorter ICU (four vs. five days, p = 0.0002), and hospital stays (7.8 vs. 10 days, p = 0.0151). Mortality, overall rates of complications in all categories, ICU readmissions, and reintubations were similar in both groups. Each additional minute of CPB decreased the odds of extubation in the OR by a factor of 0.988 (odds ratio = 0.988; 95%CI: 0.980, 0.997). Pulmonary perfusion and ventilation during CPB increased the likelihood of extubation in the OR by a factor of 2.45 (odds ratio = 2.453; 95%CI: 1.247, 4.824). CONCLUSIONS: In select patients, extubation in the OR after on-pump valve surgery is safe. It is facilitated by shorter duration of CPB and pulmonary perfusion and ventilation during CPB. doi: 10.1111/jocs.12736 (J Card Surg 2016;31:274-281).

Complications and oncologic outcomes following elective neck dissection with salvage laryngectomy for the N0 neck.

PURPOSE: To investigate the difference in survival and complication outcomes between patients with a clinically and radiologically N0 neck who received an elective neck dissection at the time of salvage total laryngectomy compared to those who had salvage total laryngectomy alone. MATERIALS AND METHODS: A retrospective chart review was performed on 125 salvage total laryngectomy patients who were clinically and radiologically N0 preoperatively. Performance of an elective neck dissection and other factors were tested for associations with various postoperative complications, disease-free survival, and overall survival. RESULTS: Ninety-eight patients underwent elective neck dissection, of which ten had positive nodal pathology. Elective neck dissection was not significantly associated with complications or survival outcomes. Positive nodal disease was associated with worse disease-free and overall survival on multivariate analysis. CONCLUSIONS: In patients with clinically and radiologically N0 necks undergoing salvage total laryngectomy, an elective neck dissection can provide prognostic information but does not appear to be significantly associated with increased complications or improved survival.

Weight estimation in an inner-city pediatric ED: the effect of obesity.

BACKGROUND AND OBJECTIVE: Weight estimation for pediatric resuscitation occurs frequently in emergency departments. Historically, different approaches to estimation have been studied with varied results. With increasing obesity rates among inner-city children, this study aims to determine the best method for pediatric weight estimation in our population. METHODS: This is a prospective, nonblinded, observational study. A total of 324 patients (aged 1 month to 12 years) were enrolled in the study to exceed sample size calculations. The accuracy of 4 methods for weight estimation--the Broselow tape, advanced pediatric life support formulas, the PAWPER tape, and mid-arm circumference formula--were compared across age ranges and body sizes to determine the most appropriate method for our population. RESULTS: In this inner-city population, 32% of the patients 2 to 12 years of age were found to be overweight or obese. This rate increased to 41% for patients 6 to 12 years of age. In this setting, the PAWPER tape outperformed the other 3 methods, estimating patients' weight within ±5% of actual weight in 35.2% of our cohort. When compared with the other 3 methods tested, the PAWPER tape was statistically superior with a P value less than .02 in each case. CONCLUSION: Each of the methods tested in our population performed poorly. Current methods for weight estimation should be used with caution, especially for populations with an increased prevalence of obesity. Efforts should be dedicated to improving or deriving new methods for weight estimation that perform better in this vulnerable population.

Hand and nasal carriage of discordant Staphylococcus aureus isolates among urban jail detainees.

In 928 Dallas County Jail detainees, nasal carriage of Staphylococcus aureus was found in 32.8% (26.5% methicillin-susceptible Staphylococcus aureus [MSSA] and 6.3% methicillin-resistant S. aureus [MRSA]), and hand carriage was found in 24.9% (20.7% MSSA and 4.1% MRSA). Among MRSA nasal carriers, 41% had hand MRSA carriage; 29% with hand MRSA carriage had no nasal S. aureus carriage. The prevalence of carriage was not associated with duration of the jail stay up to 180 days.

Transoral laser microsurgery in previously irradiated patients with laryngeal cancer.

