Cost effectiveness of commercial portable ex vivo lung perfusion at a low-volume US lung transplant center.

BACKGROUND: Portable ex vivo lung perfusion during lung transplantation is a resource-intensive technology. In light of its increasing use, we evaluated the cost-effectiveness of ex vivo lung perfusion at a low-volume lung transplant center in the USA. METHODS: Patients listed for lung transplantation (2015-2021) in the United Network for Organ Sharing database were included. Quality-of-life was approximated by Karnofsky Performance Status scores 1-year post-transplant. Total transplantation encounter and 1-year follow-up costs accrued by our academic center for patients listed from 2018 to 2021 were obtained. Cost-effectiveness was calculated by evaluating the number of patients attaining various Karnofsky scores relative to cost. RESULTS: Of the 13 930 adult patients who underwent lung transplant in the United Network for Organ Sharing database, 13 477 (96.7%) used static cold storage and 453 (3.3%) used ex vivo lung perfusion, compared to 30/58 (51.7%) and 28/58 (48.3%), respectively, at our center. Compared to static cold storage, median total costs at 1 year were higher for ex vivo lung perfusion ($918 000 vs. $516 000; p = 0.007) along with the cost of living 1 year with a Karnofsky functional status of 100 after transplant ($1 290 000 vs. $841 000). In simulated scenarios, each Karnofsky-adjusted life year gained by ex vivo lung perfusion was 1.00-1.72 times more expensive. CONCLUSIONS: Portable ex vivo lung perfusion is not currently cost-effective at a low-volume transplant centers in the USA, being 1.53 times more expensive per Karnofsky-adjusted life year. Improving donor lung and/or recipient biology during ex vivo lung perfusion may improve its utility for routine transplantation.

Laryngeal and pharyngeal actinomycosis: a systematic review and report of 3 cases.

INTRODUCTION: Actinomycosis is a granulomatous infection that rarely involves the larynx or pharynx. Three cases of actinomycosis of the larynx or pharynx from our institution were reviewed and a systematic literature review was performed to better define surgical management, antibiotic therapy, risk factors, and incidence of recurrence or complications. MATERIALS AND METHODS: PubMed/Medline, Cochrane, Embase, and Google Scholar were searched on November 30, 2021 using the terms "laryngeal actinomycosis", "pharyngeal actinomycosis", "actinomycosis AND larynx", and "actinomycosis AND pharynx." Articles which did not describe appropriate sites or were non-English were excluded. Results were collected for demographic information, site(s) of infection, comorbidities, lesion characteristics and treatments. RESULTS: Along with three cases reported from our institution, 40 unique cases were reviewed from 37 studies for a total of 43 patients (Table 1). 34 (81.0 %) of the patients were male with the highest incidence of infection in the seventh decade (54.8 %). The most common site for the infection was the larynx (69.0 %) followed by the pharynx (16.7 %). Risk factors included a history of radiation therapy, immunosuppression, inhalational irritant, and diabetes (Table 3). The duration of antibiotic therapy varied greatly, from one month to one year and total follow up ranged from 1 month to 2.5 years (Table 1). CONCLUSIONS: A comprehensive review of the literature on pharyngolaryngeal actinomycosis shows that this infection has increased prevalence within the head and neck cancer patient population. Similar to cervicofacial actinomycosis, these atypical sites have shown favorable responses to extended antibiotic therapy and generally do not require aggressive surgical management.

Boholamide A, an APD-Class, Hypoxia-Selective Cyclodepsipeptide.

Calcium homeostasis is implicated in some cancers, leading to the possibility that selective control of calcium might lead to new cancer drugs. On the basis of this idea, we designed an assay using a glioblastoma cell line and screened a collection of 1000 unique bacterial extracts. Isolation of the active compound from a hit extract led to the identification of boholamide A (1), a 4-amido-2,4-pentadieneoate (APD)-class peptide. Boholamide A (1) applied in the nanomolar range induces an immediate influx of Ca2+ in glioblastoma and neuronal cells. APD-class natural products are hypoxia-selective cytotoxins that primarily target mitochondria. Like other APD-containing compounds, 1 is hypoxia selective. Since APD natural products have received significant interest as potential chemotherapeutic agents, 1 provides a novel APD scaffold for the development of new anticancer compounds.

