Comparison of outcomes and cost in patients undergoing tonsillectomy with electrocautery and thermal welding.

PURPOSE: To assess the morbidity and efficacy of thermal tissue welder instrument for tonsillectomy and compare it with monopolar electrocautery. MATERIALS AND METHODS: IRB approval was obtained at the Wexner Medical Center at Ohio State University for a prospective, randomized, single-blinded, controlled clinical study of 48 healthy adult volunteers undergoing tonsillectomy for chronic tonsillitis and tonsil hypertrophy. Subjects were randomized to the TW or EC group. Post-operative pain, pain medication use, return to normal oral intake, return to normal activity, and bleeding were measured on the post-operative log. We recorded operative time, operating room time, and blood loss. All procedures were performed by one surgeon to eliminate variations in time and experience. Operative and patient data were analyzed using a Student T-test and evaluated by cost analysis. RESULTS: There was a statically significant increase in operative time with the TW taking an average of 4min longer per procedure, p<0.001. However, when total anesthesia time was compared, this did not translate into a statistically significant increase in total operating room time and therefore did not translate into additional cost. The remaining categories were not significantly different between the two groups. In 3/23 TW cases, suction cautery was required for hemostasis. Two patients had 3 occurrences of secondary bleeding in the electrocautery group and none in the tissue welder group. TW cost increase per case was $167 per instrument but averaged $700 per case. CONCLUSIONS: While the tissue welder remains a viable option for the adult tonsillectomy procedure, it has not demonstrated in our study the necessary parameters intraoperatively, postoperatively, or via cost analysis to become the choice instrument at our institution. We cannot ignore the increase in cost that may be seen for short and routine procedures without an added benefit to the patient in terms of outcome or safety. A larger study is needed to determine if secondary bleeding rates are lower with this instrument.

Cooling the flames: Navigating menopausal vasomotor symptoms with nonhormone medications.

DISCLAIMER: In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE: While the gold standard for vasomotor symptoms remains hormone therapy, prescription menopause therapies are significantly underutilized. Nonhormone therapies represent an alternative treatment modality that may improve access to care for patients who cannot or choose not to take hormones. This review aims to update pharmacists on the evidence behind new-to-market fezolinetant and all other nonhormone prescription treatment options for menopausal vasomotor symptoms. SUMMARY: Prescription nonhormone therapy options for vasomotor symptoms include selective serotonin reuptake inhibitors, including Food and Drug Administration-approved low-dose paroxetine, serotonin-norepinephrine reuptake inhibitors, gabapentin, pregabalin, oxybutynin, and fezolinetant. Evidence supporting the use of these options is summarized in this review. All have an important place in treatment for those unable to take the gold standard of hormone therapy; however, most offer only mild to moderate improvement in symptoms. Fezolinetant has been shown to result in a significant reduction in vasomotor symptom frequency when compared to other nonhormone therapies and was not different when compared to hormone therapies. However, additional studies and efforts to address the affordability of fezolinetant and head-to-head comparisons with other agents are needed. CONCLUSION: Vasomotor symptoms of menopause can severely impact the health and well-being of individuals. However, treatment of these symptoms is underutilized due to real and perceived drawbacks of therapy. Pharmacists are ideally suited to bridge this gap, but first it is important for pharmacists to be knowledgeable about and comfortable with the evidence supporting all treatment options.

A comparison of new and existing mild traumatic brain injury vignettes: recommendations for research into post-concussion syndrome.

OBJECTIVE: To review and compare the mild traumatic brain injury (mTBI) vignettes used in postconcussion syndrome (PCS) research, and to develop 3 new vignettes. METHOD: The new vignettes were devised using World Health Organization (WHO) mTBI diagnostic criteria [1]. Each vignette depicted a very mild (VM), mild (M), or severe (S) brain injury. Expert review (N = 27) and readability analysis was used to validate the new vignettes and compare them to 5 existing vignettes. RESULTS: The response rate was 44%. The M vignette and existing vignettes were rated as depicting a mTBI; however, the fit-to-criteria of these vignettes differed significantly. The fit-to-criteria of the M vignette was as good as that of 3 existing vignettes and significantly better than 2 other vignettes. As expected, the VM and S vignettes were a poor fit-to-criteria. CONCLUSIONS: These new vignettes will assist PCS researchers to test the limits of important etiology factors by varying the severity of depicted injuries.

The Thoughts Questionnaire (TQ) for family caregivers of people with dementia.

