Postoperative opioid protocol: A 5-year resident-led effort to standardize prescribing patterns.

OBJECTIVES: The combined impact of variable surgeon prescribing preferences and low resident prescribing comfort level can lead to significant disparity in opioid prescribing patterns. We report an update on the expanded scope of this now 5-year, resident led initiative to standardize postoperative prescription practices within the Department of Otolaryngology. METHODS: With Institutional Review Board approval, performed a retrospective review of 12 months before (July 2016 - June 2017) and 48 months after (July 2019-June 2021) implementation of the Expanded Postoperative Analgesia Protocol. The Pre-Protocol and Expanded Protocol cohorts were compared using ANOVA, chi-squared and Fisher Exact tests, with ANCOVA and binary logistic regression for covariate analysis. Cost impact was calculated using average medication spending data for 2018-2019. RESULTS: 470 patients were included in the Pre-Protocol cohort (54 % male, mean age 35 years) and 679 in the Expanded Protocol cohort (63 % male, mean age 36 years). The protocol was effectively implemented as reflected in the reduction of combination opioid medications from 429 (91.3 %) to 26 (3.8 %) (87 % reduction, 95 % CI 86 % to 89 %, p < .001). The protocol resulted in a 66 % reduction in average morphine milligram equivalents per patient (333 mg to 114 mg, mean reduction 219 mg, 95 % CI 206 mg to 232 mg, p < .001), a 68 % reduction in medication refills (refill rate 20 % to 6 %; 14 % reduction, 95 % CI 12 % to 16 %, p < .001) and a 74 % reduction in cost of postoperative medications ($93.82 to $24.64 per patient). CONCLUSION: Through purposeful standardization, this 5-year resident led effort resulted in sustained changes to departmental wide prescribing practices yielding reduced variability, reduced cost, improved opioid management and superior pain control for postoperative patients.

Pedicled Forearm Fasciocutaneous Flap for Tracheal Reconstruction: Anomalous Radial Vasculature Preventing Free-Flap.

A 61-year-old female presented with poorly differentiated thyroid carcinoma with anterior tracheal wall invasion. Following resection, the patient was to undergo anterior tracheal wall reconstruction with a radial forearm fasciocutaneous free flap and costal cartilage grafts. However, intraoperative identification of a "brachioradial artery" was identified with the deep radial and ulnar arteries completely separated from the radial artery. To maximize the chance for flap success, the fasciocutaneous flap was converted to a pedicled rotational flap with excellent results. This is the first pedicled radial forearm fasciocutaneous flap for composite reconstruction of the anterior trachea.

Airway Management of COVID-19 Positive Patients Aboard USNS COMFORT Mission to New York City.

During the USNS Comfort mobilization to New York City in response to the pandemic, the ship's medical team cared for over 35 mechanically ventilated corona virus disease 2019 (COVID-19) infected patients. Due to the better than expected mortality rates of these patients, tracheotomy for prolonged intubation or other indicated interventional bronchoscopies were performed on 7 COVID positive patients, as well as 2 with negative screening tests. No member of the health care team subsequently became symptomatic or tested positive for COVID-19. This was in part due to the formation of a dedicated surgical airway team, use of standardized procedural techniques and personal protective equipment (PPE), and construction of a negative pressure operating room within the COVID-19 isolation ward on the ship. This experience shows that tracheotomies and other aerosolizing procedures can be performed with due concern for patient and provider safety, regardless of patient's COVID status.

Multicenter prospective evaluation of the reliability of the combined use of two models to predict non-sentinel lymph node status in breast cancer patients with metastatic sentinel lymph nodes: the MSKCC nomogram and the Tenon score. Results of the NOTEGS study.

