The power of interdependence: Linking health systems, communities, and health professions educational programs to better meet the needs of patients and populations.

Promoting optimal health outcomes for diverse patients and populations requires the acknowledgement and strengthening of interdependent relationships between health professions education programs, health systems, and the communities they serve. Educational programs must recognize their role as integral components of a larger system. Educators must strive to break down silos and synergize efforts to foster a health care workforce positioned for collaborative, equitable, community-oriented practice. Sharing interprofessional and interinstitutional strategies can foster wide propagation of educational innovation while accommodating local contexts. This paper outlines how member schools of the American Medical Association Accelerating Change in Medical Education Consortium leveraged interdependence to accomplish transformative innovations catalyzed by systems thinking and a community of innovation.

Otolaryngology Nurses' Awareness of Clinical Practice Guidelines.

Clinical practice guidelines (CPG) are developed to inform clinical decision-making and standardize care based on scientific evidence, benefits and harms of treatment, and patient preferences to achieve optimal health outcomes. This survey study explored the level of awareness of otorhinolaryngology (ORL) nurses in using CPGs in clinical practice. The study sought to answer the following: (1) How aware are ORL nurses of CPGs developed by the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF)? (2) Which CPGs are most widely identified by ORL nurses? and (3) Do ORL nurses perceive that AAO-HNSF guidelines can benefit their practice? An online survey was developed, piloted, and launched to all eligible registered nurse SOHN members in October 2015. A total of 146 nurses (29%) completed the survey. Over 60% of respondents were in nursing for more than 20 years, 20% were in ORL for 5 years or less, and 40% worked in the hospital, 25% were aware of one or less of the guidelines, with 75% aware of 2 or more specialty guidelines. Nurses were most aware of the tracheostomy care (64%), tonsillectomy in children (47%), and tympanostomy tubes in children (46%) guidelines. The majority of ORL nurses was aware of specialty CPGs and used them to help guide their clinical practice on a regular basis. They also perceived support by their organizations to engage in evidence-based practice. Increasing nurses' awareness and knowledge of CPGs will likely increase guideline use and advance clinical practices based on these recommendations. Strategies to enhance evidence-based guideline recommendations into practice will also be discussed.

Asthma Self-Management Goals, Beliefs and Behaviors of Urban African American Adolescents Prior to Transitioning to Adult Health Care.

UNLABELLED: Adolescence is a unique time of development incorporating a transition from child centered to adult centered health care. This transition period can be particularly challenging for individuals with a chronic disease such as asthma. Inadequate transition planning during adolescence may place an already vulnerable population such as African American adolescents with known health disparities in asthma prevalence, morbidity and mortality at risk for a continuation of poor health outcomes across the lifespan. Central to transition planning for these youth is the core element of developing and prioritizing goals. The purpose of this qualitative study was to explore the asthma self-management goals, beliefs and behaviors of urban African American adolescents prior to transitioning from pediatric to adult health care. METHODS: A focus group composed of 13 African American adolescents with asthma ages 14-18 years from an urban population was conducted. Responses from transcripts and field notes were reviewed using an iterative process to best characterize asthma self-management goals and beliefs that emerged. RESULTS: Four core themes were identified: 1) medication self-management, 2) social support, 3) independence vs. interdependence, and 4) self-advocacy. Medication self-management included subthemes of rescue medications, controller medications and medication avoidance. The social support theme included three subthemes: peer support, caregiver support and healthcare provider support. CONCLUSION: Findings suggest that adolescents with asthma form both short term and long term goals. Their goals indicated a need for guided support to facilitate a successful health care transition.

Samter's Triad to Aspirin-Exacerbated Respiratory Disease: Historical Perspective and Current Clinical Practice.

Aspirin-exacerbated respiratory disease (AERD), formerly known as Samter's Triad, is a syndrome of airway inflammation characterized by rhinosinusitis with polyposis, asthma, and nonsteroidal anti-inflammatory drug (NSAID) intolerance. Approximately 7% of patients with asthma will also have AERD making prompt identification, diagnosis, and management of this syndrome important to controlling the disease progression. This paper will provide a brief biographical background on Max Samter, MD, followed by an epidemiologic overview, clinical presentation and diagnosis, and management strategies, which highlight patient counseling and educational needs.