Anatomic Considerations for Injection of the Lateral Atlanto-Axial Joint.

OBJECTIVE: We aimed to define the potential complications of intra-articular steroid injections into the lateral C1-2 articulations and safety margins to the relevant structures. METHODS: A total of 488 contrast-enhanced computed tomography angiogram (CTA) "arch to vertex" studies were retrospectively reviewed for theoretical intersection of the vertebral artery or thecal sac and distance of the named structures from the anticipated/theoretical trajectory of injection into the lateral C1-C2 joint. RESULTS: Patients were 60.4±15.8 years old and 55.5% male. In total, seven vertebral arteries and 11 thecal sac theoretical intersections were found. In cases without a direct intersection, the distance from the trajectory (range) was 0.71±0.18 (0.22-1.44) cm to the vertebral artery and 0.6±0.22 (0.14-1.8) cm to the thecal sac. CONCLUSIONS: Although injection of steroid into the lateral C1-C2 articulation for pain management has historically been reported to carry risk of severe complications due to close proximity and location variability of surrounding structures, our study quantifies the potential risk of such injections. Further, our analysis suggests that preprocedural imaging should be considered.

The prognostic value and pathophysiologic significance of three-dimensional fluid-attenuated inversion recovery (3D-FLAIR) magnetic resonance imaging in idiopathic sudden sensorineural hearing loss: A systematic review and meta-analysis.

BACKGROUND: The underlying pathophysiology of idiopathic sudden sensorineural hearing loss (ISSNHL) is still unknown. However, an increasing number of observational studies report intralabyrinthine signal alterations in patients with ISSNHL using three-dimensional fluid-attenuated inversion recovery (3D-FLAIR) magnetic resonance imaging (MRI). These findings warrant a meta-analysis. OBJECTIVE OF REVIEW: To conduct a meta-analysis assessing the value of 3D-FLAIR MRI in identifying possible underlying labyrinthine pathophysiologic mechanisms and prognostication in patients with ISSNHL. SEARCH STRATEGY: Two reviewers independently searched the Pubmed, Embase and Cochrane Library from inception until October 10, 2018 and evaluated eligibility based on titles and abstracts of all retrieved studies. All studies reporting on 3D-FLAIR imaging in ISSNHL were included. Subsequently, the full text of eligible studies were evaluated. EVALUATION METHOD: Adhering to the MOOSE guideline, two independent reviewers extracted data, assessed risk of bias and evaluated the relevance and quality of evidence. Data on the number of patients and events were extracted and hearing levels were converted to standardised mean differences (SMD) for conducting meta-analyses. Random effects models for meta-analyses were applied. RESULTS: Eight observational studies met our inclusion criteria (n = 638 patients). In 29%, high signal intensity was found on 3D-FLAIR imaging, suggesting labyrinthine pathology (labyrinthitis [79%], intralabyrinthine haemorrhage [21%]). High signal intensity on 3D-FLAIR was associated with poorer hearing (SMD: 14 dB, 95% CI 5.67-22.94) and vertigo (RR: 1.92, 95% CI 1.16-3.17) at baseline. Multivariate analyses demonstrated that patients with high 3D-FLAIR signal intensity had 21 dB lower final hearing pure-tone averages (SMD: 21 dB, 95% CI 9.08-33.24). CONCLUSIONS: Three-dimensional fluid-attenuated inversion recovery MR imaging can identify an underlying labyrinthine condition in up to 29% of patients with sudden hearing loss in whom previously no cause could be identified. Their final pure-tone averages are more than 20 dB worse than 3D-FLAIR-negative patients, suggesting more severe labyrinthine damage. Findings such as these may contribute to our understanding of pathophysiologic mechanisms of ISSNHL.