BACKGROUND: The purpose of this study was to prospectively evaluate the combined use of The Memorial Sloan Kettering Cancer Center nomogram and Tenon score to select, in patients with metastatic sentinel lymph node (SN), those at low risk of metastatic non-SN for whom additional axillary lymph node dissection (ALND) could be avoided. METHODS: From January 2011 to July 2012, a prospective non-interventional nationwide study was conducted (NCT01509963). We sought to identify the false reassurance rate (FRR, a negative test result is false) in patients with both a ⩽10% probability of metastatic non-SN with the MSKCC nomogram and a Tenon score ⩽3.5 (low risk): the proportion of patients with metastatic non-SN at additional ALND. Our hypothesis was that these patients would have a FRR⩽5%. RESULTS: Data on 2822 patients with breast cancer from 53 institutions were prospectively recorded. At least one SN was metastatic (isolated tumour cells, micro- or macrometastases) in 696 patients (24.7%). Among patients with ALND and complete data to calculate combined risk (n=504), 67 and 437 patients had low and high combined risk, respectively. Patients at low risk had less ALND (47%) compared to patients at high risk (P<0.001). This study did not meet its primary objective because the FRR in patients with low risk was 16.4% (11 out of 67) (95% confidence interval (CI): 9.7-23.1%). In the high-risk group, 33.9% (148 out of 437) (95% CI: 29.6-38.4%) had non-SN metastases (P=0.004). CONCLUSIONS: In this controlled prospective study, metastatic SN patients with both a ⩽10% probability of metastatic non-SN with the MSKCC nomogram and a Tenon score ⩽3.5 failed to identify patients at low risk of metastatic non-SN when completion ALND was not systematic.

When the world comes to us.

To do this job well, we may need to reanalyze our attitudes toward the potpourri of humanity we encounter in the exam room.

Predictors of multiple dilations and functional outcomes after total laryngectomy and laryngopharyngectomy.

BACKGROUND: Following total laryngectomy (TL) or laryngopharyngectomy (TLP), patients may develop strictures that require multiple dilations to treat. However, the risk factors associated with dysphagia refractory to a single dilation are unknown. METHODS: Single-institution retrospective review of patients who underwent at least one stricture dilation after TL/TLP between March 2013 and March 2022. RESULTS: A total of 49 patients underwent stricture dilation after TL/TLP. Thirty-five (71%) underwent multiple dilations. Pharyngocutaneous fistula, primary chemoradiation therapy, and a shorter time interval from TL/TLP to first dilation were independently associated with dysphagia requiring multiple dilations. Patients in the multiple dilations group had a higher rate of limited diet and G-tube dependence compared to patients in the single dilation group. CONCLUSIONS: Shorter time interval to stricture formation is a prognostic indicator of the need for multiple dilations following TL/TLP. Patients requiring multiple dilations are at increased risk of persistent dysphagia long-term.

Early Weight-Bearing After Fibula Free Flap Surgery.

Importance: Despite the widespread use of fibula free flap (FFF) surgery for head and neck reconstruction, there are no studies assessing if early weight-bearing (EWB) affects postoperative recovery, and the timing of weight-bearing initiation following FFF surgery varies considerably across institutions. Therefore, it is important to understand the effect of EWB in these patients and whether it could improve postoperative recovery. Objective: To assess the association of EWB after FFF surgery with donor-site complications, length of stay, and discharge to home status. Design, Setting, and Participants: This retrospective cohort study took place at Massachusetts Eye and Ear, a single tertiary care institution in Boston, Massachusetts. A total of 152 patients who received head and neck reconstruction with a fibula osteocutaneous free flap between January 11, 2010, and August 11, 2022, were included. Exposure: EWB on postoperative day 1 vs non-EWB on postoperative day 2 or later. Main Outcomes and Measures: Patient characteristics, including demographic characteristics and comorbidities, surgical characteristics, donor-site complications, length of stay, and discharge disposition, were recorded. Descriptive statistics and multivariate logistic regressions were used to compute effect sizes and 95% CIs to compare postoperative outcomes in EWB and non-EWB groups. Results: A total of 152 patients (median [IQR] age, 63 [55-70] years; 89 [58.6%] male) were included. The median (IQR) time to postoperative weight-bearing was 3 (1-5) days. Among all patients, 14 (9.2%) had donor-site complications. EWB on postoperative day 1 was associated with shorter length of stay (adjusted odds ratio [AOR], 0.10; 95% CI, 0.02-0.60), increased rate of discharge to home (AOR, 7.43; 95% CI, 2.23-24.80), and decreased donor-site complications (AOR, 0.11; 95% CI, 0.01-0.94). Conversely, weight-bearing 3 or more days postoperatively was associated with an increased risk of pneumonia (AOR, 6.82; 95% CI, 1.33-34.99). Conclusions and Relevance: In this cohort study, EWB after FFF surgery was associated with shorter length of stay, increased rate of discharge to home, and decreased donor-site complications. These findings support the role of early mobilization to optimize postoperative recovery after FFF surgery.

