Effect of tobacco use on Zenker's diverticulotomy outcomes.

OBJECTIVE: To compare clinical outcomes in patients with and without history of tobacco use who underwent Zenker's diverticulotomy (ZD). STUDY DESIGN: Single institution retrospective review. SETTING: Tertiary care academic hospital. METHODS: A retrospective review of patients who underwent ZD via an open stapler, rigid endoscopic CO2 laser, stapler or harmonic scalpel, and flexible endoscopic technique from January 2006 to December 2020 was performed. Data were abstracted for patient demographics, diverticular features, and rates of adverse events and symptomatic recurrence. RESULTS: Out of 424 patients, 146 (34.4 %) had a history of tobacco use: 126 (29.7 %) were former smokers, and 20 (4.7 %) were active smokers. In univariable cross-sectional analyses, the likelihood of postoperative bleeding, perforation, emergency department visits, unplanned readmission, or recurrence did not demonstrate an association with tobacco use history even after adjustment for age, sex, and surgical approach. Similarly, in Cox Proportional Hazards regression, tobacco use was not associated with an increased risk of recurrence, even after correcting for age, sex, and type of surgery. The median time to recurrence observed in our cohort was 11.5 years amongst non-smokers, 8.7 years amongst former smokers, and 1.2 years amongst active smokers (p = 0.94). CONCLUSIONS: There were no significant differences in post-operative adverse events or frequency of recurrence of ZD between active, former, and non-smokers. Although underpowered and not statistically significant, median time to recurrence appears to be shorter in smokers when compared with former and non-smokers following surgery.

RNA Sequencing of Idiopathic Subglottic Stenosis Tissues Uncovers Putative Profibrotic Mechanisms and Identifies a Prognostic Biomarker.

Idiopathic subglottic stenosis (iSGS) is a localized airway disease that almost exclusively affects females. Understanding the molecular mechanisms involved may provide insights leading to therapeutic interventions. Next-generation sequencing was performed on tissue sections from patients with iSGS (n = 22), antineutrophil cytoplasmic antibody-associated vasculitis (AAV; n = 5), and matched controls (n = 9) to explore candidate genes and mechanisms of disease. Gene expression changes were validated, and selected markers were identified by immunofluorescence staining. Epithelial-mesenchymal transition (EMT) and leukocyte extravasation pathways were the biological mechanisms most relevant to iSGS pathogenesis. Alternatively activated macrophages (M2) were abundant in the subepithelium and perisubmucosal glands of the airway in iSGS and AAV. Increased expression of the mesenchymal marker S100A4 and decreased expression of the epithelial marker epithelial cell adhesion molecule (EPCAM) further supported a role for EMT, but to different extents, in iSGS and antineutrophil cytoplasmic antibody-associated subglottic stenosis. In patients with iSGS, high expression of prostate transmembrane protein, androgen induced 1 (PMEPA1), an EMT regulator, was associated with a shorter recurrence interval (25 versus 116 months: hazard ratio = 4.16; P = 0.041; 95% CI, 1.056-15.60). Thus, EMT is a key pathogenetic mechanism of subglottic stenosis in iSGS and AAV. M2 macrophages contribute to the pathogenesis of both diseases, suggesting a shared profibrotic mechanism, and PMEPA1 may be a biomarker for predicting disease recurrence in iSGS.

Flexible endoscopic Zenker's diverticulotomy - A retrospective review of outcomes in 75 patients.

OBJECTIVE: Flexible endoscopic Zenker's diverticulotomy (FEZD) is a procedure performed primarily by gastroenterologists for treatment of symptomatic Zenker's diverticulum (ZD). Given the lack of prior investigations with large sample sizes, we report on one of the largest series of patients who underwent FEZD. METHODS: A review of patients who underwent FEZD at our institution from 2006 to 2021 was performed. Data were abstracted for patient demographics, clinical features, procedural characteristics, adverse events, and outcomes. RESULTS: A total of 75 patients (37 women) with mean age of 77.9 (33-102) years and mean (range) follow-up of 1.1 (0-13.2) years were identified. 67.9 % of FEZD cases were performed under general anesthesia. The mean procedure time was 37.1 min. Same day discharge and resumption of oral intake was seen in 56.4 % and 57.1 % of cases, respectively. Adverse events included intraprocedural bleeding (15.7 %) controlled with endoscopic means, infection (4.8 %) exclusively managed with antibiotics in all but one case, subcutaneous emphysema (2.4 %), and perforation (10.7 %) conservatively managed in all but one case. 97.6 % of patients had sustained subjective improvement in symptoms following their procedure. Fifteen patients (20 %) experienced recurrence after undergoing initial FEZD-26.7 % percent of whom were sufficiently treated with repeat FEZDs. Younger age was associated with recurrence (p < 0.01). CONCLUSION: FEZD is an effective, safe procedure for the management of symptomatic ZD. It is a viable alternative for patients in whom otorhinolaryngological procedures via rigid endoscopy are not an option.