Lichen planus and lichenoid dermatoses: Conventional and emerging therapeutic strategies.

Having reviewed the diverse clinical subtypes of lichenoid disease and the postulated molecular basis thereof in the first article in this 2-part continuing medical education series, we discuss herein the existing and emerging treatment strategies in the most common clinical forms of lichenoid inflammation and provide an overview of their pharmacodynamics and evidence base. The scope of this review is not to exhaustively discuss treatment modalities for all lichenoid variants discussed in the previous article of this series. Instead, the focus will be on frequently encountered subtypes of lichen planus and on linking mechanisms of disease with mechanisms of drug action. Future directions and potential avenues for translational research will also be discussed.

Lichen planus and lichenoid dermatoses: Clinical overview and molecular basis.

Deriving from the Greek word λειχήν for "tree moss" and the Latin word planus for "planar," lichen planus is a relatively uncommon and heterogeneous cutaneous disorder that typically develops in middle-aged adults. Despite the significant clinical burden associated with the disorder, little well-conducted molecular research has been undertaken, possibly because of heterogeneity impeding consistent and confident phenotyping. The multiple variants of lichenoid disease bear overlapping clinical and pathologic features despite manifesting as distinct clinical disorders. The first article in this 2-part continuing medical education series provides a comprehensive overview of the clinical and pathologic characteristics of cutaneous lichenoid dermatoses and links these manifestations to recent advances in our understanding of the underlying pathobiology of such diseases.

Permanent alopecia in patients with breast cancer after taxane chemotherapy and adjuvant hormonal therapy: Clinicopathologic findings in a cohort of 10 patients.

BACKGROUND: Anagen effluvium with reversible scalp alopecia is a known side effect of chemotherapy. However, there are an increasing number of reports in the literature documenting permanent alopecia in patients treated with taxanes. OBJECTIVE: We sought to describe the clinicopathologic features in breast cancer patients who underwent treatment with taxanes and adjuvant hormonal chemotherapy. METHODS: We reviewed the clinical and histopathologic information of a cohort of 10 patients treated with taxanes and adjuvant hormonal chemotherapy. RESULTS: We have observed 3 types of clinical patterns of alopecia (types A, B, and C), and have validated the histopathologic features showing alopecia areata-like and female pattern hair loss. LIMITATIONS: The study was based on a small sample size and retrospective retrieval of clinical information and histopathologic review of posttreatment slides. CONCLUSIONS: We hypothesize a clinicopathologic model of hair follicle cycle disruption in response to the chemoinflammatory and hormonal insults to the hair follicles resulting in permanent alopecia. Clinicopathologic correlation is paramount to the understanding of the morphobiologic pathways in chemotherapy-induced alopecia caused by taxanes and adjuvant hormonal treatment.

Frontal fibrosing alopecia: reflections and hypotheses on aetiology and pathogenesis.

Since first described by Kossard in 1994, frontal fibrosing alopecia (FFA) has been something of an enigma. The clinical heterogeneity of FFA, its apparent rarity and investigators' suboptimal access to phenotypically consistent patient cohorts may all have had a negative impact on delineating disease pathogenesis. Moreover, there is a relative paucity of epidemiological, interventional and basic research studies, and there have been no advances in translational therapeutics, unlike for other inflammatory dermatoses, such as alopecia areata (AA). Dermatologists anecdotally describe an increasing incidence in FFA over the last decade, which has led to the notion that the disorder may be induced by unknown environmental triggers. On the other hand, segregation of FFA in some families lends support to an unexplored genetic element implicated in disease pathogenesis. We herein review what is known about the pathobiology of FFA and formulate working hypotheses to advance insight into this intriguing hair disorder.

Hair Follicle Miniaturization in a Woolly Hair Nevus: A Novel "Root" Perspective for a Mosaic Hair Disorder.

