Obesity Does Not Increase Operative Time in Otologic Surgery: An Analysis of 5125 Cases.

OBJECTIVES: A large shoulder can impact otologic surgical access. The physical obstruction of a large shoulder may force the surgeon to adjust his or her posture or hand position. We sought to assess the effect of body mass index (BMI) on operative time in tympanoplasties and tympanomastoidectomies. STUDY DESIGN: Cross-sectional analysis. SETTING: National surgical quality improvement program dataset (NSQIP) 2011 to 2014. PATIENTS: Current procedural terminology (CPT) codes were used to identify patients undergoing tympanoplasties and tympanomastoidectomies. INTERVENTIONS: Otologic surgery as indicated by CPT code. MAIN OUTCOME MEASURES: Targeted variables included height, weight, and operative time. BMI was stratified to assess a range of body compositions (<25, 25-30, >30-35, >35-40, >40). Categorical variables were compared using χ tests and continuous variables were compared using Kruskal-Wallis tests. Correlation between operative time and BMI was assessed using Spearman's rho. A generalized linear model was used to analyze the variables affecting operative time. Surgical complications were assessed in binary logistic regression using the enter method. Two-tailed significance was set at α = 0.05. RESULTS: Two surgical groups were identified: tympanoplasty (n = 3,508) and tympanomastoidectomy (n = 1,617). There was not a significant difference in mean operative time across the BMI subgroups for either surgical group (p = 0.617, 0.859, respectively). Multivariate analyses showed no significant difference in operative times based on BMI classification. CONCLUSIONS: The body habitus of obese patients may force the otologic surgeon to adapt, but obese patients do not have a statistically significant longer mean operative time for tympanoplasties and tympanomastoidectomies than patients with a lower BMI.

Impact of Resident Participation on Operative Time and Outcomes in Otologic Surgery.

Objectives To describe the impact of resident involvement in tympanoplasty on operative time and surgical complication rates. Study Design Case series with chart review. Setting Tertiary medical center. Subjects and Methods Current Procedural Terminology codes were used to identify patients in the 2011-2014 public use files of the American College of Surgeons National Surgical Quality Improvement Program who underwent a tympanoplasty or tympanomastoidectomy. Cases were included if the database indicated whether the operating room was staffed with an attending alone or an attending with residents. Categorical and continuous variables were compared with chi-square, Fisher's exact, and Mann-Whitney U tests. Generalized linear models with a log-link and gamma distribution were used to examine the factors affecting operative time. Results Overall, 1045 cases met our study criteria (tympanoplasty, n = 797; tympanomastoidectomy, n = 248). Resident involvement increased mean operative time for tympanoplasties by 46% (107 vs 73 minutes, P < .001) and tympanomastoidectomies by 49% (175 vs 117 minutes, P < .001). While controlling for confounding factors, the variable with the largest impact on operative time was resident involvement. There were no significant differences observed in the rate of surgical complications between attending-alone and attending-resident cases. Conclusion Resident involvement in tympanoplasty and tympanomastoidectomy did not affect the surgical complication rate. Resident involvement increased operative time for tympanoplasties and tympanomastoidectomies; however, the specific reasons for the increase are not explained by the available data.

Therapeutic Mastoidectomy Does Not Increase Postoperative Complications in the Management of the Chronic Ear.

