EMR quantity autopopulation removal on hospital discharge prescribing patterns: Implications for opioid stewardship.

WHAT IS KNOWN AND OBJECTIVE: Prescription drug stewardship is critical. Autopopulation(AP) of medication quantities may influence prescriber behaviour. We investigate the impact of AP removal(APR) on opioid prescribing. METHODS: Inpatient and emergency department(ED) discharges with opioid pain medications 2 years before and after APR were identified. Milligrams of morphine equivalents(MMEs) prescribed were recorded. Group comparisons were performed using Mann-Whitney U tests. Spearman's rho was used to analyse correlations between pain level and quantity of prescribed opioids. Mann-Kendall tests assessed trends in prescription patterns. Generalized estimating equations assessed trends in total quantity of prescribed MME. RESULTS AND DISCUSSION: A total of 53 608 patient encounters were included for analysis. In surgical patients, there were no trends in the frequency of prescriptions below, at or above the AP quantity pre-APR. Post-APR, there was a decrease in the percentage of prescriptions written for the AP quantity(τ = -.493, P = .001) and an increase in prescriptions for <30 tablets(τ = .468,P = .001). In non-operative patients, the pre-APR period was associated with a lower percentage of prescriptions >30 tablets and a greater percentage of prescriptions for <30 tablets. Interestingly, APR reversed this trend in prescriptions for >30 tablets and resulted in an increase in larger prescriptions. Multivariate analysis of the total prescribed quantity of MME found no significant trend across months for inpatients prior to and after APR (0.997, P = .065 and 1.003, P = .142; respectively). The ED model found a monthly downward trend in amount of prescribed MME prior to and after APR (0.986, P < .001 and 0.990, P < .001; respectively). In the inpatient setting, pain was positively correlated to discharge MME (ρ = .028, P < .001); with those reporting the highest pain receiving the greatest amount of opioids both pre- and post-APR. Interestingly, in the ED, this finding was negatively correlated (ρ = -.086, P < .001); with those reporting the lowest pain receiving the greatest amount of opioids both pre- and post-APR. WHAT IS NEW AND CONCLUSIONS: AP removal may have unintended consequences, such as increased prescriptions for greater quantities. To drive down prescription amounts, lower anchor values may be of more utility than APR. The poor correlation of pain values with prescribed medications warrants further investigation.

The penumbra coil 400 system for treatment of wide-necked intracranial aneurysms: initial single-center experience.

Endovascular treatment of wide-necked intracranial aneurysms frequently requires stent- or balloon-assisted coiling to prevent coil herniation into the parent artery. Provided that coils can be securely deployed within the aneurysm sac, these adjunctive devices and their associated risk can be avoided. The Penumbra 400 Coil (PC-400) has a larger diameter than conventional coils and is constructed completely of metal, a feature that increases the coil stability and may improve its ability to respect the aneurysm neck. The purpose of this study was to examine the frequency of adjunctive stent usage when coiling wide-necked intracranial aneurysms with the PC-400 in comparison with conventional coils. We examined consecutive patients with unruptured wide-necked aneurysms treated at our institution with endovascular coils. Aneurysm characteristics and procedural outcomes were compared between patients treated with PC-400 compared with a control group treated with conventional coils. Thirty-eight patients met criteria for this study. Stent-assisted coiling was required in 34 % fewer cases using PC-400 compared with conventional coils (P = .049). Fewer coils and less length were required with the PC-400 to obtain the same packing densities, occlusion types, and short-term stability. This may reduce treatment cost and prove to be valuable in patients with contraindications to dual antiplatelet therapy.

Mild exercise reduces cerebral vasospasm after aneurysm subarachnoid hemorrhage: a retrospective clinical study and correlation with laboratory investigation.