PURPOSE: Early laryngeal cancer is successfully managed with transoral laser microsurgery. Previously radiated patients may experience more post-operative complications. We investigate disease-free survival and secondarily prolonged pain and chondronecrosis. MATERIALS AND METHODS: Retrospective review of 52 patients undergoing transoral laser microsurgery after previous radiation. RESULTS: Mean disease-free survival was 36.7 months. Overall disease-free survival was 57.6% at 3-year and 48.4% at 5-year follow-up, with no significant difference between surgery within as opposed to after 60 months of radiation or within as opposed to after 12 months of radiation. Thirteen patients, all with surgery within 60 months of radiation, experienced prolonged pain. Twelve experienced chondronecrosis, all within 12 months of surgery. CONCLUSION: Transoral laser microsurgery for early laryngeal cancer is an adequate therapeutic option in patients with history of radiation with comparable disease-free survival to other reports. Patients undergoing transoral laser microsurgery within 60 months of radiation treatment are more likely to experience prolonged pain.

Cancer mortality in poultry slaughtering/processing plant workers belonging to a union pension fund.

BACKGROUND: The role of zoonotic biological agents in human cancer occurrence has been little studied. Humans are commonly exposed to viruses that naturally infect and cause cancer in food animals such as poultry that constitute part of the biological environment. It is not known if these viruses cause cancer in humans. OBJECTIVE: To study cancer mortality in the largest cohort to date, of 20,132 workers in poultry slaughtering and processing plants, a group with the highest human exposures to these viruses. METHODS: Mortality in poultry workers was compared with that in the US general population through the estimation of standardized mortality ratios. RESULTS: Significantly increased risks were observed in the cohort as a whole or in subgroups, for several cancer sites, viz: cancers of the buccal cavity and pharynx; pancreas; trachea/bronchus/lung; brain; cervix; lymphoid leukemia; monocytic leukemia; and tumors of the hemopoietic and lymphatic systems. Elevated SMRs that were not statistically significant were observed for cancers of the liver, nasopharynx, myelofibrosis, and myeloma. New sites observed to be significantly in excess in this study were cancers of the cervix and penis. CONCLUSION: This large study provides evidence that a human group with high exposure to poultry oncogenic viruses has increased risk of dying from several cancers. Other occupational carcinogenic exposures could be of importance in explaining some of the findings, such as fumes from wrapping machines. These findings may have implications for public health amongst persons in the general population who may also be exposed to these viruses. What is needed now are epidemiologic studies that can demonstrate whether the excess of specific cancers can be attributed to specific occupational exposures while adequately controlling for other potential occupational and non-occupational carcinogenic exposures.

P16 and human papillomavirus in sinonasal squamous cell carcinoma.

Human papillomavirus (HPV) in oropharyngeal squamous cell carcinoma (SCC) is a well-known cause and prognostic indicator, and the utility of p16 as a surrogate marker for HPV status has been established. P16 and its relationship with HPV have not been defined in sinonasal malignancy nor has a link with outcomes been established. Patients with sinonasal SCC from 2011 to 2017 were identified from our pathology database. P16 immunohistochemistry and HPV RNA in situ hybridization were performed on tissue specimens. Forty-seven patients were included. Disease-free survival for p16+ patients was significantly higher than p16- patients (P = .043). Fewer HPV+ patients died (P = .052) or experienced recurrence (P = .0437). Odds ratio between p16 and HPV status was 14.19 (95% CI: 1.72, 442.03). Our findings demonstrate improved survival in both the p16+ and HPV+ groups and a positive association between p16 and HPV. There may be similar potential for modifying classification for HPV+ sinonasal SCC.

Meta-analysis comparing outcomes of different transoral surgical modalities in management of oropharyngeal carcinoma.