OBJECTIVE: Tympanoplasty with or without concurrent therapeutic mastoidectomy is a controversial topic in the management of chronic ear disease. We sought to describe whether there is a significant difference in postoperative complications. STUDY DESIGN: Retrospective cohort study. SETTING: American College of Surgeons National Surgical Quality Improvement Program public files. PATIENTS: Current procedural terminology codes were used to identify patients with chronic ear disease undergoing tympanoplasty ± concurrent mastoidectomy in the 2011 to 14 American College of Surgeons National Surgical Quality Improvement Program files. INTERVENTION: Therapeutic. MAIN OUTCOME MEASURES: Variables were compared with χ, Fischer's exact, and Mann-Whitney U tests, as appropriate to analyze postoperative complications between tympanoplasty with or without concurrent mastoidectomy. To account for confounding factors, presence of a complication was analyzed in binary logistic regression. Analysis considered sex, hypertension, obesity, advanced age, diabetes, smoking status, American Society of Anesthesiologists Physical status, procedure. RESULTS: There were 4,087 patients identified meeting criteria (tympanoplasty = 2,798, tympanomastoidectomy = 1,289). There was no statistical difference in postoperative complications (tympanoplasty n = 49 [1. 8%], tympanomastoidectomy n = 33 [2. 6%]; p = 0. 087) or return to the operating room (tympanoplasty = 4 [0. 1%], tympanomastoidectomy = 6 [0. 5%]; p = 0. 082). Binary logistic regression demonstrated smoking as a predictor of a postoperative complication (OR: 1. 758, 95% CI: 1. 084-2. 851; p = 0. 022), while concurrent mastoidectomy did not significantly increase the risk of complication (OR: 1. 440, 95% CI: 0. 915-2. 268; p = 0. 115). There was a significant difference in mean operative time between tympanoplasty and tympanomastoidectomy: 85.7 versus 154.23 min, p < 0. 001. CONCLUSION: In the management of chronic ear disease, tympanoplasty with concurrent mastoidectomy increases time under anesthesia, but it is not associated with any increased postoperative complications compared with tympanoplasty alone.

Correlation of Ventricular Arrhythmogenesis with Neuronal Remodeling of Cardiac Postganglionic Parasympathetic Neurons in the Late Stage of Heart Failure after Myocardial Infarction.

Introduction: Ventricular arrhythmia is a major cause of sudden cardiac death in patients with chronic heart failure (CHF). Our recent study demonstrates that N-type Ca2+ currents in intracardiac ganglionic neurons are reduced in the late stage of CHF rats. Rat intracardiac ganglia are divided into the atrioventricular ganglion (AVG) and sinoatrial ganglion. Only AVG nerve terminals innervate the ventricular myocardium. In this study, we tested the correlation of electrical remodeling in AVG neurons with ventricular arrhythmogenesis in CHF rats. Methods and Results: CHF was induced in male Sprague-Dawley rats by surgical ligation of the left coronary artery. The data from 24-h continuous radiotelemetry ECG recording in conscious rats showed that ventricular tachycardia/fibrillation (VT/VF) occurred in 3 and 14-week CHF rats but not 8-week CHF rats. Additionally, as an index for vagal control of ventricular function, changes of left ventricular systolic pressure (LVSP) and the maximum rate of left ventricular pressure rise (LV dP/dtmax) in response to vagal efferent nerve stimulation were blunted in 14-week CHF rats but not 3 or 8-week CHF rats. Results from whole-cell patch clamp recording demonstrated that N-type Ca2+ currents in AVG neurons began to decrease in 8-week CHF rats, and that there was also a significant decrease in 14-week CHF rats. Correlation analysis revealed that N-type Ca2+ currents in AVG neurons negatively correlated with the cumulative duration of VT/VF in 14-week CHF rats, whereas there was no correlation between N-type Ca2+ currents in AVG neurons and the cumulative duration of VT/VF in 3-week CHF. Conclusion: Malignant ventricular arrhythmias mainly occur in the early and late stages of CHF. Electrical remodeling of AVG neurons highly correlates with the occurrence of ventricular arrhythmias in the late stage of CHF.

In vivo transfection of manganese superoxide dismutase gene or nuclear factor κB shRNA in nodose ganglia improves aortic baroreceptor function in heart failure rats.