Extreme risk protection orders in response to threats of multiple victim/mass shooting in six U.S. states: A descriptive study.

Extreme risk protection orders (ERPOs), also known as red flag laws, are a potential tool to prevent firearm violence, including mass shootings, but little is currently known about the extent of their use in cases of mass shooting threats or about the threats themselves. We collected and abstracted information from ERPO cases from six states (California, Colorado, Connecticut, Florida, Maryland, and Washington). Ten percent (N = 662) of all ERPO cases (N = 6787) were in response to a threat of killing at least 3 people. Using these cases, we created a typology of multiple victim/mass shooting threats, the most common of which was the maximum casualty threat. The most common target for a multiple victim/mass shooting threat was a K-12 school, followed by businesses, then intimate partners and their children and families. Judges granted 93% of petitions that involved these threats at the temporary ERPO stage and, of those cases in which a final hearing was held, judges granted 84% of final ERPOs. While we cannot know how many of the 662 ERPO cases precipitated by a threat would have resulted in a multiple victim/mass shooting event had ERPO laws not been used to prohibit the purchase and possession of firearms, the study provides evidence at least that ERPOs are being used in six states in a substantial number of these kinds of cases that could have ended in tragedy.

Association of state-level intoxicated driving laws with firearm homicide and suicide.

OBJECTIVES: To determine if an association exists between the number of driving under the influence (DUI) convictions required to activate federal firearms prohibitions and annual firearm homicide and suicide rates by state. METHODS: Ecological cross-sectional study of all US states from 2013 to 2017. We collected DUI law data from Thomson Reuters Westlaw database and firearm mortality data from the Centers for Disease Control and Prevention Vital Statistics programme. RESULTS: Five states had laws such that one or two DUI convictions could result in prohibitions to firearms access according to federal law. Four states had no legal framework that would restrict firearms access because of DUI convictions; the remaining states could activate federal restrictions at three or more DUI convictions. Firearm-specific homicide (victimisations) rates were 19% lower among women in states where federal restrictions of firearms access occurred after one or two DUI offences (incidence rate ratio (IRR) 0.81; 95% CI 0.64 to 1.01) and 18% lower in states with firearm prohibitions after three or more offences (IRR 0.82; 95% CI 0.71 to 0.95) compared with the states with no legal framework for prohibiting firearms after DUI convictions. There was no association between number of DUI activations and overall, or firearm-specific, suicide among the entire population (men and women) or among only women, or only men. CONCLUSIONS: DUI penalties that activate federal firearms prohibitions may be one pathway to reduce firearm homicide of female victims.

Complications following laser wedge excision for idiopathic subglottic stenosis.

OBJECTIVES: Endoscopic laser wedge excision (LWE) is an effective treatment option for idiopathic subglottic stenosis (iSGS); however, data regarding complications following LWE are limited. The aim of the following analysis was to provide a review of frequency and type of complications that occur with LWE in patients with iSGS. STUDY DESIGN: Retrospective review. METHODS: Patients with iSGS undergoing LWE between January 2002 and September 2021 were performed. Demographic data were recorded. Complications were stratified into major and minor categories. The frequency of these complications and the respective treatment for them was analyzed. RESULTS: 212 patients within the study period underwent a total of 573 LWE procedures. All but two patients were female, with a median age of 54 years at time of LWE. Of these patients, 43 (20 %) patients experienced a complication. Of these, only 7 (15 %) of the reported complications were considered major while the rest were minor in nature. Major complications included 3 cases of post-operative hemoptysis, 1 case of tracheitis, and 3 cases of reduced vocal fold hypomobility with concurrent glottic stenosis. Minor complications consisted of 2 cases of tooth fracture and 34 cases of tongue paresthesia post-operatively that was self-limited. There were no mortalities. CONCLUSION: Major complications occur in <5 % of LWE procedures based off the analysis. All major complications were managed without significant long-term morbidity. Minor complications with the LWE are self-limited in nature. Our data supports the LWE as a safe treatment option for iSGS.