BACKGROUND: Optimal transoral surgical modality for oropharyneal carcinoma is currently unclear. Transoral laser surgery (TLS), transoral robotic surgery (TORS), and conventional direct transoral (DT) oropharyngectomy are the main current transoral surgical modalities for oropharyngeal carcinoma. METHODS: MEDLINE was systematically searched through PubMed. Reference lists were reviewed. Random-effects models were used to combine studies within each group. Tests for heterogeneity were used to explore difference in effect size between groups in subgroup analysis. RESULTS: Nine studies (404 patients) in TORS arm, five studies (498 patients) in TLS arm, and three studies (335 patients) in DT arm were included. Early T classification (T1-T2) for TORS and DT were higher compared to TLS group (P < .001). There was no significant difference between groups in the rate of invaded margin, post-operative oropharyngeal bleeding, temporary tracheotomy, and gastrostomy dependence. CONCLUSION: The available data do not yet provide clear evidence of superiority of any one modality.

Assessment of human papillomavirus awareness in association with head and neck cancer at a screening event.

OBJECTIVES/HYPOTHESIS: To assess the baseline awareness of human papillomavirus (HPV) infection as a cause of head and neck cancer (HNC) to design improved targeted screening and education efforts. STUDY DESIGN: Retrospective review of collected survey at a cancer screening event. METHODS: This was a screening event at three hospitals and one community center in Miami, Florida. Participants were recruited throughout the Greater Miami area. Descriptive statistics were used to summarize the demographic characteristics of those who were aware of HPV and those who were not. Adjusted odds ratios, odds ratios, and χ2 tests were used in statistical analysis. RESULTS: A total of 196 women and 112 men were screened across four sites, with 187 participants at hospital-based events and 124 participants at the community-based event. Forty percent of respondents had heard of HPV, and 28.0% identified HPV as a risk factor for HNC. Non-Hispanic and Hispanic respondents were 3.309 and 2.445 times, respectively, more likely than Haitian respondents to have heard of HPV. Women were 2.488 times more likely than men to be aware of HPV. College graduates were 2.268 times more likely than those with less than a college degree to be aware of HPV. Younger respondents were more likely to be aware of HPV. Of those who identified HPV as a risk factor for HNC, 95.4% also correctly identified smoking and 75.9% also correctly identified alcohol as risk factors. CONCLUSIONS: Disparities in HPV and HNC awareness were noted between gender, age, education level, and ethnicity. LEVEL OF EVIDENCE: NA. Laryngoscope, 128:386-392, 2018.

Human papillomavirus-induced oropharyngeal cancer in Hispanics in the United States.

OBJECTIVES/HYPOTHESIS: Determine disparities in survival outcome and clinical presentation between Hispanic and non-Hispanic white patients with human papillomavirus-positive oropharyngeal squamous cell carcinoma. STUDY DESIGN: Retrospective clinical research. METHODS: Clinical data on Hispanics and non-Hispanic white patients with diagnosis of human papillomavirus/p16-positive oropharyngeal squamous cell carcinoma were drawn from a tumor registry from the University of Miami Hospitals and Clinics from 2008 to 2014. Of 436 patients with oropharyngeal squamous cell carcinoma, 237 patents met inclusion criteria. Patient's age, gender, smoking history, alcohol history, race/ethnicity, tumor T stage, nodal N stage, and composite TNM stage were included in the analysis. Associations between race and other categorical variables were explored with χ2 test or Fisher exact test where appropriate. Survival curves were generated using the Kaplan-Meier method. RESULTS: Significant differences in clinical presentation was detected between Hispanic (N = 70) and non-Hispanic white (N = 167) patients. Hispanic human papillomavirus-positive oropharyngeal squamous cell carcinoma patients showed a higher proportion of women with disease, a higher proportion of patients presenting with tonsil rather than tongue base primary subsite cancer, and a higher proportion of patients who do not consume alcohol compared to non-Hispanic white human papillomavirus-positive oropharyngeal squamous cell carcinoma patients. A statistically significant survival difference between these two ethnic groups was not detected in the current dataset. CONCLUSIONS: Unique differences in clinical presentations between Hispanic patients and non-Hispanic whites with human papillomavirus-positive oropharyngeal squamous cell carcinoma were detected. This may be the first study to report novel clinical presentation in Hispanic human papillomavirus-positive patients with oropharyngeal squamous cell carcinoma living in the United States. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:1097-1101, 2017.