Arterial baroreflex sensitivity is attenuated in chronic heart failure (CHF) state, which is associated with cardiac arrhythmias and sudden cardiac death in patients with CHF. Our previous study showed that CHF-induced sodium channel dysfunction in the baroreceptor neurons was involved in the blunted baroreflex sensitivity in CHF rats. Mitochondria-derived superoxide overproduction decreased expression and activation of the sodium channels in the baroreceptor neurons from CHF rats. However, the molecular mechanisms responsible for the sodium channel dysfunction in the baroreceptor neurons from CHF rats remain unknown. We tested the involvement of nuclear factor κB (NFκB) in the sodium channel dysfunction and evaluated the effects of in vivo transfection of manganese superoxide dismutase gene and NFκB shRNA on the baroreflex function in CHF rats. CHF was developed at 6 to 8 weeks after left coronary artery ligation in adult rats. Western blot and chromatin immunoprecipitation data showed that phosphorylated NFκB p65 and ability of NFκB p65 binding to the sodium channel promoter were increased in the nodose ganglia from CHF rats. In vivo transfection of adenoviral manganese superoxide dismutase gene or lentiviral NFκB p65 shRNA into the nodose ganglia partially reversed CHF-reduced sodium channel expression and cell excitability in the baroreceptor neurons and improved CHF-blunted arterial baroreflex sensitivity. Additionally, transfection of adenoviral manganese superoxide dismutase also inhibited the augmentation of phosphorylated NFκB p65 in the nodose neurons from CHF rats. The present study suggests that superoxide-NFκB signaling contributes to CHF-induced baroreceptor dysfunction and resultant impairment of baroreflex function.

Assessment of a chief complaint-based curriculum for resident education in geriatric emergency medicine.

INTRODUCTION: We hypothesized that a geriatric chief complaint-based didactic curriculum would improve resident documentation of elderly patient care in the emergency department (ED). METHODS: A geriatric chief complaint curriculum addressing the 3 most common chief complaints-abdominal pain, weakness, and falls-was developed and presented. A pre- and postcurriculum implementation chart review assessed resident documentation of the 5 components of geriatric ED care: 1) differential diagnosis/patient evaluation considering atypical presentations, 2) determination of baseline function, 3) chronic care facility/caregiver communication, 4) cognitive assessment, and 5) assessment of polypharmacy. A single reviewer assessed 5 pre- and 5 postimplementation charts for each of 18 residents included in the study. We calculated 95% confidence and determined that statistical significance was determined by a 2-tailed z test for 2 proportions, with statistical significance at 0.003 by Bonferroni correction. RESULTS: For falls, resident documentation improved significantly for 1 of 5 measures. For abdominal pain, 2 of 5 components improved. For weakness, 3 of 5 components improved. CONCLUSION: A geriatric chief complaint-based curriculum improved emergency medicine resident documentation for the care of elderly patients in the ED compared with a non-age-specific chief complaint-based curriculum.

Blunted excitability of aortic baroreceptor neurons in diabetic rats: involvement of hyperpolarization-activated channel.

AIMS: Although dysfunction of arterial baroreflex occurs in human and animal models of type-1 diabetes (T1D), the mechanisms involved in the impairment of the baroreflex still remain unclear. The nodose ganglion (NG) contains the cell bodies of the aortic baroreceptor (AB) neurons. Hyperpolarization-activated cyclic nucleotide-gated (HCN) channels are expressed in AB neurons and play an important role in regulating the cell excitability. We investigated whether the excitability of AB neurons is depressed in streptozotocin (STZ)-induced T1D rats and whether HCN channels are involved in this depression. METHODS AND RESULTS: Using the whole-cell patch clamp technique, we found that AB neuron excitability (action potential frequency at 50 pA current stimulation) in the T1D rats was lower than that in the sham rats (0.4 +/- 0.5 vs. 4.8 +/- 0.6 spikes/s, P < 0.05; AB neurons were identified by DiI staining). In addition, HCN current density in AB neurons from the T1D rats was bigger than that from the sham rats (60.2 +/- 6.1 vs. 30.7 +/- 4.9 pA/pF at test pulse -140 from holding potential -40 mV, P < 0.05). Furthermore, HCN channel blockers (5 mM cesium chloride and 100 microM ZD7288) significantly reduced HCN currents and increased action potential frequency of the AB neurons in sham and T1D rats. Immunofluorescent and western blot analyses demonstrated that the expression of HCN1 and HCN2 channel protein in the NG from the T1D rats was higher than that from the sham rats. CONCLUSION: These results indicate that the HCN channels influence the excitability of AB neurons, and more importantly, contribute to the decreased excitability of AB neurons in T1D rats.