Differences in provider approach to initiating and titrating guideline directed medical therapy in heart failure with reduced ejection fraction.

BACKGROUND: Despite the strong evidence supporting guideline-directed medical therapy (GDMT) in patients with heart failure with reduced ejection fraction (HFrEF), prescription rates in clinical practice are still lacking. METHODS: A survey containing 20 clinical vignettes of patients with HFrEF was answered by a national sample of 127 cardiologists and 68 internal/family medicine physicians. Each vignette had 4-5 options for adjusting GDMT and the option to make no medication changes. Survey respondents could only select one option. For analysis, responses were dichotomized to the answer of interest. RESULTS: Cardiologists were more likely to make GDMT changes than general medicine physicians (91.8% vs. 82.0%; OR 1.84 [1.07-3.19]; p = 0.020). Cardiologists were more likely to initiate beta-blockers (46.3% vs. 32.0%; OR 2.38 [1.18-4.81], p = 0.016), angiotensin receptor blocker/neprilysin inhibitor (ARNI) (63.8% vs. 48.1%; OR 1.76 [1.01-3.09], p = 0.047), and hydralazine and isosorbide dinitrate (HYD/ISDN) (38.2% vs. 23.7%; OR 2.47 [1.48-4.12], p < 0.001) compared to general medicine physicians. No differences were found in initiating angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEi/ARBs), initiating mineralocorticoid receptor antagonist (MRA), sodium-glucose transporter protein 2 (SGLT2) inhibitors, digoxin, or ivabradine. CONCLUSIONS: Our results demonstrate cardiologists were more likely to adjust GDMT than general medicine physicians. Future focus on improving GDMT prescribing should target providers other than cardiologists to improve care in patients with HFrEF.

Risk of otitis externa following manual cerumen removal.

OBJECTIVES: Based on an interpretation of a recent Joint Commission protocol to sterilize instruments coming into contact with mucous membranes, there has been institutional interest in sterile packaging of cerumen curettes used for manual cerumen removal. To date, there are no studies that have assessed the risk of otitis externa (OE) following cerumen removal and the utility of sterile packaging is questionable. The objective of this study is to assess the incidence of OE following cerumen disimpaction prior to the implementation of sterile packaging at our institution. METHODS: This was a retrospective chart review. Over a I-year period, 1457 episodes of manual cerumen removal took place in the otolaryngology clinic. Charts were assessed for signs or symptoms of OE within 2 weeks of the procedure through follow-up phone calls and clinic visits in the otolaryngology division. RESULTS: There were no patients who followed up with symptoms or signs suggestive of OE in the 2-week postprocedure period. CONCLUSION: There is no evidence that OE is a complication of manual cerumen removal when performed by otolaryngologists using clean technique. Unnecessary sterilization of tools leads to increased cost and time for this common outpatient procedure performed by the otolaryngologist.

A Computable Algorithm for Medication Optimization in Heart Failure With Reduced Ejection Fraction.

Background: Guideline-directed medical therapy (GDMT) optimization can improve outcomes in heart failure with reduced ejection fraction. Objectives: The objective of this study was to determine if a novel computable algorithm appropriately recommended GDMT. Methods: Clinical trial data from the GUIDE-IT (Guiding Evidence-Based Therapy Using Biomarker Intensified Treatment in Heart Failure) and HF-ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training) trials were evaluated with a computable medication optimization algorithm that outputs GDMT recommendations and a medication optimization score (MOS). Algorithm-based recommendations were compared to medication changes. A Cox proportional-hazards model was used to estimate the associations between MOS and the composite primary end point for both trials. Results: The algorithm recommended initiation of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, beta-blockers, and mineralocorticoid receptor antagonists in 52.8%, 34.9%, and 68.1% of GUIDE-IT visits, respectively, when not prescribed the drug. Initiation only occurred in 20.8%, 56.9%, and 15.8% of subsequent visits. The algorithm also identified dose titration in 48.8% of visits for angiotensin-converting enzyme inhibitor/angiotensin receptor blockers and 39.4% of visits for beta-blockers. Those increases only occurred in 24.3% and 36.8% of subsequent visits. A higher baseline MOS was associated with a lower risk of cardiovascular death or heart failure hospitalization (HR: 0.41; 95% CI: 0.21-0.80; P = 0.009) in GUIDE-IT and all-cause death and hospitalization (HR: 0.61; 95% CI: 0.44-0.84; P = 0.003) in HF-ACTION. Conclusions: The algorithm accurately identified patients for GDMT optimization. Even in a clinical trial with robust protocols, GDMT could have been further optimized in a meaningful number of visits. The algorithm-generated MOS was associated with a lower risk of clinical outcomes. Implementation into clinical care may identify and address suboptimal GDMT in patients with heart failure with reduced ejection fraction.

