Rethinking Surge Preparedness After COVID-19: Effective Patient Load Balancing Within Health Systems and Beyond.

Within weeks of New York State's first confirmed case of COVID-19, New York City became the epicenter of the nation's COVID-19 pandemic. With more than 80,000 COVID-19 hospitalizations during the first wave alone, hospitals in downstate New York were forced to adapt existing procedures to manage the surge and care for patients facing a novel disease. Given the unprecedented surge, effective patient load balancing-moving patients from a hospital with diminishing capacity to another hospital within the same health system with relatively greater capacity-became chief among the capabilities required of New York health systems. The Greater New York Hospital Association invited members of downstate New York's 6 largest health systems to talk about how each of their systems evolved their patient load balancing procedures throughout the pandemic. Informed by their insights, experiences, lessons learned, and collaboration, we collectively present a set of consensus recommendations and best practices for patient load balancing at the facility and health system level, which may inform regional approaches to patient load balancing.

Clinical and genomic signatures of SARS-CoV-2 Delta breakthrough infections in New York.

BACKGROUND: In 2021, Delta became the predominant SARS-CoV-2 variant worldwide. While vaccines have effectively prevented COVID-19 hospitalization and death, vaccine breakthrough infections increasingly occurred. The precise role of clinical and genomic determinants in Delta infections is not known, and whether they contributed to increased rates of breakthrough infections compared to unvaccinated controls. METHODS: We studied SARS-CoV-2 variant distribution, dynamics, and adaptive selection over time in relation to vaccine status, phylogenetic relatedness of viruses, full genome mutation profiles, and associated clinical and demographic parameters. FINDINGS: We show a steep and near-complete replacement of circulating variants with Delta between May and August 2021 in metropolitan New York. We observed an increase of the Delta sublineage AY.25 (14% in vaccinated, 7% in unvaccinated), its spike mutation S112L, and AY.44 (8% in vaccinated, 2% in unvaccinated) with its nsp12 mutation F192V in breakthroughs. Delta infections were associated with younger age and lower hospitalization rates than Alpha. Delta breakthrough infections increased significantly with time since vaccination, and, after adjusting for confounders, they rose at similar rates as in unvaccinated individuals. INTERPRETATION: We observed a modest adaptation of Delta genomes in breakthrough infections in New York, suggesting an improved genomic framework to support Delta's epidemic growth in times of waning vaccine protection despite limited impact on vaccine escape. FUNDING: The study was supported by NYU institutional funds. The NYULH Genome Technology Center is partially supported by the Cancer Center Support Grant P30CA016087 at the Laura and Isaac Perlmutter Cancer Center.

Clinical and genomic signatures of rising SARS-CoV-2 Delta breakthrough infections in New York.

In 2021, Delta has become the predominant SARS-CoV-2 variant worldwide. While vaccines effectively prevent COVID-19 hospitalization and death, vaccine breakthrough infections increasingly occur. The precise role of clinical and genomic determinants in Delta infections is not known, and whether they contribute to increased rates of breakthrough infections compared to unvaccinated controls. Here, we show a steep and near complete replacement of circulating variants with Delta between May and August 2021 in metropolitan New York. We observed an increase of the Delta sublineage AY.25, its spike mutation S112L, and nsp12 mutation F192V in breakthroughs. Delta infections were associated with younger age and lower hospitalization rates than Alpha. Delta breakthroughs increased significantly with time since vaccination, and, after adjusting for confounders, they rose at similar rates as in unvaccinated individuals. Our data indicate a limited impact of vaccine escape in favor of Delta's increased epidemic growth in times of waning vaccine protection.

Bevacizumab for Hearing Preservation in Neurofibromatosis Type 2: Emphasis on Patient-Reported Outcomes and Toxicities.