Transformational leadership practices of nurse leaders in professional nursing associations.

OBJECTIVE: This study describes the transformational leadership (TL) practices of nurse leaders in professional nursing associations (PNAs). BACKGROUND: Professional nursing associations are vehicles to provide educational opportunities for nurses as well as leadership opportunities for members. Little has been published about the leadership practices of PNA members. METHOD: E-mail surveys of 448 nurse leaders in PNAs were conducted in 2013 using the Leadership Practices Inventory (LPI). RESULTS: The top 2 TL practices of these nurse leaders were enabling others to act and encouraging the heart. Respondents with more leadership training reported higher TL practices. CONCLUSION: This is the 1st study to describe TL practices of nurse leaders in PNAs. Results of this study show that nurse leaders of PNAs emulate practices of TL. Transformational leaders can mobilize and direct association members in reaching shared values, objectives, and outcomes. Understanding TL practices of nurse leaders in PNAs are important to the future of nursing in order to enable nurses to lead change and advance health through these organizations.

Goals, beliefs, and concerns of urban caregivers of middle and older adolescents with asthma.

OBJECTIVE: Caregiver goals, an integral part of a partnership for asthma management, have been found to influence asthma outcomes in children. These goals are likely to change during the transitional period of adolescence to address the needs of teenagers as they mature and assume greater responsibilities for their own care. Little is known about the goals, beliefs, and concerns of caregivers as they begin to shift responsibilities for asthma management to teens. This study sought to identify the asthma management goals, beliefs, and concerns of primarily African American caregivers of urban middle and older adolescents. METHODS: Fourteen caregivers of urban African American adolescents aged 14-18 years with asthma participated in a focus group session. An iterative process was used to identify themes from the session related to asthma management goals, concerns, and beliefs of caregivers. RESULTS: Caregivers identified goals that related to supporting their teens' progress toward independent asthma self-management. They described significant concerns related to the teens' ability to implement asthma self-management, especially in school settings. Caregivers also revealed beliefs that represented knowledge deficits related to asthma medications and factors that improved or worsened asthma. Most caregivers identified grave concerns about school policies regarding asthma medication administration and the lack of knowledge and support provided by teachers and staff for their teen. CONCLUSION: Caregivers are an invaluable resource in the care of adolescents with asthma. An opportunity exists to improve caregiver understanding of asthma medications and to provide support through improvements in asthma care for adolescents in school-based settings.

Self-care predictors for success post-bariatric surgery: a literature review.

The prevalence of obesity in the United States has more than doubled from 1980 to 2008. Obesity leads to a multitude of comorbidities, most notably diabetes and cardiovascular diseases, resulting in more than $147 billion annually in healthcare costs. Bariatric surgery is becoming a common weight loss option for morbidly obese individuals. Studies in this review examine patients who have undergone laparoscopic adjustable gastric banding or Roux-en-Y gastric bypass surgery. Patients initially lose large amounts of weight postoperatively; unfortunately, around 30% of these individuals begin to regain weight 18-24 months after surgery. The purpose of this article is to analyze the current literature to ascertain which self-care variables are predictors of successful long-term weight loss after bariatric surgery. The studies analyzed in this review found that patients who undergo a surgical weight loss intervention lose more weight faster than patients who do not have a surgical weight loss intervention. However, patients reported feeling unprepared for the extreme psychosocial and lifestyle changes after bariatric surgery. Findings from these studies point to the need for future research in the area of postsurgical psychosocial support for successful long-term weight loss maintenance.

Asthma, rhinitis, and the unified airway.