BACKGROUND: Aneurysmal subarachnoid hemorrhage (SAH) is a leading cause of death and disability and is often complicated by cerebral vasospasm (CV). Conventional management to prevent CV includes bedrest; however, inactivity places the patient at risk for nonneurological complications. We investigated the effect of mild exercise after SAH in clinical and laboratory settings. METHODS: Clinical: Data from 80 patients with SAH were analyzed retrospectively. After aneurysms were secured, physical therapy was initiated as tolerated. CV and complications were compared by the timing of active physical therapy. Laboratory: 18 Rodents were divided into three groups: (1) control, (2) SAH without exercise, and (3) SAH plus mild exercise. On day 5, brainstems were removed and analyzed for the injury marker inducible nitric oxide synthase (iNOS). RESULTS: Clinical: Mild exercise before day 4 significantly lowered the incidence of symptomatic CV compared with the nonexercised group. There was no difference in the incidence of additional complications based upon exercise. Laboratory: Staining for iNOS was significantly higher in the SAH group than the control group, but there was no difference between exercised and nonexercised SAH groups, confirming that exercise did not promote neuronal injury. CONCLUSION: Early mobilization significantly reduced clinical CV. The relationship should be studied further in a prospective trial with defined exercise regimens.

Time-dependent changes in cerebrospinal fluid metal ions following aneurysm subarachnoid hemorrhage and their association with cerebral vasospasm.

Aneurysm subarachnoid hemorrhage affects 10 in 100,000 people annually, 40 % of whom will develop neurological deficits from ischemic stroke caused by cerebral vasospasm. Currently, the underlying mechanisms are uncertain. Metal ions are important modulators of neuronal electrophysiological conduction and smooth muscle cell activity, thereby potentially contributing to vasospasm. We hypothesized that metal ion concentrations in the cerebrospinal fluid (CSF) after aneurysm rupture would change over time and be associated with vasospasm. To test this hypothesis, for 21 days, we collected CSF from patients with aneurysmal rupture and subjected it to spectrometry to detect metals. A repeated measures analysis was performed to analyze concentration changes over time. Six of the seven patients with aneurysmal rupture experienced vasospasm, all resolving by day 14. Changes in Fe²âº and Zn²âº concentrations in the CSF paralleled the incidence of vasospasm in this study population. Na²âº, Ca²âº, Mg²âº, and Cu²âº concentrations exhibited no statistically significant changes over time. In conclusion, Fe²âº concentration in the CSF was significantly elevated during days 7-10, whereas Zn²âº concentrations spiked shortly thereafter, during days 11-14. This suggests that Fe²âº may be related to the induction of vasospasm and Zn²âº may be a marker of early brain injury secondary to ischemic injury and inflammation.

Tracheostomy timing affects stroke recovery.

BACKGROUND: The timing of tracheostomy in stroke patients unable to protect their airway has become a topic of debate. Proponents for early tracheostomy (ET) cite benefits including less ventilation-associated pneumonia, less sedative drug use, shorter length of stay, and reduced mortality in comparison with late tracheostomy (LT). METHODS: We examined the timing of tracheostomy on stroke patient outcomes across the United States using the Nationwide Inpatient Sample (2008-2010). Independent samples t tests and chi-squared tests were used to make comparisons between early (≤10 days) and late (11-25 days) tracheostomy. Multivariable models, adjusted for confounding factors, investigated outcome measures. RESULTS: In total, 13,165 stroke cases were included in the study (5591 in the ET group and 7574 in the LT group). Patients receiving an ET had a significant reduction in the odds of ventilator-associated pneumonia in comparison with the LT group (OR: .688, P = .026). The length of stay for patients receiving an ET was significantly lower in comparison with the LT group (P < .001) and was associated with an 18% reduction in total hospital costs (P < .001). CONCLUSIONS: Early tracheostomy for stroke patients may reduce the incidence of ventilator-associated pneumonia, thereby shortening the hospital stay and lowering total hospital costs. These relationships warrant further investigation in a large prospective multicenter trial.

Stenting versus endarterectomy and the impact of ultra-early revascularization for emergent admissions of carotid artery stenosis.