OBJECTIVE: Bevacizumab for hearing preservation in patients with neurofibromatosis type 2 (NF2) is an emerging practice. We set out to characterize the effectiveness and toxicity of bevacizumab in our patient group. STUDY DESIGN: Case series with chart review. SETTING: Tertiary referral center. SUBJECTS AND METHODS: Seventeen consecutive patients with NF2 received bevacizumab treatment for vestibular schwannomas, including 2 patients treated to maintain cochlear implant performance. Volumetric analysis of serial magnetic resonance imaging scans was used to evaluate radiographic response, and hearing response was evaluated with serial audiograms. Patient-reported outcomes were also assessed, including subjective hearing improvement, changes in tinnitus, vertigo, headaches, ear pain, and improvement in ability to communicate via telephone. RESULTS: A positive radiographic response occurred in 8 of 17 (47%) patients and the median tumor volume change was a tumor decrease of 19%. A positive hearing response was recorded in 5 of 9 (56%) patients. Two patients had a word recognition score improvement over 40%. There was an approximately 40% improvement in patient-reported outcomes. Primary toxicities included hypertension, proteinuria, dysgeusia, and amenorrhea. CONCLUSION: Bevacizumab treatment was followed by hearing improvement in 56% of patients, while decreased tumor volume was noted in 47%. These outcomes agree favorably with prior reported series. There were significant improvements in patient-reported outcomes that have not been described previously.

Hazardous noise exposure from noisy toys may increase after purchase and removal from packaging: A call for advocacy.

OBJECTIVE: Previous studies identified hazardous noise levels from packaged toys. Sound levels may increase when packaging is removed and therefore, complicate the ability to accurately assess noise levels before purchase. The goal of this study was to evaluate how packaging affects the decibel (dB) level of toys by: 1) Assessing dB level of toys with and without packaging. 2) Evaluating the percentage of packaged and unpackaged toys that exceed a safety limit of 85 dB. METHODS: Thirty-five toys were selected from the 2009-2011 Sight and Hearing Association (SHA) based on availability for purchase. Toys' speakers were categorized as Exposed, Partially Exposed, or Covered, based on its packaging. The dB level of each toy was tested at 0 cm and 25 cm from the speaker using a handheld digital sound meter in a standard audiometric booth. T tests and ANOVA were performed to assess mean change in sound level before and after packaging removal. RESULTS: Significant dB increases were noted after packaging was removed (mean change 11.9 dB at 0 cm; and 2.5 dB at 25 cm, p < 0.001). Sixty-four percentage of Covered toys (n = 14) had dB greater than 85 dB when packaged and this increased to 100% when unpackaged. CONCLUSION: Many manufactured toys have hazardous sound levels. Caregivers and healthcare providers should be aware that toys tested in the store may actually be louder when brought home and removed from their packaging. Limits on and disclosure of dB level of toys should be considered nationally.

Randomized Controlled Pilot Study of Video Self-assessment for Resident Mastoidectomy Training.

A prospective randomized controlled pilot study was performed to determine if video self-assessment improves competency in mastoidectomy and to assess interrater agreement between expert and resident evaluations of recorded mastoidectomy. Sixteen otolaryngology residents were recorded while performing cadaveric mastoidectomy and randomized into video self-assessment and control groups. All residents performed a second recorded mastoidectomy. Performance was evaluated by blinded experts with a validated assessment scale. Video self-assessment did not lead to greater skill improvement between the first and second mastoidectomy. Interrater agreement was fair to substantial between the expert evaluators and between resident self-evaluations by recall and video review. Agreement between experts and residents was only slight to fair; residents consistently rated their performance higher than experts (P < .05). In conclusion, 1 session of video self-review did not lead to improved competence in mastoidectomy over standard practice. While experts agree on assessments, residents may overestimate their competency in performing cadaveric mastoidectomy.

Utilization of Nerve Integrity Monitor for Promontory Stimulation Testing Prior to Cochlear Implant.