Patients with rhinitis and rhinosinusitis are commonly treated in otolaryngologists' offices. Many of these patients have concurrent lower respiratory diseases such as asthma. The simultaneous presence of upper and lower airway diseases occurs frequently, and has resulted in the unified airway model, which describes the close relationships between these inflammatory diseases. Understanding the coexistence of respiratory illnesses has implications for the diagnosis and management of both upper and lower airway conditions. It is important for otolaryngologists and otolaryngology nurses to be aware of these common comorbid processes, and to evaluate for the presence of asthma in all patients with upper airway conditions such as rhinitis and rhinosinusitis. This paper will discuss the epidemiology, pathophysiology, mechanisms, and diagnosis and treatment considerations in patients with unified airway diseases.

International consensus statement on allergy and rhinology: Allergic rhinitis - 2023.

BACKGROUND: In the 5 years that have passed since the publication of the 2018 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis (ICAR-Allergic Rhinitis 2018), the literature has expanded substantially. The ICAR-Allergic Rhinitis 2023 update presents 144 individual topics on allergic rhinitis (AR), expanded by over 40 topics from the 2018 document. Originally presented topics from 2018 have also been reviewed and updated. The executive summary highlights key evidence-based findings and recommendation from the full document. METHODS: ICAR-Allergic Rhinitis 2023 employed established evidence-based review with recommendation (EBRR) methodology to individually evaluate each topic. Stepwise iterative peer review and consensus was performed for each topic. The final document was then collated and includes the results of this work. RESULTS: ICAR-Allergic Rhinitis 2023 includes 10 major content areas and 144 individual topics related to AR. For a substantial proportion of topics included, an aggregate grade of evidence is presented, which is determined by collating the levels of evidence for each available study identified in the literature. For topics in which a diagnostic or therapeutic intervention is considered, a recommendation summary is presented, which considers the aggregate grade of evidence, benefit, harm, and cost. CONCLUSION: The ICAR-Allergic Rhinitis 2023 update provides a comprehensive evaluation of AR and the currently available evidence. It is this evidence that contributes to our current knowledge base and recommendations for patient evaluation and treatment.

COVID-19 Disparities and Vaccine Hesitancy in Black Americans: What Ethical Lessons Can Be Learned?

OBJECTIVE: This state of the art review focuses on bioethical questions and considerations from research findings and methodological issues, including design and recruitment of participants, in studies related to COVID-19 vaccine hesitation in Black individuals. Ethical concerns identified were applied to otolaryngology with recommendations for improving health inequities within subspecialties. DATA SOURCES: An internet search through PubMed, CINAHL, and socINDEX was conducted to identify articles on COVID-19 vaccine hesitation among the Black population between 2020 and 2021. REVIEW METHODS: A systematic review approach was taken to search and analyze the research on this topic, which was coupled with expert analysis in identifying and classifying vital ethical considerations. CONCLUSIONS: The most common COVID-19 vaccine hesitation factors were related to the development of the vaccine, mistrust toward government agencies, and misconceptions about safety and side effects. These findings raised bioethical concerns around mistrust of information, low health literacy, insufficient numbers of Black participants in medical research, and the unique positions of health professionals as trusted sources. These bioethical considerations can be applied in otolaryngology and other health-related areas to aid the public in making informed medical decisions regarding treatments, which may reduce health inequalities among Black Americans and other racial and ethnic minority groups. IMPLICATIONS FOR PRACTICE: Addressing ethical questions by decreasing mistrust, tailoring information for specific populations, increasing minority representation in research, and using health professionals as primary sources for communicating health information and recommendations may improve relationships with Black communities and increase acceptance of new knowledge and therapies such as COVID-19 vaccination.

Whatever Happened to Evidence-Based Practice During COVID-19?

Contemporary medical practice is grounded in rigorous scientific evidence in concert with best clinical practices and informed shared decision making with patients. During these times of uncertainty, disruption, and even anxiety, it becomes critical that we engage with our patients and communities in thoughtful dialogue and realistic expectations regarding treatments surrounding COVID-19. The hope for a "miracle" cure and urgency to return back to normal times can stimulate irrational thought and behavior and even desperate measures by individuals or groups. It becomes especially important that we continue to use reasonable, informed clinical judgment in discussing the various options with patients.