Comparison of activated caspase detection methods in the gentamicin-treated chick cochlea.

Aminoglycoside antibiotics induce caspase-dependent apoptotic death in cochlear hair cells. Apoptosis, a regulated form of cell death, can be induced by many stressors, which activate signaling pathways that result in the controlled dismantling of the affected cell. The caspase family of proteases is activated in the apoptotic signaling pathway and is responsible for cellular destruction. The initiator caspase-9 and the effector caspase-3 are both activated in chick cochlear hair cells following aminoglycoside exposure. We have analyzed caspase activation in the avian cochlea during gentamicin-induced hair cell death to compare two different methods of caspase detection: caspase antibodies and CaspaTag kits. Caspase antibodies bind to the cleaved activated form of caspase-9 or caspase-3 in specific locations in fixed tissue. CaspaTag is a fluorescent inhibitor that binds to a reactive cysteine residue on the large subunit of the caspase heterodimer in unfixed tissue. To induce cochlear hair cell loss, 1-2 week-old chickens received a single injection of gentamicin (300 mg/kg). Chicks were sacrificed 24, 30, 42, 48, 72, or 96 h after injection. Cochleae were dissected and labeled for activated caspase-9 or caspase-3 using either caspase-directed antibodies or CaspaTag kits. Ears were co-labeled with either phalloidin or myosin VI to visualize hair cells and to determine the progression of cochlear damage. The timing of caspase activation was similar for both assays; however, caspase-9 and caspase-3 antibodies labeled only those cells currently undergoing apoptotic cell death. Conversely, CaspaTag-labeled all the cells that have undergone apoptotic cell death and ejection from the sensory epithelium, in addition to those that are currently in the cell death process. This makes CaspaTag ideal for showing an overall pattern or level of cell death over a period of time, while caspase antibodies provide a snapshot of cell death at a specific time point.

Infectious complications and ventilation tubes in pediatric cochlear implant recipients.

OBJECTIVES/HYPOTHESIS: At many centers, ventilating tubes (VTs) are placed routinely in otitis-prone pediatric cochlear implant recipients. However, this practice is controversial, as many otologists believe VTs represent a possible route for contamination of the device. Toward better understanding of the safety of VTs, we reviewed our center's infectious complications and their relationship to the presence of tubes. STUDY DESIGN: Retrospective cohort study. METHODS: All patients undergoing cochlear implantation at our institution between 1990 and 2012 were reviewed for complications and their association with the presence of VTs. RESULTS: A total of 478 patients (557 ears) were reviewed, representing over 2,978 patient-years of follow-up. In 135 ears (24.2%), a VT was present at time of, or placed at some point after, implantation. The remainder either never had a VT or it had extruded prior to implantation. Overall, 63 complications occurred, of which 17 were infectious. The most common were cellulitis (four), device infection (five), and meningitis (four). Only one occurred while a tube was present, and was a device infection in an ear having a retained VT in place for almost 4 years. No difference was observed in overall rates of infectious complications between the group with VTs and those who never had VTs. CONCLUSIONS: This series, the largest to date, indicates that infectious complications after cochlear implantation are rarely associated with the presence of VTs, supporting the concept that, overall, VTs are safe in cochlear implant recipients. Close monitoring is essential, including prompt removal of tubes when they are no longer needed. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:1671-1676, 2016.

Clinician Perception of the Effectiveness of an Automated Early Warning and Response System for Sepsis in an Academic Medical Center.

RATIONALE: We implemented an electronic early warning and response system (EWRS) to improve detection of and response to severe sepsis. Sustainability of such a system requires stakeholder acceptance. We hypothesized that clinicians receiving such alerts perceive them to be useful and effective. OBJECTIVES: To survey clinicians after EWRS notification about perceptions of the system. METHODS: For a 6-week study period 1 month after EWRS implementation in a large tertiary referral medical center, bedside clinicians, including providers (physicians, advanced practice providers) and registered nurses (RNs), were surveyed confidentially within 2 hours of an alert. MEASUREMENTS AND MAIN RESULTS: For the 247 alerts that triggered, 127 providers (51%) and 105 RNs (43%) completed the survey. Clinicians perceived most patients as stable before and after the alert. Approximately half (39% providers, 48% RNs) felt the alert provided new information, and about half (44% providers, 56% RNs) reported changes in management as a result of the alert, including closer monitoring and additional interventions. Over half (54% providers, 65% RNs) felt the alert was appropriately timed. Approximately one-third found the alert helpful (33% providers, 40% RNs) and fewer felt it improved patient care (24% providers, 35% RNs). CONCLUSIONS: A minority of responders perceived the EWRS to be useful, likely related to the perception that most patients identified were stable. However, management was altered half the time after an alert. These results suggest further improvements to the system are needed to enhance clinician perception of the system's utility.