OBJECTIVE: To demonstrate the feasibility of a nerve integrity monitor as a tool for promontory stimulation testing in patients with profound sensorineural hearing loss considering cochlear implantation. PATIENTS: Adult patients considered for cochlear implantation with no auditory response on audiometric testing INTERVENTION:: Promontory stimulation testing using the nerve integrity monitor. MAIN OUTCOME MEASURE: By using a facial nerve stimulator and the nerve integrity monitor, transtympanic promontory stimulation testing was performed to assess auditory nerve function and determine candidacy for cochlear implantation. Patients indicated if they heard the stimulus. RESULTS: Of the four patients completing the promontory stimulation tests, three patients heard the stimulus and one patient did not hear the stimulus. Of the three patients with a positive stimulation test, two patients have a history of progressive profound sensorineural hearing loss and one patient had a history of severe blunt temporal bone trauma. Two of these patients proceeded with cochlear implantation. The patient who had a negative promontory stimulation test has a history of neurofibromatosis type 2. CONCLUSION: The nerve integrity monitor is a convenient tool that can be used in the clinic setting to perform promontory stimulation tests and aid in determining cochlear implant candidates, specifically in those patients who require verification of auditory nerve function. This tool is a feasible and reasonable method for promontory stimulation testing.

Quantitative Proteomics of Vestibular Schwannoma Cerebrospinal Fluid: A Pilot Study.

This pilot study aimed to identify candidate proteins for future study that are differentially expressed in vestibular schwannoma (VS) cerebrospinal fluid (CSF) and to compare such proteins with those previously identified in perilymph and specimen secretions. CSF was collected intraoperatively prior to removal of untreated sporadic VS (3 translabyrinthine, 3 middle cranial fossa approaches) and compared with reference CSF samples. After proteolytic digestion and iTRAQ labeling, tandem mass spectrometry with ProteinPilot was used to identify candidate proteins. Of the 237 proteins detected, 13 were dysregulated in ≥3 of the 6 VS patients versus controls, and 13 were dysregulated (12 up, 1 down) in samples from patients with class D versus class B hearing. Four perilymph proteins of interest were dysregulated in ≥1 VS CSF samples. Thus, 26 candidate VS CSF biomarkers were identified that should be considered in future VS biomarker and tumor pathophysiology investigations.

Complication from hearing aid mold material: a case report and review of legal matters.

Ear mold impression middle ear foreign bodies are a rare complication of hearing aid fitting. Only a small number of cases have been reported; however, the actual incidence is unknown and likely much higher than expected. We present the case of a 77-year-old man with a history of preexisting tympanic membrane perforations who presented with an ear mold impression middle ear foreign body that required surgical removal. We explore the state and federal laws that guide the interaction between patients, hearing aid sellers and otolaryngologists. We highlight steps that can be taken to reduce the incidence of this complication.

Limiting hazardous noise exposure from noisy toys: simple, sticky solutions.

OBJECTIVES/HYPOTHOSIS: To assess noise levels of toys from the Sight & Hearing Association (SHA) 2010 Noisy Toys List and evaluate the change in noise of these toys after covering the speakers with tape or glue. STUDY DESIGN: One Group Pretest-Posttest Design. METHODS: SHA 2010 Toys List (n = 18) toys were tested at distances of 0 and 25 cm from sound source in a soundproof booth using a digital sound-level meter. The dBA level of sound produced by toy was obtained. Toys with speakers (n = 16) were tested before and after altering speakers with plastic packing tape or nontoxic glue. RESULTS: Mean noise level for non-taped toys at 0 and 25 cm was 107.6 dBA (SD ± 8.5) and 82.5 dBA (SD ± 8.8), respectively. With tape, there was a statistically significant decrease in noise level at 0 and 25 cm: 84.2 dBA and 68.2 dBA (P <0.001). With glue, there was a statistically significant decrease in noise level at 0 cm and 25 cm: 79.7 dBA and 66.4 dBA (P <0.001). CONCLUSIONS: Both tape and glue significantly decreased the noise level produced by the toys. However, there was no significant difference between tape or glue. Overall, altering the toy can significantly decrease the sound a child may experience when playing with toys. However, some toys, even after altering, still produce sound levels that may be considered dangerous.