Woolly hair nevus is a mosaic disorder characterized by unruly, tightly curled hair in a circumscribed area of the scalp. This condition may be associated with epidermal nevi. We describe an 11-year-old boy who initially presented with multiple patches of woolly hair and with epidermal nevi on his left cheek and back. He had no nail, teeth, eye, or cardiac abnormalities. Analysis of plucked hairs from patches of woolly hair showed twisting of the hair shaft and an abnormal hair cuticle. Histopathology of a woolly hair patch showed diffuse hair follicle miniaturization with increased vellus hairs.

Severe penile necrotizing infection with subsequent glandular gangrene after distal corporal aspiration and irrigation procedure for ischemic priapism.

Necrotizing penile infection following ischemic priapism takedown is a rare complication. A 60-year-old man presented with 1-week history of green and pink purulent discharge, penile swelling, and inability to void. Computed tomography demonstrated gas and fluid accumulation within the corporal bodies, suggestive for bilateral penile necrotizing corporal infection with possibility of intra-corporal abscesses. The patient underwent extensive serial surgical debridement of the penile and corporal tissues which was complicated with poly-microbial tissue cultures, growing Candida albicans and Staphylococcus epidermidis. Despite maximal penile drainage, glans penis gangrene was developed to level of mid penile shaft necessitating a partial penectomy.

Workforce diversity in cardiothoracic surgery: An examination of recent demographic changes and the training pathway.

INTRODUCTION: The purpose of our study was to examine changes in the demographic makeup of resident physicians in integrated 6-year cardiothoracic surgery and traditional thoracic surgery residency programs from 2013 to 2022 compared with other surgical subspecialties and determine potential leaks in the training pathway. METHODS: Data from US Graduate Medical Education reports from 2013 to 2022 and medical student enrollment data from the Association of American Medical Colleges were obtained. Average percentages of women and underrepresented minorities were calculated in 2 5-year intervals: 2013 to 2017 and 2018 to 2022. Average percentages of women, Black, and Hispanic medical students and residents were calculated for the 2019 to 2022 period. Pearson χ2 tests were conducted to determine significant differences in proportions of women, Black/African American, and Hispanic trainees across time (α = 0.05). RESULTS: Thoracic surgery and I6 residents saw a significant increase in the proportion of women trainees across the 2 time periods (19.9% (210 out of 1055) to 24.6% (287 out of 1169) (P < .01) and 24.1% (143 out of 592) to 28.9% (330 out of 1142) (P < .05)), respectively. There was no significant change in the proportion of Black and Hispanic trainees in thoracic surgery fellowship or integrated 6-year cardiothoracic residency programs. Hispanic trainees were the only group whose proportion of cardiothoracic surgery trainees was not significantly lower than their medical school proportion. Women and Black trainees had significantly lower proportions of thoracic surgery residents and integrated 6-year cardiothoracic residency program residents than their proportions in medical school (P < .01). CONCLUSIONS: Cardiothoracic surgery has not significantly increased the number of Black and Hispanic trainees during the past decade. The lower proportion of Blacks and women in thoracic surgery residency and fellowship programs compared with their proportion in medical schools is concerning and is an opportunity for intervention.

Rapid Identification of Suspected Drug Overdose Deaths by Death Investigators, New Jersey, 2020.