BACKGROUND: The factors influencing outcomes after emergent admission for symptomatic carotid artery stenosis treated with revascularization by endarterectomy or stenting are yet to be fully elucidated. METHODS: We analyzed revascularization of carotid artery stenosis for patients admitted emergently using the Nationwide Inpatient Sample (2008-2011). Admission characteristics, economic measures, in-hospital mortality, and iatrogenic stroke were compared between (1) endarterectomy and stenting, (2) patients with and without cerebral infarction, and (3) ultra-early (within 48 hours of admission) and deferred (up to 2 weeks) intervention. RESULTS: 72,797 admissions meeting our inclusion criteria were identified. Factors associated with ultra-early revascularization were male patients, low comorbidity burden, stenosis without infarction, and stenting. Ultra-early intervention significantly decreased cost and length of stay, and stenting for patients without infarction decreased length of stay but increased cost. Patients without infarction treated within 48 hours had significantly lower mortality and iatrogenic stroke rate. Patients with infarction receiving ultra-early revascularization had increased odds of mortality and iatrogenic stroke in comparison with the deferred group. Patients with infarction receiving stenting experienced increased odds of mortality in comparison with those receiving endarterectomy, but there was no significant difference in iatrogenic stroke rate. Recombinant tissue plasminogen activator (rtPA) administration on the day of revascularization greatly increased the odds of iatrogenic stroke and mortality. CONCLUSIONS: Larger prospectively randomized trials evaluating the optimum timing of revascularization after emergent admission of carotid artery stenosis seem warranted.

In vivo biomechanical evaluation of a novel angle-stable interlocking nail design in a canine tibial fracture model.

OBJECTIVE: To compare clinical outcome and callus biomechanical properties of a novel angle stable interlocking nail (AS-ILN) and a 6 mm bolted standard ILN (ILN6b) in a canine tibial fracture model. STUDY DESIGN: Experimental in vivo study. ANIMALS: Purpose-bred hounds (n = 11). METHODS: A 5 mm mid-diaphyseal tibial ostectomy was stabilized with an AS-ILN (n = 6) or an ILN6b (n = 5). Orthopedic examinations and radiographs were performed every other week until clinical union (18 weeks). Paired tibiae were tested in torsion until failure. Callus torsional strength and toughness were statistically compared and failure mode described. Total and cortical callus volumes were computed and statistically compared from CT slices of the original ostectomy gap. Statistical significance was set at P < .05 RESULTS: From 4 to 8 weeks, lameness was less pronounced in AS-ILN than ILN6b dogs (P < .05). Clinical union was reached in all AS-ILN dogs by 10 weeks and in 3/5 ILN6b dogs at 18 weeks. Callus mechanical properties were significantly greater in AS-ILN than ILN6b specimens by 77% (failure torque) and 166% (toughness). Failure occurred by acute spiral (control and AS-ILN) or progressive transverse fractures (ILN6b). Cortical callus volume was 111% greater in AS-ILN than ILN6b specimens (P < .05). CONCLUSIONS: Earlier functional recovery, callus strength and remodeling suggest that the AS-ILN provides a postoperative biomechanical environment more conducive to bone healing than a comparable standard ILN.

Disparities in Olfactory Dysfunction in African Americans.

OBJECTIVES: To examine olfactory performance in African Americans (AA) and Whites by comparing individual scent scores on objective olfactory tests to assess potential racial-ethnic differences of scent detection. METHODS: Cross-sectional study of healthy participants, age 18+ years, and without sinonasal inflammatory disease from June 2021 to April 2022. Included participants self-identified as AA or White. Patients were recruited from outpatient clinics at University of Kansas Medical Center, and the local community. Two smelling tests were employed: Affordable Rapid Olfactory Measurement Array (AROMA) and Sniffin' Sticks (SST-12). Sino-Nasal Outcome Test (SNOT-22) was used for self-reported olfactory function . Pearson correlation and chi-square tests were used to detect statistical significance. RESULTS: Our sample included 102 (46 AA and 56 Whites) participants. AROMA and SST-12 scores were significantly correlated in AA (P < .01, Pearson's Rho = .642) and Whites (P < .05, Pearson's Rho = .297). Mean scores on AROMA were significantly lower for AAs: 64.2 and Whites: 75.5 (P < .01). On AROMA, AA less accurately identified the scents of Licorice, Orange, Lavender, Cinnamon, Clove, and Rosemary (P < .05). Similarly, SST-12 mean scores for AAs: 84.2 were also lower than Whites: 89.9 (P < .01). On SST-12, AA less accurately identified the scent of pineapple Based on SST-12 scoring criteria, 60.9% of AA and 30.4% of Whites were classified as hyposmic (P < .05). SNOT-22 Smell scores were equivalent for both groups. CONCLUSION: On both tests of olfaction, AA performed worse than Whites and a greater proportion of AA were considered hyposmic compared to Whites. This is a discrepancy with self-reported olfaction, which showed no difference between Whites and AA. AA performed significantly worse than their White counterparts on several scents, with possible implications regarding cultural appropriateness of scents used in olfactory testing.