Relation of Driving Under the Influence Laws to Access to Firearms Across US States.

Objectives. To determine differences among US states in how driving under the influence of alcohol (DUI) laws activate federal firearm possession and purchase prohibitions.Methods. We performed primary legislative research to characterize DUI laws in each state. The primary outcome was the number of DUI convictions an individual must be convicted of in each state to activate the federal firearm possession and purchase prohibition. We also determined the time interval in which previous DUI convictions count for future proceedings.Results. Forty-seven states had DUI laws that activated the federal prohibition of firearm possession and purchase for a threshold number of repeated DUIs. Variation exists among states in the number of convictions (1-4) and length of liability period (5 years-lifetime) required to prohibit firearm possession and purchase.Conclusions. Variation in state laws on DUI results in differences in determining who is federally prohibited from possessing and purchasing firearms. Future research should explore whether these federal prohibitions arising from DUI convictions are enforced and whether an association exists between stricter DUI policies and reduction in firearm crimes, injuries, and deaths.

Assessment of county-level proxy variables for household firearm ownership.

Our objective in this study was to evaluate how well proxy variables for firearm ownership used in county-level studies measure firearm ownership. We applied Bayesian spatial smoothing methods to calculate county-level estimates of household firearm ownership using Behavioral Risk Factor Surveillance System (BRFSS) data (2013-2018). We compared these estimates to four proxies for county-level firearm ownership: the proportion of suicides that were firearm suicides, the average of the proportion of suicides that were firearm suicides and the proportion of homicides that were firearm homicides, gun shops per capita, and federal firearm licenses per capita. U.S. counties for which BRFSS data on household firearm ownership were collected and available for release (n = 304) were included. The median (interquartile range) prevalence of household firearm ownership was 46.6% (37.2%, 56.4%). The per capita rate of federal firearm licenses was most strongly correlated with household firearm ownership (r = 0.70; 95% CI: 0.63, 0.75) followed by the proportion of suicides that were firearm suicides (r = 0.45; 95% CI: 0.36, 0.54). These correlations were stronger among counties with populations of ≥250,000 people. The per capita rate of federal firearm licenses was the best proxy variable for firearm ownership at the county level, however, a better proxy should be identified.

Is tracheotomy on the decline in otolaryngology? A single institutional analysis.

OBJECTIVE: A recent study reported decreasing trends in tracheotomy procedures by its otolaryngology service. We set out to determine whether the previously reported decrease in otolaryngology performed tracheotomies by one institution is a local or generalizable phenomenon. DESIGN: Retrospective cohort study from 2010 to 2015. SETTING: Tertiary care hospital and affiliated regional hospitals. SUBJECT AND METHODS: All patients who received tracheotomy during the period of analysis were included. Performing specialty, surgical technique, and procedure location were recorded. Procedures were stratified by year and specialty to generate incidence rate ratios for otolaryngologists and non-otolaryngologists. Incidence rate ratios were estimated with negative binomial regression across services. RESULTS: The otolaryngology service demonstrated a yearly decrease of 3.4% in the total number of tracheotomies (95% CI -7.9% to +1.4, P=0.17). While the thoracic service remained constant (+0.3%, 95% CI -2.6% to +3.3%, p=0.83), general surgery demonstrated the greatest increase in procedures (+4.4%, 95% CI -6.0% to +15.8%, P=0.42). Thoracic and general surgery both dramatically increased the number of percutaneous tracheotomies performed, with general surgery also performing a greater number of bedside procedures. CONCLUSIONS AND RELEVANCE: We observed a similar decline in the number of tracheotomies otolaryngology over six years. Our trend is likely due to changes in consultations patterns, increasing use of the percutaneous method, and an increase in adjunctive gastrostomy tube placements. Investigations on the impact of a greater number of non-otolaryngology performed tracheotomies on follow up care is warranted.

Voice and swallowing outcomes following hypoglossal nerve stimulation for obstructive sleep apnea.

