Optimization of diagnostic and procedural codes to identify patients with acute invasive fungal sinusitis.

KEY POINTS: Acute invasive fungal sinusitis (IFS) is a rare disease with high mortality There is no designated International Classification of Diseases code for IFS We propose a novel method to identify IFS using optimized codes complemented by medications.

Climate change, the environment, and rhinologic disease.

BACKGROUND: The escalating negative impact of climate change on our environment has the potential to result in significant morbidity of rhinologic diseases. METHODS: Evidence based review of examples of rhinologic diseases including allergic and nonallergic rhinitis, chronic rhinosinusitis, and allergic fungal rhinosinusitis was performed. RESULTS: The lower socioeconomic population, including historically oppressed groups, will be disproportionately affected. CONCLUSIONS: We need a systematic approach to improve healthcare database infrastructure and funding to promote diverse scientific collaboration to address these healthcare needs.

A Remarkable Response of Granulomatous Hypophysitis to Infliximab in a Patient With a Background of Crohn's Disease-A Case Report.

Background: Hypophysitis is primary or idiopathic or secondary to another disease process. The histologic subtypes of hypophysitis are lymphocytic, granulomatous, xanthomatous, xanthogranulomatous, or IgG4-related. Granulomatous hypophysitis is the second most common form and is characterized by multinucleated giant cells with granulomas and histiocytes. It can be idiopathic or secondary to another process such as infection, sarcoidosis, vasculitis, dendritic cell disorders, Crohn's disease (CD) or a reaction to rupture of a Rathke's cyst or pituitary adenoma. We present a case of granulomatous hypophysitis in a patient with CD who had resistance to corticosteroids but a dramatic response to immunosuppressive therapy with anti-tumor necrosis factor (TNF)-α therapy. Case description: A 43-year-old woman with a 9-year history of ileal and colonic CD presented to the Pituitary Center with headaches, visual disturbance, fatigue, nausea, and secondary amenorrhea. She was not on active therapy for her CD at the time of presentation and had no gastrointestinal symptoms. Hormonal evaluation revealed hyperprolactinemia, secondary hypothyroidism and adrenal insufficiency. MRI revealed a 12 × 12 × 19 mm sellar lesion abutting the optic chiasm, reported as a macroadenoma. The patient underwent endoscopic transsphenoidal biopsy of the pituitary mass. Pathology revealed granulomatous hypophysitis. Evaluation for secondary causes of hypophysitis, apart from CD, was negative. Despite a course of high dose prednisone, her symptoms and MRI findings worsened and she developed symptoms consistent with diabetes insipidus. Using a personalized medicine approach, she was started on anti-(TNF)-α therapy with infliximab combined with azathioprine, which are indicated for treatment of CD. Her headaches and polyuria resolved and her menstrual cycles resumed. MRI at 3 months and more than 1.5 years after initiation of anti-TNF-α therapy revealed durable resolution of the pituitary mass. Conclusion: To our knowledge, this is the first report of successful use of anti-TNF-α therapy for a patient with granulomatous hypophysitis, in this case associated with a previous diagnosis of CD. Although glucocorticoids are used frequently as first-line therapy for primary hypophysitis, granulomatous hypophysitis can be corticosteroid resistant and other immunosuppressive approaches may need to be considered within the context of the patient.

Electronic health records and resident workflow: a time-motion study of otolaryngology residents.

OBJECTIVES/HYPOTHESIS: To evaluate the impact of electronic health records (EHRs) on the workflow of otolaryngology residents. STUDY DESIGN: Prospective, time-motion study. METHODS: A time-motion study was conducted both in the 2009 to 2010 and 2012 to 2013 postgraduate years. Eight otolaryngology residents were directly observed on both operative and clinic days, with resident activities categorized by way of a database program. Comparisons were made to the same data collected in the same setting prior to and following integration of an EHR system. RESULTS: Residents spent their day on direct patient care (41.1%), indirect patient care (35.3%), didactic education (14.0%), personal activities (6.9%), and transit (3.1%). The primary activity during operative days was direct patient care, and during clinic days it was indirect patient care. Activities of marginal educational value comprised a considerable component of their time (16.5%). Compared to data collected prior to use of an EHR, time was spent similarly. However, residents using an EHR devoted significantly more time to indirect patient care on clinic days (P < .05). CONCLUSIONS: This is the first study to evaluate EHR integration on otolaryngology resident workflow. Overall resident efficiency was not significantly altered by the implementation of an EHR. However, more time was shifted from directly caring for patients to documenting on the EHR in the clinic setting. These findings provide an important objective insight into EHRs, especially given the looming mandate for their use and the need to streamline resident curriculum in the duty hours era.

Otolaryngology resident workflow: a time-motion and efficiency study.

OBJECTIVE: To investigate workflow in an otolaryngology-head and neck surgery residency program over 1 year and identify areas for improvement in the efficiency of resident education and training. STUDY DESIGN: Time-motion study. SETTING: An urban, county hospital and a Veterans Affairs medical center hospital. Subjects and Methods. Eight otolaryngology residents (4 residents at postgraduate year [PGY] 2 and 4 at PGY 4) were studied using direct observations early and late in the 2008-2009 academic year. Resident activities were categorized, and a database program was generated for a handheld computer to facilitate time entry. Resident activities were classified into a taxonomy of tasks and their educational value was assessed. For each PGY level studied, observations were made for clinic and operative days. RESULTS: Residents spent their day on direct patient care (43.5%), indirect patient care (33.7%), didactic education (9.6%), personal activities (7.5%), and transit (5.8%), with activities of marginal educational value consuming 16% of their time. Major inefficiencies included managing administrative tasks, scheduling, and technical difficulties. On average, residents devoted significantly more time to marginal tasks on clinic days (19%) than on operative days (12%; P < .001). These data were compared with previously published data obtained during the pre­Accreditation Council for Graduate Medical Education (ACGME) duty hour mandates era. CONCLUSION: This study evaluates resident workflow and efficiency over the course of a PGY in an ACGME-accredited otolaryngology residency program. By understanding the time motion of residents, interruptions and inefficiencies in workflow can be identified to direct future changes to enhance resident education and training in the era of the ACGME duty hours mandate.