Aneurysm embolization grade: a predictive tool for aneurysm recurrence after coil embolization.

BACKGROUND: Coil embolization has gained importance in the management of intracranial aneurysms over the past decade. However, the recurrence risk after embolization mandates closer follow-up than surgical clip ligation. Currently, there is no reliable system for predicting aneurysm sac thrombosis. An aneurysm embolization grade (AEG) reported previously by the senior author (EMD) has been proposed as a tool for predicting the durability of aneurysm occlusion based on hemodynamic characteristics. Here, we present our internal validity results. METHODS: AEG and Raymond-Roy Occlusion Classification (RROC) scores were prospectively assigned to all aneurysms coiled from June 2008 to June 2011. The prospectively assigned AEG and RROC scores from the cerebral angiograms were collected for data analysis and validity assessment of the AEG system. 110 consecutive patients who had aneurysm coil embolization were included in this study. RESULTS: The post-coiling AEG significantly predicted follow-up angiographic filling characteristics. Pairwise comparisons revealed that the follow-up AEG for those initially scored 'A' (complete obliteration) was significantly better than the contrast-flow groups. Significant differences were also noted between contrast-stasis and contrast-flow groups. A pairwise comparison between RROC scores demonstrated that only the RROC Type 1 could be used to predict follow-up occlusion durability. Stent placement in wide-neck aneurysms had no effect on initial AEG, RROC, or long-term occlusion durability. Packing density significantly predicted initial AEG and RROC, but had no effect on long-term occlusion. CONCLUSIONS: The AEG system is uniquely based on angiographic filling characteristics of the aneurysm, and this study demonstrated its high predictive value for determining aneurysm sac thrombosis. Assigning an AEG to the aneurysm can guide the neurointerventionalist in discussions with the patient regarding the probability of aneurysm recurrence and potential need for retreatment.

Investigation of a Novel Activity-Based Checks (ABC) Functional Pain Scale in the Post-Operative Urologic Surgery Patient.

Introduction: The authors investigated a novel functional pain scale, the Activity-Based Checks (ABCs) of Pain, following open urologic surgery. The primary objectives were to establish the strength of the correlation between the ABCs and the numeric rating scale (NRS) and determine the impact of functional pain on the patient's opioid requirements. We hypothesized that ABC score would correlate strongly with NRS and that the ABC score during hospitalization would be more closely correlated with the number of opioids prescribed and used. Methods: This prospective study included patients at a tertiary academic hospital undergoing nephrectomy and cystectomy. The NRS and ABCs were collected pre-operatively, during the inpatient stay, and at the one-week follow-up. Milligrams of morphine equivalents (MMEs) prescribed at discharge and the MME reportedly taken during the first post-operative week were recorded. Spearman's Rho was used to assess the correlation between scale variables. Results: Fifty-seven patients were enrolled. The ABCs correlated strongly with the NRS at baseline and post-operative appointments (r = 0.716, p < 0.001 and 0.643, p < 0.001). Neither the NRS nor the composite ABCs score was predictive of outpatient MME requirements; the ABCs function, "Walking outside the room" significantly correlated to MMEs taken after discharge (r = 0.471, p = 0.011). The greatest predictor of MMEs taken was the number of MMEs prescribed (0.493, p = 0.001). Conclusions: This study highlighted the importance of post-operative pain assessment that takes functional pain into consideration to evaluate pain, inform management decisions, and reduce opiate reliance. It also emphasized the strong relationship between opioids prescribed and opioids consumed.