Challenges in accurate registration of 3-D medical imaging and histopathology in primary prostate cancer.

Due to poor correlation between slice thickness and orientation, verification of medical imaging results by histology is difficult. Often validation of imaging findings of lesions suspicious for prostate cancer is driven by a subjective, visual approach to correlate in vivo images with histopathology. We describe fallacious assumptions in the correlation of imaging findings with pathology and identify the lack of accurate registration as a major obstacle in the validation of PET and PET/CT imaging in primary prostate cancer. Specific registration techniques that facilitate the most difficult part of the registration process--the mapping of pathology onto high-resolution imaging, preferably aided by the ex vivo prostate specimen--are discussed.

Multi-system repeatability and reproducibility of apparent diffusion coefficient measurement using an ice-water phantom.

PURPOSE: To determine quantitative quality control procedures to evaluate technical variability in multi-center measurements of the diffusion coefficient of water as a prerequisite to use of the biomarker apparent diffusion coefficient (ADC) in multi-center clinical trials. MATERIALS AND METHODS: A uniform data acquisition protocol was developed and shared with 18 participating test sites along with a temperature-controlled diffusion phantom delivered to each site. Usable diffusion weighted imaging data of ice water at five b-values were collected on 35 clinical MRI systems from three vendors at two field strengths (1.5 and 3 Tesla [T]) and analyzed at a central processing site. RESULTS: Standard deviation of bore-center ADCs measured across 35 scanners was <2%; error range: -2% to +5% from literature value. Day-to-day repeatability of the measurements was within 4.5%. Intra-exam repeatability at the phantom center was within 1%. Excluding one outlier, inter-site reproducibility of ADC at magnet isocenter was within 3%, although variability increased for off-center measurements. Significant (>10%) vendor-specific and system-specific spatial nonuniformity ADC bias was detected for the off-center measurement that was consistent with gradient nonlinearity. CONCLUSION: Standardization of DWI protocol has improved reproducibility of ADC measurements and allowed identifying spatial ADC nonuniformity as a source of error in multi-site clinical studies.

Online Searches Related to Total Laryngectomy.

OBJECTIVE: To identify the most frequently asked questions regarding "laryngectomy" through an assessment of online search data. METHODS: Google Search data based on the search term "laryngectomy" were analyzed using Google Trends and Search Response. The most common People Also Ask (PAA) questions were identified and classified by the concept. Each website linked to its respective PAA question was rated for understandability, ease of reading, and reading grade level. RESULTS: Search popularity for the term "laryngectomy" remained stable between 2017 and 2022. The most popular PAA themes were post-laryngectomy speech, laryngectomy comparison to tracheostomy, stoma and stoma care, survival/recurrence, and post-laryngectomy eating. Of the 32 websites linked to the top 50 PAA's, eleven (34%) were at or below an 8th grade reading level. CONCLUSION: Post-laryngectomy speech, eating, survival, the stoma, and the difference between laryngectomy and tracheostomy are the most common topics searched online in relation to "laryngectomy." These are important areas for both patient and healthcare provider education. LEVEL OF EVIDENCE: N/A Laryngoscope, 133:2971-2976, 2023.

Robotic Thyroidectomy via Posterior Neck Approach Using the Da Vinci Single Port System.

We describe a remote access thyroidectomy technique: robotic thyroidectomy via posterior neck approach using the Da Vinci single port (Sp) robotic system. This approach is feasible and safe in the Western population. Laryngoscope, 2023.

Depth of resection predicts loss of tongue tip sensation after partial glossectomy in oral tongue cancer: A pilot study.

OBJECTIVE(S): To characterize the change in sensory function following partial glossectomy for oral tongue cancer (OTC) and to identify predictors of loss of tongue-tip sensation (LoTTS). MATERIALS AND METHODS: Patients with at least three months follow-up after partial glossectomy for primary OTC were included. All patients underwent a qualitative tongue sensation assessment and an objective tongue sensory exam of the native tongue tip. Additional details regarding the oncologic resection, surgical reconstruction, and pathological stage were collected. Multiple linear and logistic regressions were used for statistical analysis. RESULTS: Sixty-four patients were enrolled, including 34 (53%) men with a median age of 65 at enrollment. Ten (15%) patients reported LoTTS. Increased depth of resection (DOR) was an independent predictor of LoTTS on multivariate analysis, with an increased risk at a threshold of 1.3 cm. LoTTS was also associated with worse subjective quality of life and perceptive speech performance in our qualitative tongue assessment. CONCLUSIONS: In this pilot study, we found that DOR is a critical prognostic factor in predicting post treatment function. Patients with an increased DOR, particularly above 1.3 cm, are at greatest risk of LoTTS and associated morbidity. These findings may be used to predict post-operative sensory deficits, manage patients' expectations, and optimize the reconstructive approach. Future studies are needed to validate and replicate our results.