Development and Validation of the Cochlear Implant Surgical Competency Assessment Instrument.

OBJECTIVE: We present a new instrument for evaluation of cochlear implant (CI) surgical skills and review its validation process. METHODS: An instrument to assess CI surgical competency incorporated results of structured surveys of comprehensiveness sent to 30 international CI experts and US trainees. One-hundred evaluations of 28 residents, fellows, and practicing CI surgeons were completed. Surgical skills were evaluated by four experienced neurotologists (two raters per subject) using two temporal bones per subject. A training session was completed by 24 subjects between the first and second procedure. Comparison of two blinded rater's scores per subject provided information on interrater reliability. Correlation of competency scores with degree of training and with improvement after a training session provided information on construct validity. RESULTS: High levels of interrater reliability were confirmed by using the intraclass correlation coefficient. Construct validity was demonstrated by correlation of higher performance scores with increasing years of training, board certification, and fellowship training. Construct validity is also supported by improvement in scores after a CI training session as well as by acceptability surveys. DISCUSSION: Data indicate that this instrument is an objective, accurate, and dependable procedure-specific instrument for evaluating CI surgical competency. CONCLUSION: The cochlear implant surgical competency assessment (CI-SCA) can be used to establish CI surgical competency, identify surgical skills that require remediation and demonstrate progress during training.

Current State of Antimicrobial Stewardship at Solid Organ and Hematopoietic Cell Transplant Centers in the United States.

OBJECTIVE To assess the extent of antimicrobial stewardship programs (ASPs) at solid organ transplant (SOT) and hematopoietic cell transplant (HCT) centers in the United States. DESIGN An 18-item voluntary survey was developed to gauge current antimicrobial stewardship practices in transplant patients, examine the availability and perceived usefulness of novel diagnostics and azole levels to guide therapy, and identify challenges for implementation of ASPs at these centers. PARTICIPANTS The survey was distributed electronically to infectious disease physicians and pharmacists at adult and pediatric SOT and HCT centers during May 1-22, 2015. Facilities were deidentified. RESULTS After duplicate removal, 71 (56%) of 127 unique transplant centers in 32 states were analyzed. Forty-four sites (62%) performed at least 100 SOT annually, and 40 (56%) performed at least 100 HCT annually. Top 5 stewardship activities encompassing transplant patients were formulary restriction, guideline development, prospective audit and feedback, education, and dose optimization. Respiratory viral panels (66/66 [100%]), azole levels (64/66 [97%]), and serum/bronchoalveolar lavage galactomannan (58/66 [88%]) were perceived as most useful to guide therapy. Apparent challenges to antimicrobial stewardship included undefined duration for certain infections (53/59 [90%]), diagnostic uncertainty (47/59 [80%]), the perception that antibiotic-resistant infections required escalation (42/59 [71%]), prescriber opposition (41/59 [69%]), and costly drugs (37/59 [63%]). CONCLUSIONS ASP activities were performed at many adult and pediatric SOT and HCT centers in the United States. Diagnostic and therapeutic uncertainty in transplant patients is challenging for ASPs. Collaborative research should examine the impact of antimicrobial stewardship practices in SOT and HCT. Infect Control Hosp Epidemiol 2016;1-6.

Pulmonary Perfusion and Ventilation during Cardiopulmonary Bypass Are Not Associated with Improved Postoperative Outcomes after Cardiac Surgery.