Prognostic Implications of Skin Invasion in Locally Advanced Oral Cavity Squamous Cell Carcinoma.

OBJECTIVE: To evaluate the effect of histopathologic skin invasion on 2- and 5-year disease-free survival (DFS) and overall survival (OS) in patients treated with primary surgery for locally advanced oral cavity squamous cell carcinoma (OCSCC). STUDY DESIGN: A retrospective case-control study was performed comparing previously untreated patients with pT4a OCSCC with and without skin invasion. SETTING: Academic medical center. METHODS: Propensity score-matched cohorts were derived by age, sex, surgical margins, pathologic N classification, adjuvant treatment, and primary tumor site. The Kaplan-Meier method was used to evaluate 2- and 5-year OS and DFS, which were compared between cohorts via the log rank (Mantel-Cox) test statistic. RESULTS: Overall 25 patients were identified to have pathologic skin invasion, and 50 were selected for the matched control group. OS was significantly lower for patients with skin invasion as compared with controls at 2 years (30.8% vs 53.3%, P = .018) and 5 years (16.6% vs 42.2%, P = .01). DFS was significantly lower for patients with skin invasion vs controls at 2 years (23.7% vs 47.7, P = .037) and 5 years (15.8% vs 41.4%, P = .024). CONCLUSION: Histopathologic skin invasion in OCSCC is associated with dismal prognosis in patients who underwent primary surgical treatment. OS outcomes for patients with skin invasion are comparable to survival of patients with recurrent/metastatic disease and T4N2 disease.

Adjuvant radiotherapy mitigates impact of perineural invasion on oncologic outcomes in early-stage oral cavity squamous cell carcinoma. A multi-institutional analysis of 557 patients.

OBJECTIVES: Understand the prognostic impact of perineural invasion (PNI) in early-stage oral cavity squamous cell carcinoma (OCSCC). Assess the influence of adjuvant radiotherapy on outcomes of patients with PNI-positive early-stage OCSCC. MATERIALS AND METHODS: Retrospective seven-institution cohort study including patients with pathologic T1-2 N0-1 OCSCC who underwent primary surgery with negative margins. Outcomes included disease-free survival (DFS) and locoregional control (LRC). Cox proportional hazards models were used to evaluate oncologic outcomes. Interaction terms were introduced to assess relationships between PNI and adjuvant radiotherapy. RESULTS: Among 557 patients (mean (SD) age 61.0 (13.9), 47.2% female, 66.6% pathologic T1, 93.5% pathologic N0), 93 had PNI-positive tumors, among which 87.1% underwent neck dissection and 39.6% received radiotherapy. On multivariable analysis, PNI was associated with lower DFS and LRC. Adjuvant radiotherapy was not associated with improved outcomes on multivariable analysis of the entire cohort. However, among patients with PNI-positive tumors, adjuvant radiotherapy significantly decreased hazard for DFS. CONCLUSION: Among patients with low-risk, early-stage OCSCC, PNI was associated with worse DFS and LRC. In patients with PNI-positive tumors, adjuvant radiotherapy lowered hazard for DFS on multivariable analysis. These data support using adjuvant radiotherapy for patients with early-stage OCSCC with PNI.

Decision regret 3 and 6 months after treatment for head and neck cancer: Observational study of associations with clinicodemographics, anxiety, and quality of life.