OBJECTIVES: To develop a new measure of dysfunctional thoughts for family caregivers of people living with dementia. These thoughts can contribute to negative outcomes, but they may be modifiable. METHOD: A stepwise process was used to develop the Thoughts Questionnaire, commencing with item generation, concept mapping, and pilot testing in a sample of professional and nonprofessional caregivers of people with dementia (n = 18). Next, an independent sample of 35 family caregivers of people with dementia (30 female; Mage = 64.30, standard deviation = 10.65) completed: (a) the Thoughts Questionnaire; (b) an existing measure of dysfunctional thoughts, the Dementia Thoughts Caregivers Questionnaire; and (c) separate validated measures of depressive symptoms, caregiver stress, and coping, respectively. RESULTS: The level of agreement with dysfunctional thought statements from the Dementia Thoughts Caregivers Questionnaire and Thoughts Questionnaire was low. However, a small number of Thoughts Questionnaire statements were strongly endorsed by over 85% of the sample. Both dysfunctional thought measures had adequate reliability, but total scores were not significantly intercorrelated (r = .287, p = .095). Only the Thoughts Questionnaire was significantly, positively correlated with most caregiver stress measures. Thoughts Questionnaire items required a much lower reading level than the Dementia Thoughts Caregivers Questionnaire items. DISCUSSION: This study provides preliminary data on a tool for assessing the negative role-related thoughts that family caregivers of people with dementia may experience. Given that these thoughts are implicated in depression but they may be modified, the capacity to identify dysfunctional thoughts may prove useful in caregiver support programs.

Sensitivity and Specificity of Histoplasma Antigen Detection by Enzyme Immunoassay.

The objective of this study was to evaluate the sensitivity and specificity of an antigen enzyme immunoassay (EIA) on urine samples for the diagnosis of histoplasmosis in dogs. This retrospective medical records review included canine cases with urine samples submitted for Histoplasma EIA antigen assay between 2007 and 2011 from three veterinary institutions. Cases for which urine samples were submitted for Histoplasma antigen testing were reviewed and compared to the gold standard of finding Histoplasma organisms or an alternative diagnosis on cytology or histopathology. Sensitivity, specificity, negative predictive value, positive predictive value, and the kappa coefficient and associated confidence interval were calculated for the EIA-based Histoplasma antigen assay. Sixty cases met the inclusion criteria. Seventeen cases were considered true positives based on identification of the organism, and 41 cases were considered true negatives with an alternative definitive diagnosis. Two cases were considered false negatives, and there were no false positives. Sensitivity was 89.47% and the negative predictive value was 95.35%. Specificity and the positive predictive value were both 100%. The kappa coefficient was 0.9207 (95% confidence interval, 0.8131-1). The Histoplasma antigen EIA test demonstrated high specificity and sensitivity for the diagnosis of histoplasmosis in dogs.

Psychological impact of benign breast biopsy: a longitudinal, comparative study.

The impact of benign breast biopsy (BBB) on distress and perceptions of risk for breast cancer (BC) was examined. Interviews were conducted with 100 women shortly after notification of biopsy results and 4 and 8 months post-BBB. Compared with matched healthy comparison (HC) women without BBB, the BBB group evidenced greater BC-specific distress at baseline. BC-specific distress declined after BBB, remaining elevated relative to the HC group at the 8-month follow-up. Dispositional (optimism, informational coping style), demographic (education), clinical (family history of BC), and cognitive (BC risk perception) variables were associated with baseline levels of BC-specific distress or persistence of distress. Results support the monitoring process model (S. M. Miller, 1995) and the cognitive social health information processing model (S. M. Miller, Y. Shoda, & K. Hurley, 1996).

Characterization of human ocular mucin secretion mediated by 15(S)-HETE.

PURPOSE: The eicosanoid 15-(S)-hydroxy-5,8,11,13-eicosatetraenoic acid [15(S)-HETE] is reported to stimulate mucin production in both airway and ocular surface epithelia. The current study was undertaken to evaluate the effects of 15(S)-HETE on secretion of specific ocular mucins by human conjunctiva. METHODS: Segments of human bulbar conjunctival tissue were incubated with 15(S)-HETE (1-1000 nM) for 30 minutes at 37 degrees C. Secretion of human ocular mucins MUC1, MUC2, MUC4, and MUC5AC into the incubation media was measured by dot-blot immunoassay using antibodies directed to unique mucin polypeptide epitopes. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis and Western blotting were used to verify the specificity of anti-mucin antibody binding and to investigate the presence of MUC1 mucin in human tears. RESULTS: 15(S)-HETE (10(-8)-10(-6) M) stimulated secretion of conjunctival mucins in a concentration-dependent manner. Significant increases in total mucin secretion were observed at 10(-7) M 15(S)-HETE with a maximum response (>50% increase above controls) at 10(-6) M. Results of immunoassays showed that 15(S)-HETE differentially stimulates secretion of MUC1 mucin with no detectable effects on MUC2, MUC4, or MUC5AC release. Western analysis of tear samples from human volunteers indicated that MUC1 is a component of the preocular tear film. CONCLUSIONS: The results demonstrate that 15(S)-HETE is a selective secretogogue for MUC1 in isolated human conjunctival tissue. Although the biochemical mechanism(s) and cellular origins of MUC1 secretion remain to be established, the ubiquitous expression of MUC1 in corneal and conjunctival epithelia and its presence in human tears suggest that secreted MUC1 may contribute to the mucin layer that coats and protects the ocular surface.