DCE and DW-MRI monitoring of vascular disruption following VEGF-Trap treatment of a rat glioma model.

Vascular-targeted therapies have shown promise as adjuvant cancer treatment. As these agents undergo clinical evaluation, sensitive imaging biomarkers are needed to assess drug target interaction and treatment response. In this study, dynamic contrast enhanced MRI (DCE-MRI) and diffusion-weighted MRI (DW-MRI) were evaluated for detecting response of intracerebral 9 L gliosarcomas to the antivascular agent VEGF-Trap, a fusion protein designed to bind all forms of Vascular Endothelial Growth Factor-A (VEGF-A) and Placental Growth Factor (PGF). Rats with 9 L tumors were treated twice weekly for two weeks with vehicle or VEGF-Trap. DCE- and DW-MRI were performed one day prior to treatment initiation and one day following each administered dose. Kinetic parameters (K(trans), volume transfer constant; k(ep), efflux rate constant from extravascular/extracellular space to plasma; and v(p), blood plasma volume fraction) and the apparent diffusion coefficient (ADC) over the tumor volumes were compared between groups. A significant decrease in kinetic parameters was observed 24 hours following the first dose of VEGF-Trap in treated versus control animals (p < 0.05) and was accompanied by a decline in ADC values. In addition to the significant hemodynamic effect, VEGF-Trap treated animals exhibited significantly longer tumor doubling times (p < 0.05) compared to the controls. Histological findings were found to support imaging response metrics. In conclusion, kinetic MRI parameters and change in ADC have been found to serve as sensitive and early biomarkers of VEGF-Trap anti-vascular targeted therapy.

Burn Pit Exposure Is Associated With Increased Sinonasal Disease.

OBJECTIVE: The aim of this study was to determine whether self-reported burn pit exposure is associated with increased subjective and objective sinus disease. DESIGN: A cross-sectional study was performed evaluating consecutive adult patients presenting to a US Military rhinology clinic. Demographics, medical histories, sinonasal quality-of-life scores, and nasal endoscopy examinations were obtained. Participants were divided into three cohorts based on self-reported exposure histories and outcomes compared. RESULTS: One hundred eighty-six patients met the inclusion criteria, the majority of whom were male. Patients with burn pit exposure had worse Sinonasal Outcome Test-22 scores (49.9) compared with those deployed without burn pit exposure (31.8) or never deployed (31.5). Endoscopic findings demonstrated worse disease within those exposed (Lund-Kennedy score, 3.3) compared with the other cohorts (1.8 and 1.7, respectively). CONCLUSIONS: These novel findings suggest that deployment-related burn pit exposure is associated with increased subjective and objective sinus disease.

Investigation on tumor hypoxia in resectable primary prostate cancer as demonstrated by 18F-FAZA PET/CT utilizing multimodality fusion techniques.