BACKGROUND: While quality of life (QOL), psychosocial health, and adverse treatment outcomes have been studied in head and neck cancer (HNC) patients, decision regret is an important and understudied complication that can negatively impact future health care decision making. METHODS: Data collected using a HNC patient registry with questionnaires administered at initial consultation visits plus 3 and 6 months after treatment completion was retrospectively analyzed. A visual analog anxiety scale and the University of Washington Quality of Life were given at clinic visits. Decision regret was determined using a validated scale. Demographic and clinical variables were collected retrospectively and at baseline. RESULTS: Patients with higher anxiety and lower self-reported QOL had higher concurrent regret at 3-month (n = 140) and at 6-month (n = 82) post-treatment. Later disease stage at presentation, nonprimary surgical treatment, and lower health literacy were associated with greater regret. CONCLUSIONS: Decision regret was highest in HNC patients with high anxiety, low QOL, and more advanced disease.

Rates of bone reabsorption and union in mandibular reconstruction using the osteocutaneous radial forearm free flap.

BACKGROUND: Historical concerns over bone resorption and malunion of the osteocutaneous radial forearm free flap (OCRFFF) limited its widespread adoption for head and neck reconstruction, despite lack of outcomes data evaluating this notion. METHODS: A retrospective cohort study was performed including patients 18 years or older who underwent reconstruction of the mandible using an OCRFFF. Linear modeling and logistic regression were used to evaluate the change in bone volume and union over time. RESULTS: One hundred and twenty-one patients were included in the study. A mixed effects linear model incorporating age, sex, treatment type, and number of bone segments did not demonstrate a significant loss of bone volume over time. A logistic regression model identified lack of adjuvant treatment and time to be significantly associated with complete union. CONCLUSION: This study supports that the OCRFFF is a stable form of osseus reconstruction for defects of the head and neck.

ABCs of Pain: A Functional Scale Measuring Perioperative Pain in Total Hip Arthroplasty Patients.

INTRODUCTION: Functional pain assessments are critical in total hip arthroplasty. This pilot study investigated a novel functional pain scale-the Activity-Based Checks of Pain (ABCs)-and its correlations with the 0 to 10 numeric rating scale (NRS) and outpatient milligram of morphine equivalents (MMEs) prescribed and needed in the first 2 weeks after total hip arthroplasty. METHODS: ABCs and NRS were collected at the baseline, inpatient, and 2-week follow-up. Primary outcome metrics were needed for pain medication at the time of pain scale completion, MMEs prescribed at discharge, and MMEs taken. Individual ABC functions and composite score were analyzed using Spearman rho and Mann-Whitney U tests. RESULTS: ABC and NRS scores were greatest preoperatively (n = 39). At each stage, the ABCs correlated with the NRS (ρ = 0.450, P < 0.01; ρ = 0.402, P < 0.05; and ρ = 0.563, P < 0.01). ABC or NRS scores did not correlate with MMEs prescribed. Last in-house NRS correlated with MMEs taken postoperatively (r = 0.571, P < 0.01). Specific ABCs functions-"sitting up" (ρ = 0.418, P < 0.01), "walking in room" (ρ = 0.353, P < 0.05), and "walking outside room" (ρ = 0.362, P < 0.05)-on the day of discharge correlated with MMEs taken. CONCLUSION: ABCs scale correlates with NRS. Neither scale correlated with MMEs prescribed at discharge, suggesting pain is undervalued in analgesic planning. Clinicians should assess pain with functions found to correlate with MMEs taken-"sitting up," "walking in room," and "walking outside room."

Olfactory Phenotypes Differentiate Cognitively Unimpaired Seniors from Alzheimer's Disease and Mild Cognitive Impairment: A Combined Machine Learning and Traditional Statistical Approach.