OBJECTIVE: Hypoglossal nerve stimulation is an effective treatment for a subset of patients with Obstructive Sleep Apnea (OSA). Although multiple clinical trials demonstrate its efficacy, no previous literature explores the potential impact the stimulator has on swallowing and voice. Our primary objective is to evaluate patient reported post-operative changes in voice or swallowing following hypoglossal nerve stimulator placement. STUDY DESIGN: Prospective cohort study. SETTING: Tertiary care hospital. SUBJECT AND METHODS: Patients scheduled to receive a hypoglossal stimulator were enrolled. Participants completed baseline Voice Handicap Index-10 (VHI-10) and Eating Assessment Tool-10 (EAT-10) questionnaires preoperatively and again at 1week, 3months, and 6months post-operatively following placement of a hypoglossal nerve stimulator. RESULTS: 9 males and 5 females completed the study. The mean pre-operative VHI-10 and EAT-10 score was 3 and 0.8 respectively. Using linear mixed models, a clinically and statistically significant increase in the mean EAT-10 score was observed post-operatively at 1week (p=0.007), which was not observed at the time points the stimulator was active. A clinically and statistically significant decrease in VHI-10 score was observed following 2months of active stimulator use (p=0.02), which was not observed at any other time point. CONCLUSION: The implantation and use of the hypoglossal nerve stimulator over 5months did not demonstrate any sustained, patient reported changes in voice handicap and swallowing function. While larger studies are warranted, our findings can be used to provide further informed consent for hypoglossal nerve stimulator implantation.

Biogeochemical spatio-temporal transformation of copper in Aspergillus niger colonies grown on malachite with different inorganic nitrogen sources.

This work elucidates spatio-temporal aspects of the biogeochemical transformation of copper mobilized from malachite (Cu2 (CO3 )(OH)2 ) and bioaccumulated within Aspergillus niger colonies when grown on different inorganic nitrogen sources. It was shown that the use of either ammonium or nitrate determined how copper was distributed within the colony and its microenvironment and the copper oxidation state and succession of copper coordinating ligands within the biomass. Nitrate-grown colonies yielded ∼1.7× more biomass, bioaccumulated ∼7× less copper, excreted ∼1.9× more oxalate and produced ∼1.75× less water-soluble copper in the medium in contrast to ammonium-grown colonies. Microfocus X-ray absorption spectroscopy revealed that as the mycelium matured, bioaccumulated copper was transformed from less stable and more toxic Cu(I) into less toxic Cu(II) which was coordinated predominantly by phosphate/malate ligands. With time, a shift to oxalate coordination of bioaccumulated copper occurred in the central older region of ammonium-grown colonies.

Acoustic measurement of the Deepwater Horizon Macondo well flow rate.

On May 31, 2010, a direct acoustic measurement method was used to quantify fluid leakage rate from the Deepwater Horizon Macondo well prior to removal of its broken riser. This method utilized an acoustic imaging sonar and acoustic Doppler sonar operating onboard a remotely operated vehicle for noncontact measurement of flow cross-section and velocity from the well's two leak sites. Over 2,500 sonar cross-sections and over 85,000 Doppler velocity measurements were recorded during the acquisition process. These data were then applied to turbulent jet and plume flow models to account for entrained water and calculate a combined hydrocarbon flow rate from the two leak sites at seafloor conditions. Based on the chemical composition of end-member samples collected from within the well, this bulk volumetric rate was then normalized to account for contributions from gases and condensates at initial leak source conditions. Results from this investigation indicate that on May 31, 2010, the well's oil flow rate was approximately 0.10 ± 0.017 m(3) s(-1) at seafloor conditions, or approximately 85 ± 15 kg s(-1) (7.4 ± 1.3 Gg d(-1)), equivalent to approximately 57,000 ± 9,800 barrels of oil per day at surface conditions. End-member chemical composition indicates that this oil release rate was accompanied by approximately an additional 24 ± 4.2 kg s(-1) (2.1 ± 0.37 Gg d(-1)) of natural gas (methane through pentanes), yielding a total hydrocarbon release rate of 110 ± 19 kg s(-1) (9.5 ± 1.6 Gg d(-1)).

Single-use versus reusable rhinolaryngoscopes for inpatient otorhinolaryngology consults: Resident and patient experience.