Eye movements reset visual perception.

Human vision uses saccadic eye movements to rapidly shift the sensitive foveal portion of our retina to objects of interest. For vision to function properly amidst these ballistic eye movements, a mechanism is needed to extract discrete percepts on each fixation from the continuous stream of neural activity that spans fixations. The speed of visual parsing is crucial because human behaviors ranging from reading to driving to sports rely on rapid visual analysis. We find that a brain signal associated with moving the eyes appears to play a role in resetting visual analysis on each fixation, a process that may aid in parsing the neural signal. We quantified the degree to which the perception of tilt is influenced by the tilt of a stimulus on a preceding fixation. Two key conditions were compared, one in which a saccade moved the eyes from one stimulus to the next and a second simulated saccade condition in which the stimuli moved in the same manner but the subjects did not move their eyes. We find that there is a brief period of time at the start of each fixation during which the tilt of the previous stimulus influences perception (in a direction opposite to the tilt aftereffect)--perception is not instantaneously reset when a fixation starts. Importantly, the results show that this perceptual bias is much greater, with nearly identical visual input, when saccades are simulated. This finding suggests that, in real-saccade conditions, some signal related to the eye movement may be involved in the reset phenomenon. While proprioceptive information from the extraocular muscles is conceivably a factor, the fast speed of the effect we observe suggests that a more likely mechanism is a corollary discharge signal associated with eye movement.

Symptom timeline preceding cochlear implant failure: an institutional experience.

OBJECTIVE: Review cochlear explants and determine the incidence of device and medical failures and develop a pattern of symptoms indicating probable implant failure. STUDY DESIGN: Case series with chart review. SETTING: Tertiary referral center. SUBJECTS AND METHODS: Subjects were selected if they underwent cochlear explantation. Data were reviewed to determine initial symptom and symptom timeline preceding implant failure. RESULTS: A total of 847 implants were performed from 1988 to 2008, with 128 devices explanted. Of total implants, 72% were Advanced Bionic devices, and 28% were Cochlear Nucleus devices. Overall failure rate was 128 of 847 (15%), with 51 (6%) medical failures and 77 (9%) device failures. Patients with Advanced Bionic devices underwent 102 explants (16.7% failure rate), with 35% medical failures and 65% device failures. Patients with Nucleus devices underwent 26 explants (11% failure rate), with 58% medical failures and 42% device failures. Medical failures included infected devices and wound dehiscence, with the pattern averaging 4.5 months to explantation. Hard device failures included sudden malfunction and slow decline in function, with pattern of failure over 4.2 months. Soft failures included tinnitus and discomfort, with failure over 8 months. CONCLUSIONS: There were common patterns when evaluating both medical and device failures. By recognizing patterns of symptoms that may indicate probable implant failure, otolaryngologists can better counsel patients on what to expect with their implants when they present with certain symptoms.

Interleukin-8 production in response to tumor necrosis factor-alpha by cholesteatoma keratinocytes in cell culture.