BACKGROUND: Olfactory dysfunction (OD) is an early symptom of Alzheimer's disease (AD). However, olfactory testing is not commonly performed to test OD in the setting of AD. OBJECTIVE: This work investigates objective OD as a non-invasive biomarker for accurately classifying subjects as cognitively unimpaired (CU), mild cognitive impairment (MCI), and AD. METHODS: Patients with MCI (n = 24) and AD (n = 24), and CU (n = 33) controls completed two objective tests of olfaction (Affordable, Rapid, Olfactory Measurement Array -AROMA; Sniffin' Sticks Screening 12 Test -SST12). Demographic and subjective sinonasal and olfaction symptom information was also obtained. Analyses utilized traditional statistics and machine learning to determine olfactory variables, and combinations of variables, of importance for differentiating normal and disease states. RESULTS: Inability to correctly identify a scent after detection was a hallmark of MCI/AD. AROMA was superior to SST12 for differentiating MCI from AD. Performance on the clove scent was significantly different between all three groups. AROMA regression modeling yielded six scents with AUC of the ROC of 0.890 (p < 0.001). Random forest model machine learning algorithms considering AROMA olfactory data successfully predicted MCI versus AD disease state. Considering only AROMA data, machine learning algorithms were 87.5%accurate (95%CI 0.4735, 0.9968). Sensitivity and specificity were 100%and 75%, respectively with ROC of 0.875. When considering AROMA and subject demographic and subjective data, the AUC of the ROC increased to 0.9375. CONCLUSION: OD differentiates CUs from those with MCI and AD and can accurately predict MCI versus AD. Leveraging OD data may meaningfully guide management and research decisions.

Resident Education in Laryngeal Stroboscopy: Part II-Evaluation of a Multimedia Training Module.

OBJECTIVE: To evaluate the efficacy of a web-based training module for teaching interpretation of laryngeal stroboscopy in a cohort of otolaryngology residents. STUDY DESIGN: Randomized controlled trial. SETTING: Academic tertiary center. SUBJECTS AND METHODS: Residents from three training programs were invited to complete an assessment consisting of a survey and five stroboscopic exams. Subsequently, participants were randomized to receive teaching materials in the form of (1) a handout (HO) or (2) a multimedia module (MM) and asked to complete a post-training assessment. Responses were compared to responses provided by three fellowship-trained laryngologists. RESULTS: Thirty-five of 47 invited residents (74.4%) completed both assessments. Overall mean postassessment scores were 64.3% ± 7.0, with the MM group (67.0% ± 7.6, n = 17) scoring higher (P = 0.03) than the HO (61.6% ± 5.4, n = 18) cohort. Postassessment scores did not differ by postgraduate year (P = 0.75) or institution (P = 0.17). Paired analysis demonstrated an overall mean improvement of 7.4% in the handout (HO) cohort (P = 0.03) and 10.3% in the MM cohort (P = 0.0006). Subset analysis demonstrated higher scores for the MM cohort for perceptual voice evaluation (HO = 68.8% ± 11.0; MM = 77.3% ± 10.6, P = 0.03) and stroboscopy-specific items (HO = 55.5% ± 8.2; MM = 61.9% ± 10.8, P = 0.06). On a five-point Likert scale, residents reported improved confidence in stroboscopy interpretation (P < 0.0001), irrespective of cohort (P = 0.62). Residents rated the MM (median = 5) more favorably as a teaching tool compared to the HO (median = 4, P = 0.001). CONCLUSION: Use of both the written HO and MM module improved scores and confidence in interpreting laryngeal stroboscopy. The MM was more effective in perceptual voice evaluation and stroboscopy-specific items. The MM was also rated more favorably by residents and may be an ideal adjunct modality for teaching stroboscopy.

National Database Research in Head and Neck Reconstructive Surgery: A Call for Increased Transparency and Reproducibility.

OBJECTIVE: To reproduce a published study comparing outcomes of patients who underwent microvascular reconstruction by plastic surgeons and otolaryngologists and to examine how case selection and methodology using the National Surgical Quality Improvement Program (NSQIP) data set can affect results and conclusions. STUDY DESIGN: Cross-sectional analysis of US national database. SETTING: American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from 2005 to 2017. SUBJECTS AND METHODS: A recently published study that used the NSQIP database to compare outcomes after head and neck free tissue transfer between plastic surgeons and otolaryngologists was reproduced. Different approaches to case selection and statistical analysis were evaluated and their effects on statistical significance and study conclusions were compared. RESULTS: When all cases of free tissue transfer, captured in NSQIP between 2005 and 2017, were compared between plastic surgery and otolaryngology, plastic surgery patients appeared to have lower rates of complications and length of stay. However, a more in-depth analysis demonstrated that these results were confounded by older and sicker otolaryngology patients. A second analysis of the same NSQIP data, limited to only head and neck oncologic reconstructions, demonstrated that otolaryngology patients had fewer complications on univariate and multivariable analysis. CONCLUSION: We demonstrated how case selection and analysis can significantly affect results. It is incumbent upon researchers who use NSQIP and other publicly available data sets to fully detail their methodology to allow other researchers to reproduce and evaluate their work and for the journal editorial process to carefully evaluate the methodology and conclusions of their contributing authors.