Objectives: Single-use rhinolaryngoscopes were brought to market in 2019 as an alternative to traditional reusable scopes and have garnered interest across settings given portability and potential cost advantages. While single-use was previously evaluated compared to traditional devices, the overall impact to the consult experience for both users and patients has not been captured. Methods: Eighteen residents performed consults with both single-use and reusable rhinolaryngoscope systems on alternating weeks. A five-question cumulative survey administered across three assessment points over a 12-week period using a five-point rating system to rate favorability. Residents and patients also completed four-point scale surveys following procedure(s) to capture the consult experience. Statistical analyses were performed to measure significance differences between survey responses between the two systems. Results: Single-use rhinolaryngoscopes received higher overall ratings compared with reusables across each metric captured including overall consult time (4.3 vs. 2.2, p < .001), multiscope consults (4.4 vs. 3.1, p < .001), patient communication (4.6 vs. 2.1, p < .001), teaching opportunities (4.6 vs. 2.1, p < .001), and overall ease of use (4.7 vs. 2.6, p < .001). Residents rated single-use higher than reusable after each procedure in terms of ease of use (1.07 vs. 2.68, p < .001) and visual clarity (1.27 vs. 1.89, p = .003), while patients rated single-use higher for understanding of illness (3.9 vs. 3.1, p < .001) and understanding of treatment rationale (3.9 vs. 3.1, p < .001). Conclusion: Resident and patient experience feedback favored single-use rhinolaryngoscopes compared to reusable scope technology across multiple surveyed measurables. Single-use rhinolaryngoscopes provide a viable tool for otorhinolaryngologist and other clinicians to perform rhinolaryngoscopy consults. Level of Evidence: 4.

Medical Maintenance Therapy Following Laser Excision in Patients With Granulomatosis With Polyangiitis (GPA)-Associated Subglottic Stenosis.

OBJECTIVE: To report on a series of patients with cANCA/PR3-positive, granulomatosis with polyangiitis (GPA)-associated subglottic stenosis (SGS) and evaluate response to medical maintenance therapy with rituximab versus other immunosuppressants following initial endoscopic laser excision. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary academic center. METHODS: A retrospective chart review of patients with SGS and cANCA/PR3-positive GPA who received immunosuppressive maintenance therapy following endoscopic laser excision at our institution from June 1989 to March 2020 was performed. Data pertaining to patient demographics, clinical features, medications, and endoscopic laser procedures were collected. RESULTS: A total of 27 patients (15 women) with mean age (range) of 40 (19-59) years and mean (range) follow-up of 12.6 years (1.5-28.6) were identified. Sixteen patients (60%) had limited GPA. Six patients (24%) had previously received local intervention with open surgery (n = 1, 4%) or endoscopic techniques (n = 5, 20%). All patients experienced symptom improvement following initial CO2 laser excision at our institution without any procedural complications or adverse events. Following initial laser excision, 15 patients (60%) were treated with rituximab and 10 patients (40%) were treated with nonrituximab immunosuppressive agents. Patients treated with rituximab were less likely to recur (P = 0.040). Limited GPA was associated with an increased incidence of recurrence (P = 0.031). Median time (years) to recurrence (range) was 3.2 (0.3-19.3) and was not significantly associated with treatment or GPA subtype. CONCLUSION: Endoscopic CO2 laser excision is a safe and effective local intervention for GPA-associated SGS. Medical maintenance therapy with rituximab reduces risk of recurrence following initial laser excision relative to treatment with non-rituximab agents.

Symptom-Free Intervals Following Laser Wedge Excision for Recurrent Idiopathic Subglottic Stenosis.