OBJECTIVES/HYPOTHESIS: Keratinocytes harvested from acquired cholesteatoma and grown in cell culture will demonstrate increased interleukin-8 (IL-8) production in response to tumor necrosis factor (TNF)-alpha as compared with a control keratinocyte cell line. Immunohistochemical studies have identified IL-8 and TNF-alpha, mediators of bony destruction, in tissue samples of cholesteatoma. TNF-alpha stimulates IL-8 production in healthy epidermal keratinocyte cell lines. It is not known whether TNF-alpha stimulates IL-8 production in cultured cholesteatoma keratinocytes. STUDY DESIGN: Prospective controlled tissue culture experiment. METHODS: Tissue from an acquired cholesteatoma was dissociated and grown in keratinocyte serum-free media for 8 weeks. Cholesteatoma keratinocytes and a control cell line of skin epidermal keratinocytes were treated with TNF-alpha. Conditioned media were harvested; production of IL-8 was measured by enzyme-linked immunosorbent assay, and cell counts were performed. RESULTS: At a zero concentration of TNF-alpha, mean production of IL-8 by cholesteatoma keratinocytes was 39,809 pg/mL/24hr/1 × 10(6) cells versus 1,907 pg/mL/24hr/1 × 10(6) cells from skin epidermal keratinocytes, a statistically significant difference (P < .05). The cholesteatoma keratinocytes showed a 2.1-fold increase in response to 2 pg/mL of TNF-alpha and a 2.44-fold increase in response to 20 pg/mL of TNF-alpha. The skin epidermal keratinocyte cell line demonstrated a 1.07- and 1.13-fold increase to respective concentrations of TNF-alpha. CONCLUSIONS: Cholesteatoma keratinocytes appear to retain cell signaling characteristics in vitro that distinguish them from skin epidermal keratinocytes. This finding may indicate that cholesteatoma keratinocytes undergo a change in behavior in vivo that is preserved after the cells are removed from the inflammatory environment of the middle ear.

Late failure rate of hearing preservation after middle fossa approach for resection of vestibular schwannoma.

OBJECTIVE: To explore the long-term hearing results after a middle fossa approach for resection of vestibular schwannoma. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center. PATIENTS: All patients undergoing a middle fossa approach for resection of vestibular schwannoma at a single institution with intent to preserve hearing between December 1989 and December 2009 were included in the study population. INTERVENTIONS: Standard middle fossa approach for resection of vestibular schwannoma, magnetic resonance imaging (MRI), and audiogram. MAIN OUTCOME MEASURES: Recurrence of tumor as evaluated by MRI and hearing results as measured by serial audiograms. RESULTS: Seventy-eight patients were identified who met study criteria. Fifty-one (65%) of the 78 patients had usable hearing (American Academy of Otolaryngology-Head and Neck Surgery [AAO-HNS] class A or B) postoperatively. Forty-four patients with successful hearing preservation had follow-up beyond their initial postoperative visit. Five (11%) of the 44 patients showed late degradation to nonserviceable hearing (AAO-HNS class C or D) over a mean follow-up of 4.0 years. Kaplan-Meier estimate of preservation of class A or B hearing at 10 years was 72%. Of the five patients with late degradation in hearing, 2 were found to have recurrences of their original tumor on MRI. There were 5 confirmed recurrences in the total study population. CONCLUSION: Late degradation of hearing was an infrequent occurrence after initially successful hearing preservation. When hearing degradation did occur, there seemed to be a correlation with tumor recurrence.

The first new otologic disorder in a century: superior canal dehiscence syndrome.

Superior canal dehiscence syndrome is a recently described vestibular and hearing condition caused by an absence of bone over the arc of the superior semicircular canal. Patients with the condition present with a variety of perplexing symptoms including conductive hearing loss, hyperacusis, vertigo, autophony, and eye movement in response to sound. This article presents the case of a patient with the condition, discusses how it is distinct from other vestibular and hearing disorders, and describes how patients with this disorder can be diagnosed and treated.

Implantable hearing devices.

PURPOSE OF REVIEW: Implantable hearing devices have been developed to address the shortcomings of traditional hearing aids. Currently, there are two US Food and Drug Administration clinical trials evaluating fully implantable hearing devices. RECENT FINDINGS: Implantable hearing devices attempt to improve upon stigma, cosmesis, occlusion effect, and feedback, as well as other factors that prevent patients from using traditional hearing aids. However, there are many challenges inherent in designing an implantable hearing device. Different devices have attempted to overcome these challenges in different ways. We will discuss these differences in design, their individual pros and cons as well as directions of future research. SUMMARY: Although implantable hearing devices are not currently available they do hold promise for patients not adequately served by conventional hearing aids.