Thymoma and parathyroid adenoma: false-positive imaging and intriguing laboratory test results.

IMPORTANCE: Parathyroid hormone (PTH)-secreting thymomas are an exceedingly rare entity. A PTH-secreting thymoma was discovered in the workup of a patient with primary hyperparathyroidism. A concomitant parathyroid adenoma was removed from the same patient. We present the intriguing clinical course and review the literature on this rare entity. In addition, we discuss the use of scanning with technetium Tc 99m sestamibi, the PTH assay, and cervical ultrasonography in the workup of a parathyroid adenoma. OBSERVATIONS: Scanning with technetium Tc 99m sestamibi demonstrated false-positive uptake of the mediastinal thymoma and false-negative uptake of the true cervical parathyroid adenoma. After removal of the thymoma, the parathyroid adenoma demonstrated appropriate uptake on a follow-up scan. After removal of the parathyroid adenoma, the hyperparathyroidism was cured. CONCLUSIONS AND RELEVANCE: Given the extremely rare incidence of a PTH-secreting thymoma with a concurrent parathyroid adenoma, we do not recommend alterations in the diagnostic algorithm for primary hyperparathyroidism. However, in this case, the need for 2 separate operations may have been avoided by obtaining an ultrasonogram to further explore the findings on the technetium Tc 99m sestamibi scan. We recommend that both studies be considered in unclear cases of primary hyperparathyroidism.

Conservative management of iatrogenic membranous tracheal wall injury: a discussion of 2 successful pediatric cases.

IMPORTANCE: Management of pediatric tracheal injuries is a controversial topic not well documented in the otolaryngology literature. OBJECTIVES: To present our case outcomes in 2 pediatric patients with tracheal injury and to review the literature on surgical vs conservative management of tracheal injuries in the pediatric age group. DESIGN: Case series and literature review. SETTING: Tertiary referral pediatric hospital. MAIN OUTCOME MEASURES: Morbidity and mortality outcomes. RESULTS: The 2 tracheal injuries in the case studies were successfully managed with intubation, antibiotics, and careful monitoring without morbidity related to the tracheal injury. CONCLUSIONS AND RELEVANCE: A high level of clinical suspicion is necessary for the diagnosis of tracheal injuries. Both conservatively and surgically managed patients require serial chest and lateral neck plain radiographs to follow resolution of pneumomediastinum and pneumothorax. Both require surveillance of the airway with operative laryngoscopy and bronchoscopy, in addition to long-term follow-up. Surgical repair of trachea rupture, although resulting in shorter intubation, may require tracheotomy. Promising results have been reported in the literature for conservative management with a relatively small risk of airway stenosis without the complications associated with intrathoracic repair. Conservative management should be considered in the management of tracheal injuries in the pediatric population.

Clinical evaluation of urine Histoplasma capsulatum antigen measurement in cats with suspected disseminated histoplasmosis.

Diagnosis of Histoplasma capsulatum infection in cats traditionally relies upon identification of organisms in circulating monocytes or in tissue specimens from affected organs. In this retrospective study, results of a urine antigen assay were compared with standard diagnostic methods in cats with clinical signs suggestive of histoplasmosis. Antigenuria was detected in 17/18 cats with a histopathologic or cytopathologic diagnosis of histoplasmosis. This preliminary evaluation of the Histoplasma urine antigen test suggests it may be a useful aid in diagnosing this disease in cats.

Young drivers' optimism bias for accident risk and driving skill: Accountability and insight experience manipulations.

This study aimed to determine whether two brief, low cost interventions would reduce young drivers' optimism bias for their driving skills and accident risk perceptions. This tendency for such drivers to perceive themselves as more skillful and less prone to driving accidents than their peers may lead to less engagement in precautionary driving behaviours and a greater engagement in more dangerous driving behaviour. 243 young drivers (aged 17-25 years) were randomly allocated to one of three groups: accountability, insight or control. All participants provided both overall and specific situation ratings of their driving skills and accident risk relative to a typical young driver. Prior to completing the questionnaire, those in the accountability condition were first advised that their driving skills and accident risk would be later assessed via a driving simulator. Those in the insight condition first underwent a difficult computer-based hazard perception task designed to provide participants with insight into their potential limitations when responding to hazards in difficult and unpredictable driving situations. Participants in the control condition completed only the questionnaire. Results showed that the accountability manipulation was effective in reducing optimism bias in terms of participants' comparative ratings of their accident risk in specific situations, though only for less experienced drivers. In contrast, among more experienced males, participants in the insight condition showed greater optimism bias for overall accident risk than their counterparts in the accountability or control groups. There were no effects of the manipulations on drivers' skills ratings. The differential effects of the two types of manipulations on optimism bias relating to one's accident risk in different subgroups of the young driver sample highlight the importance of targeting interventions for different levels of experience. Accountability interventions may be beneficial for less experienced young drivers but the results suggest exercising caution with the use of insight type interventions, particularly hazard perception style tasks, for more experienced young drivers typically still in the provisional stage of graduated licensing systems.