OBJECTIVE: Analyze the duration of symptom-free intervals following laser wedge excision (LWE) for recurrent idiopathic subglottic stenosis (iSGS). Secondary aim includes evaluating the influence of patient-related or disease factors. STUDY DESIGN: Retrospective review. SETTING: Tertiary center. METHODS: Review of iSGS patients who underwent LWE between 2002 and 2021. LWE patients without prior airway surgery were labeled LWE primary (LWEP) and those with prior history of dilation were labeled LWE secondary (LWES). A conditional frailty repeated events model was used to analyze the median time to recurrence (MTR) for each nth recurrence. Secondary analysis included stratification by use of medical therapy and initial preoperative characteristics of scar (Myer-Cotton grade, distance between the glottis and superior-most aspect of scar, DGS; length of scar, DL). RESULTS: Two hundred and ten iSGS patients underwent LWE (131 LWEP, 79 LWES). The proportion of patients experiencing at least 1, 3, 6, and 12 recurrences, respectively, was 68.0% (n = 143), 40.7% (n = 85), 20.0% (n = 42), and 5.2% (n = 11). There was exponential time-shortening from the 1st to 12th recurrence (P < .0001). While MTR was 4.1 years after the first LWE, this fell to 2.8, 1.7, 1.0, and 0.7 years for the 2nd, 3rd, 6th, and 12th recurrences. Furthermore, LWEP patients experienced longer MTR than LWES counterparts within the first 6 recurrences (P < .01). There was no significant relationship between intersurgical interval and medication adherence, DL, DGS, or grade for recurrences beyond the first (P = .207, P = .20, P = .43, P = .16). CONCLUSION: Symptom-free intervals in iSGS shorten with each subsequent recurrence and LWE. The difference in MTR between LWEP and LWES groups was significant within the first 6 recurrences with LWEP having longer MTR.

The effects of adjuvant fibrin sealant on the surgical repair of segmental nerve defects in an animal model.

PURPOSE: Nerve repair after a segmental defect injury remains a challenge for surgeons. Fibrin glue can be used to expedite surgical procedures and maintain proper nerve spatial orientation to potentially optimize recovery, yet surgeons hesitate to use it owing to concerns about fibrin's inhibiting regeneration and increasing scar formation. The purpose of these experiments was to evaluate whether fibrin glue impedes nerve regeneration. METHODS: A critical-size defect of 10 mm was created in 32 Sprague-Dawley rats with 4 different forms of repair: a collagen type-I conduit (n = 8), a collagen type-I conduit filled with fibrin glue (n = 8), an autologous nerve graft (n=8), and an autologous nerve graft with fibrin glue (n = 8). Behavioral tests, including sciatic functional indices, were used to evaluate functional recovery. Neurophysiology, immunohistochemistry, and nerve morphometry were used to critically analyze nerve regeneration. RESULTS: Multiple outcome parameters for nerve regeneration, remyelination, behavior, and electrophysiology were used to determine that the addition of fibrin did not influence recovery for the autograft groups. Similarly, within the conduit group, behavioral tests showed comparable functional recovery and indistinguishable results in compound motor action potential and nerve morphometry. Immunohistochemistry revealed identical degrees of Wallerian degeneration and scarring between conduit groups. CONCLUSIONS: The addition of fibrin to either the conduit or the autograft group did not result in any meaningful differences in recovery. Our data demonstrate that fibrin glue does not impede nerve regeneration or functional recovery after surgical repair of a segmental nerve defect in a rat model. CLINICAL RELEVANCE: The clinical use of fibrin glue as an adjunct with peripheral nerve repair may be considered safe because it does not impair nerve regeneration with critical size defects in an animal model.

Misclassification of firearm-related violent crime in criminal legal system records: challenges and opportunities.

BACKGROUND: Criminal legal system data are one source for measuring some types of firearm-related harms, including those that do not necessarily result in injury or death, but measurement can be hampered by imprecise criminal code statutes. We quantified the degree of misclassification in Washington state criminal codes for measuring firearm-related crime. FINDINGS: In this study of individuals aged 18 years and older who were convicted of a misdemeanor in Washington Superior Courts from 1/1/2015 through 12/31/2019, we compared firearm-related charges as measured with criminal codes and with manual review of probable cause documents, considered the gold standard. The sample included 5,390 criminal cases. Of these, 77 (1.4%) were firearm-related as measured with criminal codes and 437 (8.1%) were firearm-related as measured via manual record review. In the sample overall, the sensitivity of criminal codes was 17.6% (95% CI 14.2-21.5%), and negative predictive value (NPV) was 93.2% (95% CI 92.5-93.9%). Sensitivity and NPV were higher for cases with exclusively non-violent charges. For all cases and for cases with any violent crime charge, firearm-related crimes described in probable cause documents most often involved explicit verbal threats, firearm possession, and pointing a firearm at or touching a firearm to someone; almost 10% of all cases involved shooting/discharging a firearm. For cases with exclusively non-violent charges, the most common firearm-related crime was unlawful possession. CONCLUSIONS: Criminal records can be used for large-scale policy-relevant studies of firearm-related harms, but this study suggests Washington state criminal codes substantially undercount firearm-related crime, especially firearm-related violent crime.