OBJECTIVES: Clinical trials of either pulmonary perfusion or ventilation during cardiopulmonary bypass (CBP) are equivocal. We hypothesized that to achieve significant improvement in outcomes both interventions had to be concurrent. DESIGN: Retrospective case-control study. SETTINGS: Major academic tertiary referral medical center. PARTICIPANTS: Two hundred seventy-four consecutive patients who underwent open heart surgery with CBP 2009-2013. INTERVENTIONS: The outcomes of 86 patients who received pulmonary perfusion and ventilation during CBP were retrospectively compared to the control group of 188 patients. MEASUREMENTS AND MAIN RESULTS: Respiratory complications rates were similar in both groups (33.7 vs. 33.5%), as were the rates of postoperative pneumonia (4.7 vs. 4.3%), pleural effusions (13.9 vs. 12.2%), and re-intubations (9.3 vs. 9.1%). Rates of adverse postoperative cardiac events including ventricular tachycardia (9.3 vs. 8.5%) and atrial fibrillation (33.7 vs. 28.2%) were equivalent in both groups. Incidence of sepsis (8.1 vs. 5.3%), postoperative stroke (2.3 vs. 2.1%), acute kidney injury (2.3 vs. 3.7%), and renal failure (5.8 vs. 3.7%) was likewise comparable. Despite similar transfusion requirements, coagulopathy (12.8 vs. 5.3%, p = 0.031) and the need for mediastinal re-exploration (17.4 vs. 9.6%, p = 0.0633) were observed more frequently in the pulmonary perfusion and ventilation group, but the difference did not reach the statistical significance. Intensive care unit (ICU) and hospital stays, and the ICU readmission rates (7.0 vs. 8.0%) were similar in both groups. CONCLUSION: Simultaneous pulmonary perfusion and ventilation during CBP were not associated with improved clinical outcomes.

The economic impact of vocal attrition in public school teachers in Miami-Dade County.

OBJECTIVES/HYPOTHESIS: Teachers are a known at-risk population for voice disorders. The prevalence and risk factors for voice disorders have been well studied in this population, but little is known about the associated economic cost. The purpose of this study is to assess the economic impact of voice dysfunction in teachers and understand the difference between the cost of absenteeism and presenteeism as a direct result of voice dysfunction. STUDY DESIGN: Cross-sectional analysis via self-administered online questionnaire. METHODS: A total of 14,256 public school teachers from Miami-Dade County, Florida, were asked to participate. Questions were formatted based on the previously validated Work Productivity and Activity Impairment: Specific Health Problem questionnaire adapted for hoarseness and voice disorders. Additional demographic questions were included in the questionnaire. RESULTS: A total of 961 questionnaire responses were received. The demographic characteristics of respondents closely matched known statistics for public school teachers in Miami-Dade County. Economic calculations were performed for each questionnaire respondent and summed for all respondents to avoid bias. Per week, absenteeism-related costs were $25,000, whereas presenteeism-related costs were approximately $300,000. These figures were used to extrapolate annual cost. Per year, absenteeism-related costs were $1 million, whereas presenteeism-related costs were approximately $12 million. CONCLUSION: The economic impact of voice dysfunction on the teaching profession is enormous. With the above calculations only including lost wages and decreased productivity, the actual figures may in fact be larger (cost of substitute teachers, impact on nonwork activities, etc.). Research investigating preventative measures for voice dysfunction in teachers is necessary to reduce this costly issue. LEVEL OF EVIDENCE: 2C. Laryngoscope, 126:665-671, 2016.

Recruitment of underserved, high-risk participants to a head and neck cancer screening program.

OBJECTIVES/HYPOTHESIS: Early detection is essential in head and neck cancer treatment as prognosis varies greatly with stage at diagnosis. Underserved populations often present with advanced disease, and individuals with tobacco and heavy alcohol use demonstrate a higher head and neck cancer incidence. This study aims to evaluate whether various promotional methods differentially recruited behavioral risk factor positive and/or underserved populations to our screening event. STUDY DESIGN: Prospective cross-sectional study. METHODS: A hospital-based, medical student-run, free head and neck cancer screening event for 187 participants was held in April 2015. Medical campus-based, community-based, and media-based promotions were implemented to recruit participants. Event participants filled out questionnaires to determine how they were recruited, their risk-factor history, and their socioeconomic status. Prevalence of the higher-risk population across the various promotional methods was analyzed. RESULTS: Community-based promotions were significantly associated with the recruitment of participants in the underserved subgroups, namely uninsured (P = .019), unemployed (P = .006), and those with an annual household income <$20,000 (P < .001). Although not statistically significant, participants with behavioral risk factors reported a higher percentage of recruitment by media-based promotions. Campus-based promotions led to the highest absolute number, but not percentage, of higher-risk participants. CONCLUSIONS: Community-based promotions most efficiently recruit underserved guests to participate in a hospital-based head and neck cancer screening event as compared to media and campus-based promotions. Institutions interested in recruiting higher proportions of underserved guests to these screening events should consider focusing attention and allocation of resources to community-based promotions. LEVEL OF EVIDENCE: 4 Laryngoscope, 126:2699-2704, 2016.