COVID-19 and the Widening Gap in Health Inequity.

The coronavirus disease 2019 (COVID-19) pandemic has brought to light significant health inequities that have existed in our society for decades. Blacks, Hispanics, Native Americans, and immigrants are the populations most likely to experience disparities related to burden of disease, health care, and health outcomes. Increasingly, national and state statistics on COVID-19 report disproportionately higher mortality rates in blacks. There has never been a more pressing time for us to enact progressive and far-reaching changes in social, economic, and political policies that will shape programs aimed at improving the health of all people living in the United States.

Effects of mometasone furoate administered via a dry powder inhaler once daily in the evening on nocturnal lung function and sleep parameters in patients with moderate persistent asthma: a randomized, double-blind, placebo-controlled pilot study.

BACKGROUND AND OBJECTIVE: Nocturnal symptoms are common in asthma patients and have the potential for considerable clinical effects due to a lack of sleep and persistent daytime symptoms of somnolence and activity impairment. The primary objective of this investigation was to determine the effect of a 14-day course of once-daily evening administration of mometasone furoate 400 microg administered via a dry powder inhaler (MF-DPI 400 microg qd pm) on the overnight decline in pulmonary function observed in patients with nocturnal asthma. METHODS: Eligible enrollees were between the ages of 18 and 60 years and had established mild to moderate asthma, with an improvement in forced expiratory volume in 1 second (FEV(1)) of >15% after administration of inhaled salbutamol (albuterol) 200 microg. All enrolled patients had a history of nocturnal asthma. Enrollees were randomized to receive MF-DPI 400 microg qd pm or placebo administered between 6 pm and 8 pm for 14 days. The primary outcome evaluated in the study was reduction in nocturnal decline in evening (8 pm) to morning (6 am) FEV(1) values. Secondary outcomes included reduction in nocturnal decline in evening to morning peak expiratory flow rate (PEFR), polysomnographic indices of sleep, and psychometric indices (Nocturnal Rhinoconjunctivitis Quality of Life Questionnaire [NRQLQ], 36-item Short Form of the Medical Outcomes Survey [SF-36], and Asthma Quality of Life Questionnaire [AQLQ]). RESULTS: A total of 20 patients were randomized and completed all phases of the study. No significant differences were observed between treatment groups in the primary outcome of nocturnal decline in FEV(1) from pretreatment to end of treatment. Likewise, there was no significant difference between treatment groups in polysomnographic indices of sleep or quality-of-life assessments. However, there was a trend toward improvement in the activity scale of the AQLQ assessment in the MF-DPI 400 microg qd pm treatment group. CONCLUSION: No significant treatment effect on nocturnal pulmonary function, sleep indices or quality of life was observed with 14-day administration of MF-DPI 400 microg qd pm. These findings are limited by the small sample size and the short treatment period evaluated. Future studies are warranted to study the effects of MF-DPI therapy in patients with nocturnal asthma.

Assessing sleep quality and daytime wakefulness in asthma using wrist actigraphy.

This study evaluated the sleep/wake cycle of individuals with asthma in relation to asthma control, daytime sleepiness, and daytime activity. Ten persons with mild to moderate persistent asthma monitored their sleep quality and daytime wakefulness for 7 consecutive days using 24-hours wrist actigraphy. Degree of asthma control strongly correlated with sleep quality. Individuals whose asthma was not well controlled took longer to fall asleep, awoke more often, and spent more time awake during the night compared to those with well controlled asthma. Poor asthma control, use of rescue medications, and asthma symptoms were associated with daytime sleepiness and limitations in physical activity and emotional function. Forty percent of subjects reported clinically significant daytime sleepiness. Evaluating asthma throughout a 24-hour cycle provides valuable information on variations in the sleep/wake cycle associated with asthma control, use of rescue medications, and asthma symptoms.

Clinical practice guideline: cerumen impaction.