High-resolution metagenomics targets specific functional types in complex microbial communities.

Most microbes in the biosphere remain unculturable. Whole genome shotgun (WGS) sequencing of environmental DNA (metagenomics) can be used to study the genetic and metabolic properties of natural microbial communities. However, in communities of high complexity, metagenomics fails to link specific microbes to specific ecological functions. To overcome this limitation, we developed a method to target microbial subpopulations by labeling DNA through stable isotope probing (SIP), followed by WGS sequencing. Metagenome analysis of microbes from Lake Washington in Seattle that oxidize single-carbon (C1) compounds shows specific sequence enrichments in response to different C1 substrates, revealing the ecological roles of individual phylotypes. We also demonstrate the utility of our approach by extracting a nearly complete genome of a novel methylotroph, Methylotenera mobilis, reconstructing its metabolism and conducting genome-wide analyses. This high-resolution, targeted metagenomics approach may be applicable to a wide variety of ecosystems.

Rebounding V1 activity and a new visual aftereffect.

A serendipitous observation led to this study of V1 activity rebounds, which occur well after stimulus offset, and their relationship to visual aftereffects. We found that when a stimulus bar and background were simultaneously turned off, there was strong delayed rebounding activity (distinct from any off response). The neural rebound started 350-500 ms after stimulus offset, and its magnitude and duration were correlated with the prior visual response of the cell. In human psychophysical experiments, we found a delayed aftereffect that may be a perceptual correlate of the activity rebound. Both the rebound activity and the perceptual aftereffect disappeared if the stimulus bar and background were not extinguished together. The magnitude of the rebound varied with the spatial scale of the background even though background size had little effect on the visual response. It thus appeared that rebound magnitude was determined by a relatively large integration area. The aftereffect was not seen when the bar and background offsets were presented to different eyes, suggesting an early neural (monocular) basis for the aftereffect. Overall, we find a strong correlation between rebound activity and the perceived aftereffect. In addition to providing a possible explanation and neural correlate of a visual aftereffect, rebounding activity may provide new insight into the dynamics of early visual processing.

Secreting jugulotympanic paraganglioma with venous involvement into the thorax.

Paragangliomas are highly vascular tumors that arise from chief cells in extra-adrenal paraganglia of the autonomic nervous system. Jugulotympanic paragangliomas involve the middle ear and jugular fossa. Secreting jugulotympanic paragangliomas with thoracic extension are rare. We report a case with unexpected involvement of the internal jugular vein. Otolaryngologists should be aware that the jugulotympanic paragangliomas traverse variable anatomic pathways. Multiple imaging options, including magnetic resonance venography, are useful and should include the neck for definitive characterization of tumor anatomy. Patients with refractory hypertension and masses suspicious for paraganglioma should be examined for functional tumors.

Cochlear stem cells/progenitors and degenerative hearing disorders.

Hearing loss (deafness) affects approximately 250 million people globally. The major cause of deafness is loss of hair cells and spiral ganglion neurons due to aging, antibiotic use, noise exposure, and genetic defects. At the present time, there is no effective method for restoration of hearing biologically. Cochlear stem cells/progenitors (CSCs), quiescent in the organ of Corti, are excellent candidates for restoration of cell types in the organ of Corti biologically. However, little is known about the biology of CSCs and developmental cues for CSCs to differentiate into hair cells and neurons at the present time. In this article, we briefly reviewed the isolation of CSCs from the postnatal organ of Corti in mice and their capability to differentiate into hair cells and neurons in vitro under the guidance of a group of growth factors: sonic hedgehog (SHH), epidermal growth factor (EGF), retinoic acid (RA), and brain-derived neurotrophic factor (BDNF), herein termed SERB. The identification of CSCs and their differentiation signals is potentially of clinical importance.