Minimally invasive functional approach for cholesteatoma surgery.

OBJECTIVES/HYPOTHESIS: Report the efficacy of a functional minimally invasive approach for cholesteatoma surgery. STUDY DESIGN: Retrospective review of surgical cases performed between 1996 and 2008. METHODS: One hundred sixty-nine patient charts were reviewed in which ears with primary cholesteatomas that extended beyond the mesotympanum were operated on with a plan for canal wall up (CWU) mastoidectomy. The surgical approach consisted of progressive exposure from transcanal to postauricular tympanoplasty to CWU mastoidectomy, as needed, to identify and lyse the fibrous attachments that bind the capsule to the surrounding mucosa. Endoscopic guidance was employed as appropriate to minimize exposure needs. Any planned second-stage operations were attempted with a transcanal approach if appropriate and with endoscopic assistance. RESULTS: One hundred eighty-four ears of 169 patients were included. The median age was 32 years (range, 1-79 years). The mean follow-up was 3.2 years (range, 1-11 years). Eighty-three (45%) were planned for a second-look operation, and three (2%) required unplanned second operations. The overall recurrence rate was 24/184 (13%), and the unexpected residual rate was 5/184 (3%). The residual rate with endoscopy (5/119, 4%,) or without endoscopy (1/65, 2%), were not significantly different. Hearing results in 156 ears improved significantly, from a preoperative pure-tone average (PTA) of 41 dB to a postoperative PTA average of 29 dB (P < .0001). CONCLUSIONS: A functional minimally invasive approach to cholesteatoma surgery provided equivalent residual rates but higher recurrence rates compared to published canal wall down mastoidectomy. Endoscopic techniques were helpful in providing adequate views while minimizing exposure.

Unilateral cochlear nerve deficiency in children.

OBJECTIVE: Cochlear nerve deficiency (CND) is increasingly diagnosed in children with sensorineural hearing loss (SNHL). We sought to determine the prevalence of CND, its imaging characteristics, and correlations with audiologic phenotype in children with unilateral SNHL. DESIGN: Case series with chart review. SETTING: Tertiary pediatric hospital. SUBJECTS/METHODS: In 128 consecutive children with unilateral SNHL who underwent high-resolution magnetic resonance imaging, the diameters, area, and signal intensity of the cochlear nerve (CN) were measured and normalized to the ipsilateral facial nerve. Presence of CND was determined by comparison to normative data. Relationships among hearing loss severity, progression, and nerve size were investigated. RESULTS: Cochlear nerve deficiency was present in 26% of children with unilateral SNHL. Its prevalence was higher (48%) in severe to profound SNHL, especially when in infants (100%). Width of the bony cochlear nerve canal (BCNC) correlated strongly with relative CN diameter, density, and area (R = 0.5); furthermore, a narrow BCNC (<1.7 mm) strongly predicted CND. Severity of hearing loss modestly correlated with nerve size, although significant variability was observed. Progression never occurred unless there were other inner ear malformations, whereas in the non-CND group, it occurred in 22%. Ophthalmologic abnormalities were very common (67%) in CND children, particularly oculomotor disturbances. CONCLUSION: Cochlear nerve deficiency is a common cause of unilateral SNHL, particularly in congenital unilateral deafness. Width of the BCNC effectively predicts CND, a finding useful when only computed tomography imaging is available. In an ear with CND, hearing can be expected to remain stable over time. Diagnosis should prompt evaluation by an ophthalmologist.

Comparison of postoperative pain in pediatric patients undergoing coblation tonsillectomy versus cautery tonsillectomy.

OBJECTIVE: To compare postoperative pain scores between monopolar electrocautery and coblation subcapsular tonsillectomy. STUDY DESIGN: Prospective double-blind randomized study. SETTING: Tertiary care children's hospital. SUBJECTS AND METHODS: Between December 2004 and April 2008, 61 children, ages 4 to 20 years (mean age, 10 years; SD, 4 years), were randomized to have one tonsil removed by electrocautery and the other tonsil removed by coblation. Subjects used the FACES scale to rate pain on each side immediately postoperatively, 2 days postoperatively, and 2 weeks postoperatively. Postoperative hemorrhage was also tracked. RESULTS: Coblation tonsillectomy resulted in statistically less pain than electrocautery immediately after surgery, but this difference was not clinically significant. CONCLUSIONS: Pediatric pain is similar following monopolar electrocautery or coblation subcapsular tonsillectomy.