PURPOSE: As hypoxia is believed to play an important role in the development and progression of prostate cancer, we evaluated whether 18F-labeled fluoroazomycin arabinoside (18F-FAZA) would be useful to identify tumor hypoxia in resectable prostate cancer. METHODS: Positron emission tomography (PET)/CT was performed on 14 patients with untreated localized primary prostate cancer 3 h post-injection of approximately 390 MBq of 18F-FAZA using forced diuresis to decrease radioactivity in the urinary bladder. Anatomical trans-pelvic coil and pre- and post-contrast 1.5 T MRI with endorectal coil were performed on the same day. Patients underwent radical prostatectomy and ex vivo 3 T MRI of the prostatectomy specimen within 14 days following in vivo imaging. Imaging results were verified by whole mount histopathology plus tissue microarray (TMA) immunohistochemical (IHC) analysis for carbonic anhydrase IX (CAIX) and hypoxia-inducible factor 1α (HIF-1α). Registration of in vivo imaging with histology was achieved using mutual information software and performing ex vivo MRI of the prostatectomy specimen and whole mount sectioning with block face photography as intermediate steps. RESULTS: Whole mount histology identified 43 tumor nodules, 19 of them larger than 1 ml as determined on coregistered volumes featuring 18F-FAZA, MRI, and histological 3-D image information. None of these lesions was found to be positive for CAIX or visualized by 18F-FAZA PET/CT while IHC for HIF-1α showed variable staining of tumor tissues. Accordingly, no correlation was found between 18F-FAZA uptake and Gleason scores. CONCLUSION: Our data based on 18F-FAZA PET/CT and CAIX IHC do not support the presence of clinically relevant hypoxia in localized primary prostate cancer including high-grade disease. Activation of HIF-1α may be independent of tissue hypoxia in primary prostate cancer.

Diffusion coefficient measurement using a temperature-controlled fluid for quality control in multicenter studies.

PURPOSE: To present the use of a quality control ice-water phantom for diffusion-weighted magnetic resonance imaging (DW-MRI). DW-MRI has emerged as an important cancer imaging biomarker candidate for diagnosis and early treatment response assessment. Validating imaging biomarkers through multicenter trials requires calibration and performance testing across sites. MATERIALS AND METHODS: The phantom consisted of a center tube filled with distilled water surrounded by ice water. Following preparation of the phantom, ≈30 minutes was allowed to reach thermal equilibrium. DW-MRI data were collected at seven institutions, 20 MRI scanners from three vendors, and two field strengths (1.5 and 3T). The phantom was also scanned on a single system on 16 different days over a 25-day period. All data were transferred to a central processing site at the University of Michigan for analysis. RESULTS: Results revealed that the variation of measured apparent diffusion coefficient (ADC) values between all systems tested was ±5%, indicating excellent agreement between systems. Reproducibility of a single system over a 25-day period was also found to be within ±5% ADC values. Overall, the use of an ice-water phantom for assessment of ADC was found to be a reasonable candidate for use in multicenter trials. CONCLUSION: The ice-water phantom described here is a practical and universal approach to validate the accuracy of ADC measurements with ever changing MRI sequence and hardware design and can be readily implemented in multicenter clinical trial designs.

The Lung Image Database Consortium (LIDC) and Image Database Resource Initiative (IDRI): a completed reference database of lung nodules on CT scans.

PURPOSE: The development of computer-aided diagnostic (CAD) methods for lung nodule detection, classification, and quantitative assessment can be facilitated through a well-characterized repository of computed tomography (CT) scans. The Lung Image Database Consortium (LIDC) and Image Database Resource Initiative (IDRI) completed such a database, establishing a publicly available reference for the medical imaging research community. Initiated by the National Cancer Institute (NCI), further advanced by the Foundation for the National Institutes of Health (FNIH), and accompanied by the Food and Drug Administration (FDA) through active participation, this public-private partnership demonstrates the success of a consortium founded on a consensus-based process. METHODS: Seven academic centers and eight medical imaging companies collaborated to identify, address, and resolve challenging organizational, technical, and clinical issues to provide a solid foundation for a robust database. The LIDC/IDRI Database contains 1018 cases, each of which includes images from a clinical thoracic CT scan and an associated XML file that records the results of a two-phase image annotation process performed by four experienced thoracic radiologists. In the initial blinded-read phase, each radiologist independently reviewed each CT scan and marked lesions belonging to one of three categories ("nodule > or =3 mm," "nodule <3 mm," and "non-nodule > or =3 mm"). In the subsequent unblinded-read phase, each radiologist independently reviewed their own marks along with the anonymized marks of the three other radiologists to render a final opinion. The goal of this process was to identify as completely as possible all lung nodules in each CT scan without requiring forced consensus. RESULTS: The Database contains 7371 lesions marked "nodule" by at least one radiologist. 2669 of these lesions were marked "nodule > or =3 mm" by at least one radiologist, of which 928 (34.7%) received such marks from all four radiologists. These 2669 lesions include nodule outlines and subjective nodule characteristic ratings. CONCLUSIONS: The LIDC/IDRI Database is expected to provide an essential medical imaging research resource to spur CAD development, validation, and dissemination in clinical practice.