Classifying Firearm Injury Intent in Electronic Hospital Records Using Natural Language Processing.

Importance: International Classification of Diseases-coded hospital discharge data do not accurately reflect whether firearm injuries were caused by assault, unintentional injury, self-harm, legal intervention, or were of undetermined intent. Applying natural language processing (NLP) and machine learning (ML) techniques to electronic health record (EHR) narrative text could be associated with improved accuracy of firearm injury intent data. Objective: To assess the accuracy with which an ML model identified firearm injury intent. Design, Setting, and Participants: A cross-sectional retrospective EHR review was conducted at 3 level I trauma centers, 2 from health care institutions in Boston, Massachusetts, and 1 from Seattle, Washington, between January 1, 2000, and December 31, 2019; data analysis was performed from January 18, 2021, to August 22, 2022. A total of 1915 incident cases of firearm injury in patients presenting to emergency departments at the model development institution and 769 from the external validation institution with a firearm injury code assigned according to International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Clinical Modification (ICD-10-CM), in discharge data were included. Exposures: Classification of firearm injury intent. Main Outcomes and Measures: Intent classification accuracy by the NLP model was compared with ICD codes assigned by medical record coders in discharge data. The NLP model extracted intent-relevant features from narrative text that were then used by a gradient-boosting classifier to determine the intent of each firearm injury. Classification accuracy was evaluated against intent assigned by the research team. The model was further validated using an external data set. Results: The NLP model was evaluated in 381 patients presenting with firearm injury at the model development site (mean [SD] age, 39.2 [13.0] years; 348 [91.3%] men) and 304 patients at the external development site (mean [SD] age, 31.8 [14.8] years; 263 [86.5%] men). The model proved more accurate than medical record coders in assigning intent to firearm injuries at the model development site (accident F-score, 0.78 vs 0.40; assault F-score, 0.90 vs 0.78). The model maintained this improvement on an external validation set from a second institution (accident F-score, 0.64 vs 0.58; assault F-score, 0.88 vs 0.81). While the model showed some degradation between institutions, retraining the model using data from the second institution further improved performance on that site's records (accident F-score, 0.75; assault F-score, 0.92). Conclusions and Relevance: The findings of this study suggest that NLP ML can be used to improve the accuracy of firearm injury intent classification compared with ICD-coded discharge data, particularly for cases of accident and assault intents (the most prevalent and commonly misclassified intent types). Future research could refine this model using larger and more diverse data sets.

Proximal Scar Progression in Idiopathic Subglottic Stenosis After Wedge Excision: Does it Happen?

OBJECTIVE: To compare the incidence of glottic stenosis in idiopathic subglottic stenosis (iSGS) patients with no prior surgical intervention to those with a history of endoscopic dilation and characterize the incidence of glottic involvement, changes in scar length, and progression of scar toward glottis following laser wedge excision (LWE). METHODS: A retrospective review of iSGS patients who underwent LWE between 2002 and 2021 was performed. Patients without prior airway surgery were labeled LWE primary (LWEP) and operative findings for LWEP patients were reviewed for glottic involvement, scar length (DL ), and distance from the glottis to superior-most aspect of scar (DGS ). Rates (in mm/procedure) of DΔL , reflecting an increase in length, and D-ΔGS , reflecting proximal migration, were calculated by dividing DΔL and D-ΔGS by the number of LWE procedures. RESULTS: 213 iSGS patients underwent LWE, with 132 being LWEP patients. LWEP had a lower incidence of baseline glottic involvement (n = 6, 4.5%) than LWE secondary (LWES; n = 6, 7.5%). Four new cases of glottic involvement were noted in LWEP patients following LWE, with only one being clinically significant resulting in permanently decreased vocal fold mobility. With each procedure, scar length increased by 1.0 mm and DGS decreased by 0.7 mm, reflecting a migration or decrease in DGS of 9.5% with each procedure with respect to initial DGS . Overall rates of glottic stenosis following operations were similar between LWEP and LWES cohorts, 7.6% and 7.5% respectively. CONCLUSION: There appears to be a low risk of glottic involvement resulting from the LWE procedure in iSGS patients. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:875-882, 2023.