Educational Value of a Medical Student-Led Head and Neck Cancer Screening Event.

OBJECTIVE: To evaluate improvement of medical student knowledge of head and neck cancer (HNC) through participation in HNC screening fairs run by medical students. STUDY DESIGN: Prospective cohort study of surveys assessing medical students' knowledge of HNC before and after volunteering at screening fairs. SETTING: Four screening fairs held at the University of Miami Miller School of Medicine during Oral, Head and Neck Cancer Awareness Week. SUBJECTS: Medical student screening fair volunteers. METHODS: Four HNC screening fairs were organized by medical student volunteers. All students completed a preevent survey assessing baseline knowledge and participated in an otolaryngologist-led training session about HNC and the screening examination. During the screening events, students educated guests about HNC and performed physician-guided history and physical examinations. Finally, students completed identical surveys 1 week and 3 months after the event. RESULTS: Thirty-four (n = 34) students completed the preevent surveys. At baseline, 59%, 44%, and 24% named tobacco, alcohol, and human papilloma virus as risk factors, compared with 84%, 81%, and 69% on 3 month follow-up, respectively. Out of 6 analyzed questions, the median total number of correctly answered questions improved from 2 on pretest to 5 at 3 months (P < .0001). CONCLUSION: Volunteer participation in a HNC screening program improves medical students' knowledge of HNC risk factors and symptoms. This innovative approach to students' education via participation and organization of screening events is a useful method of improving their HNC knowledge.

Gender, Race, and Health Insurance Status in Patients Undergoing Catheter Ablation for Atrial Fibrillation.

Catheter ablation for atrial fibrillation (AF) has emerged as a popular procedure. The purpose of this study was to examine whether there exist differences or disparities in ablation utilization across gender, socioeconomic class, insurance, or race. Using the Nationwide Inpatient Sample (2000 to 2012), we identified adults hospitalized with a principal diagnosis of AF by ICD 9 code 427.31 who had catheter ablation (ICD 9 code-37.34). We stratified patients by race, insurance status, age, gender, and hospital characteristics. A hierarchical multivariate mixed-effect model was created to identify the independent predictors of AF ablation. Among an estimated total of 3,508,122 patients (extrapolated from 20% Nationwide Inpatient Sample) hospitalized with a diagnosis of AF in the United States from the year 2000 to 2012, 102,469 patients (2.9%) underwent catheter ablations. The number of ablations was increased by 940%, from 1,439 in 2000 to 15,090 in 2012. There were significant differences according to gender, race, and health insurance status, which persisted even after adjustment for other risk factors. Female gender (0.83 [95% CI 0.79 to 0.87; p <0.001]), black (0.49 [95% CI 0.44 to 0.55; p <0.001]), and Hispanic race (0.64 [95% CI 0.56 to 0.72; p <0.001]) were associated with lower likelihoods of undergoing an AF ablation. Medicare (0.93, 0.88 to 0.98, <0.001) or Medicaid (0.67, 0.59 to 0.76, <0.001) coverage and uninsured patients (0.55, 0.49 to 0.62, <0.001) also had lower rates of AF ablation compared to patients with private insurance. In conclusion we found differences in utilization of catheter ablation for AF based on gender, race, and insurance status that persisted over time.

Factors influencing botulinum toxin dose instability in spasmodic dysphonia patients.