OBJECTIVE: This guideline provides evidence-based recommendations on managing cerumen impaction, defined as an accumulation of cerumen that causes symptoms, prevents assessment of the ear, or both. We recognize that the term "impaction" suggests that the ear canal is completely obstructed with cerumen and that our definition of cerumen impaction does not require a complete obstruction. However, cerumen impaction is the preferred term since it is consistently used in clinical practice and in the published literature to describe symptomatic cerumen or cerumen that prevents assessment of the ear. This guideline is intended for all clinicians who are likely to diagnose and manage patients with cerumen impaction. PURPOSE: The primary purpose of this guideline is to improve diagnostic accuracy for cerumen impaction, promote appropriate intervention in patients with cerumen impaction, highlight the need for evaluation and intervention in special populations, promote appropriate therapeutic options with outcomes assessment, and improve counseling and education for prevention of cerumen impaction. In creating this guideline the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of audiology, family medicine, geriatrics, internal medicine, nursing, otolaryngology-head and neck surgery, and pediatrics. RESULTS: The panel made a strong recommendation that 1) clinicians should treat cerumen impaction that causes symptoms expressed by the patient or prevents clinical examination when warranted. The panel made recommendations that 1) clinicians should diagnose cerumen impaction when an accumulation of cerumen is associated with symptoms, or prevents needed assessment of the ear (the external auditory canal or tympanic membrane), or both; 2) clinicians should assess the patient with cerumen impaction by history and/or physical examination for factors that modify management, such as one or more of the following: nonintact tympanic membrane, ear canal stenosis, exostoses, diabetes mellitus, immunocompromised state, or anticoagulant therapy; 3) the clinician should examine patients with hearing aids for the presence of cerumen impaction during a healthcare encounter (examination more frequently than every three months, however, is not deemed necessary); 4) clinicians should treat the patient with cerumen impaction with an appropriate intervention, which may include one or more of the following: cerumenolytic agents, irrigation, or manual removal other than irrigation; and 5) clinicians should assess patients at the conclusion of in-office treatment of cerumen impaction and document the resolution of impaction. If the impaction is not resolved, the clinician should prescribe additional treatment. If full or partial symptoms persist despite resolution of impaction, alternative diagnoses should be considered. The panel offered as an option that 1) clinicians may observe patients with nonimpacted cerumen that is asymptomatic and does not prevent the clinician from adequately assessing the patient when an evaluation is needed; 2) clinicians may distinguish and promptly evaluate the need for intervention in the patient who may not be able to express symptoms but presents with cerumen obstructing the ear canal; 3) the clinician may treat the patient with cerumen impaction with cerumenolytic agents, irrigation, or manual removal other than irrigation; and 4) clinicians may educate/counsel patients with cerumen impaction/excessive cerumen regarding control measures. DISCLAIMER: This clinical practice guideline is not intended as a sole source of guidance in managing cerumen impaction. Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. It is not intended to replace clinical judgment or establish a protocol for all individuals with this condition, and may not provide the only appropriate approach to diagnosing and managing this problem.

Asthma: guidelines-based control and management.

Guidelines-based management of the patient with asthma allows maximal levels of function with few adverse effects. A flexible approach to therapy that emphasizes an ongoing partnership between the patient and physician allows optimal communication, facilitating treatment adherence and maximal levels of control. Through assessment of the patient's initial severity of disease and an evaluation of the patient's ongoing level of control, appropriate medical therapy can be initiated and level of therapy can be modified based on the patient's response. Patient education, environmental control strategies, and proper use of medications are vital in achieving maximal benefit in asthma management. Excellent asthma control is possible and should be a goal of both physicians and patients.

Plain Language Summary: Hoarseness (Dysphonia).

This plain language summary for patients serves as an overview in explaining hoarseness (dysphonia). The summary applies to patients in all age groups and is based on the 2018 "Clinical Practice Guideline: Hoarseness (Dysphonia) (Update)." The evidence-based guideline includes research to support more effective identification and management of patients with hoarseness (dysphonia). The primary purpose of the guideline is to improve the quality of care for patients with hoarseness (dysphonia) based on current best evidence.