Educational Informed Consent Video Equivalent to Standard Verbal Consent for Rhinologic Surgery: A Randomized Controlled Trial.

BACKGROUND: Informed consent is an integral part of pre-operative counseling. However, information discussed can be variable. Recent studies have explored the use of multimedia in providing informed consent for rhinologic surgery. OBJECTIVE: To measure impact of an educational video (Video) compared to verbal informed consent (Verbal) on knowledge gained, alleviation of concerns, and efficiency. METHODS: Patients undergoing endoscopic sinus surgery (ESS), septoplasty, or ESS+septoplasty were prospectively enrolled and randomized to receive Video or Verbal consent. The Video group watched an educational video; the Verbal group received standard verbal consent from an Otolaryngology resident per institutional protocol. Both groups had the opportunity to discuss questions or concerns with their attending surgeon. Prior to, and after, consent was signed, both groups completed surveys regarding knowledge of purpose, risks, and benefits of surgery as well as surgical concerns. Decision regret and patient satisfaction were also assessed post-operatively. RESULTS: 77 patients were enrolled (39 Video, 38 Verbal). Demographics were not significantly different between groups. Overall knowledge significantly improved (p < 0.005) and concerns significantly decreased (p < 0.001) following consent in both groups. Improvements in these metrics were equivalent between groups (p < 0.02). Furthermore, resident time to complete consent, patient satisfaction, and decision regret were not significantly different between groups. CONCLUSION: Use of an educational video was equivalent to standard verbal informed consent for patients undergoing rhinologic surgery. Otolaryngologists can consider developing procedure-specific videos to allow allocation of time to other tasks, standardized education of patients, and streamlining of the informed consent process.

Evaluation of Surgical Learning Curve Effect on Obstructive Sleep Apnea Outcomes in Upper Airway Stimulation.

OBJECTIVE: An increasing number of facilities offer Upper Airway Stimulation (UAS) with varying levels of experience. The goal was to quantify whether a surgical learning curve exists in operative or sleep outcomes in UAS. METHODS: International multi-center retrospective review of the ADHERE registry, a prospective international multi-center study collecting UAS outcomes. ADHERE registry centers with at least 20 implants and outcomes data through at least 6-month follow-up were reviewed. Cases were divided into two groups based on implant order (the first 10 or second 10 consecutive implants at a given site). Group differences were assessed using Mann-Whitney U-tests, Chi-squared tests, or Fisher's Exact tests, as appropriate. A Mann-Kendall trend test was used to detect if there was a monotonic trend in operative time. Sleep outcome equivalence between experience groups was assessed using the two one-sided tests approach. RESULTS: Thirteen facilities met inclusion criteria, contributing 260 patients. Complication rates did not significantly differ between groups (P = .808). Operative time exhibited a significant downward trend (P < .001), with the median operative time dropping from 150 minutes for the first 10 implants to 134 minutes for the subsequent 10 implants. The decrease in AHI from baseline to 12-month follow-up was equivalent between the first and second ten (22.8 vs 21.2 events/hour, respectively, P < .001). Similarly, the first and second ten groups had equivalent ESS decreases at 6 months (2.0 vs 2.0, respectively, P < .001). ESS outcomes remained equivalent for those with data through 12-months. CONCLUSIONS: Across the centers' first 20 implants, an approximately 11% reduction operative time was identified, however, no learning curve effect was seen for 6-month or 12-month AHI or ESS over the first twenty implants. Ongoing monitoring through the ADHERE registry will help measure the impact of evolving provider and patient specific characteristics as the number of implant centers increases.