OBJECTIVE: Many patients with spasmodic dysphonia (SD) see consistent effects from botulinum toxin (BTX) injections of the same dose, whereas others require dosage changes over time. We sought to determine whether demographics (age and gender) or environmental factors (smoking) affect the long-term stability of BTX dosing in these patients. STUDY DESIGN: Retrospective review. METHODS: Charts of all patients undergoing BTX injection for adductor SD were reviewed. Dosage change, defined as whether there was any difference in total dosage used between two beneficial injections, was used as a measure of dosing stability. Beneficial injections were indicated by a voice rating score of at least three of four and any non-zero duration of improved voice. Logistic regression analysis was performed to determine whether age, gender, smoking status, or duration of treatment correlated with odds of having a dosage change. RESULTS: A total of 211 patients were ultimately included. Age, gender, and smoking status were all found to have no correlative effect on dosing stability. The only factor that was predictive of dose stability was the number of previous beneficial injections, as every additional injection led to decreased odds of a change in dosage for the next injection (odds ratio=0.964; 95% confidence interval=0.947-0.981). CONCLUSIONS: Dosage of BTX injections for long-term treatment of SD has a significant propensity to remain stable over time. Factors such as age, gender, and smoking status do not appear to influence the dosage stability. These findings should allow for better patient counseling regarding expectations for their long-term treatment.

Cochlear Implantation in Children With Autism Spectrum Disorder.

OBJECTIVE: To assess the outcome of cochlear implantation in children with autism spectrum disorder (ASD). STUDY DESIGN: Retrospective case review and survey. SETTING: Tertiary referral center. PATIENTS: Children who meet criteria for cochlear implantation and diagnosis of ASD. MAIN OUTCOME MEASURES: Receptive and expressive language scores and parental survey data. RESULTS: Fifteen patients with history of ASD and cochlear implantation were analyzed and compared with 15 patients who received cochlear implant and have no other disability. Postoperatively, more than 67% of children with ASD significantly improved their speech perception skills, and 60% significantly improved their speech expression skills, whereas all patients in the control group showed significant improvement in both aspects. The top 3 reported improvements after cochlear implantation were name recognition, response to verbal requests, and enjoyment of music. Of all behavioral aspects, the use of eye contact was the least improved. Survey results in regard to improvements in patient interaction were more subtle when compared with those related to sound and speech perception. The most improved aspects in the ASD patients' lives after cochlear implantation seemed to be attending to other people's requests and conforming to family routines. Of note, awareness of the child's environment is the most highly ranked improvement attributed to the cochlear implant. CONCLUSION: Cochlear implants are effective and beneficial for hearing impaired members of the ASD population, although development of language may lag behind that of implanted children with no additional disabilities. Significant speech perception and overall behavior improvement are noted.

Surgical, Ultrasound Guided Drainage, and Medical Management of Tuboovarian Abscesses.

OBJECTIVE: To compare surgical, ultrasound guided drainage, and medical management of tuboovarian abscesses (TOA) and determine if different characteristics in patient presentation influence treatment and outcome. METHODS: Retrospective cohort study of 158 patients admitted to Jackson Memorial Hospital between 2007 and 2012 with a TOA. RESULTS: Patients treated with IV antibiotics (IV) alone were hospitalized for 5.59 days (SD 2.52), IV antibiotics and US guided drainage (IV/US) were hospitalized for 9.63 days (SD 7.58), and IV antibiotics and surgery (IV/surgery) were hospitalized for 8.14 days ((SD3.9), (P < 0.001)). A total of 52 patients were readmitted with TOA; 41.8% were treated with IV; 26.9% were readmitted with IV/US; 7.1% were readmitted with IV/surgery (P < 0.022). Patients with a TOA measuring 0-8 cm were hospitalized for 5.97 days (SD 4.24), while those greater than 8 cm were hospitalized for 7.71 days ((SD 4.69), (P < 0.029)). Patients treated with a triple antibiotic regimen were hospitalized for 8.42 days (SD 5.70) versus 5.8 days (SD 3.24) when receiving an alternative regimen (P < 0.002). CONCLUSIONS: Longer hospitalization in patients treated uniformly with either triple antibiotics, ultrasound guided drainage, or surgery represents a delay in optimal treatment. Tailoring treatment plans based on patient presentation may allow for shorter hospital stays and improved morbidity.