OBJECTIVE: While the number of overdoses in the United States continues to increase, lags in data availability have undermined efforts to monitor, respond to, and prevent drug overdose deaths. We examined the performance of a single-item mandatory radio button implemented into a statewide medical examiner database to identify suspected drug overdose deaths in near-real time. MATERIALS AND METHODS: The New Jersey Office of the Chief State Medical Examiner operates a statewide mandated case management data system to document deaths that fall under the jurisdiction of a medical examiner office. In 2018, the New Jersey Office of the Chief State Medical Examiner implemented a radio button into the case management data system that requires investigators to report whether a death is a suspected drug overdose death. We examined the performance of this tool by comparing confirmed drug overdose deaths in New Jersey during 2020 with suspected drug overdose deaths identified by investigators using the radio button. To measure performance, we calculated sensitivity, specificity, positive predictive value, negative predictive value, and false-positive and false-negative error rates. RESULTS: During 2020, New Jersey medical examiners investigated 26 527 deaths: 2952 were confirmed by the state medical examiner as a drug overdose death and 3050 were identified by investigators using the radio button as a suspected drug overdose death. Sensitivity was calculated as 96.1% (2837/2952), specificity as 99.1% (23 362/23 575), positive predictive value as 93.0% (2837/3050), negative predictive value as 99.5% (23 362/23 477), false-positive error rate as 7.0% (213/3050), and false-negative error rate as 3.9% (115/2952). PRACTICE IMPLICATIONS: Implementation of a radio button into death investigation databases provides a simple and accurate method for identifying and tracking drug overdose deaths in near-real time.

A Social Media Quality Review of Popular Sinusitis Videos on TikTok.

OBJECTIVE: Social media may inform health care decisions among younger patient populations. TikTok is a social media platform that allows users to post short-form videos. This study aimed to assess the quality of sinusitis-related videos on TikTok. STUDY DESIGN: We searched TikTok on January 29, 2023, for sinusitis-related hashtags: #sinusitis, #sinus, #sinusinfection. SETTING: Internet. METHODS: The number of views/shares per day, uploader type (nonmedical influencer, lay individual, and medical professional) content categories (medical advice, marketing, comedy, and lifestyle/acceptability), and content type (educational vs factual) were collected. The Patient Education Materials Assessment Tool for Audiovisual Material and Journal of the American Medical Association criteria score was used to measure understandability, actionability, and reliability. The Global Quality Scale (GQS) was used to evaluate the quality of videos; the harm/benefit score was used to evaluate causative effects. Analyses were performed using analysis of variance (α = .05). RESULTS: There were 221 videos identified, which garnered over 300 million views and 1 million shares. Almost half of the videos were published by nonmedical influencers. When controlling for covariates, nonmedical influencers and lay uploaders were more likely to have harmful harm/benefit scores, less understandable videos, and lower GQS scores compared to medical professionals. Less than half of videos posted by nonmedical influencers categorized as educational were factual (46.7%); lay individuals and medical professionals had higher rates of factual educational content (79.9% and 83.7%, respectively). CONCLUSION: Most nonmedical influencer-posted TikTok videos about sinusitis are inaccurate, despite being portrayed as medical advice/educational. Rhinologists must find modern ways to disseminate true disease-related content via social media to combat medical misinformation.

Socioeconomic status is associated with pediatric adenotonsillectomy outcomes: A single institution study.

OBJECTIVE: Our institution serves a diverse patient population across a large metropolitan city. Literature has shown pediatric otolaryngology patients with lower socioeconomic status (SES) have higher rates of sleep-disordered breathing, delays in treatment time, and greater risks of complications post-tonsillectomy. This study aims to examine the effects of SES on adenotonsillectomy outcomes performed at our institution. STUDY DESIGN: A retrospective chart review including 1560 pediatric patients (ages 0-18) who underwent adenotonsillectomy between January 2015 and December 2020. SETTING: Large metropolitan hospital, level 1 trauma center. METHODS: Outcome variables included postoperative hospital admission, phone calls, 30-day follow-up, and persistent obstructive sleep apnea (OSA). Descriptive statistics using Wilcoxon Signed Rank Tests and univariate and multivariate logistic regression modeling were used to determine statistically significant covariates at α = 0.05. RESULTS: The cohort included Non-Hispanic White (n = 488, 31 %), Non-Hispanic Black (n = 801, 51 %), Hispanic (n = 210, 13 %), and other (n = 61, 4 %) groups. Using multivariate regression, privately insured patients were less likely to have moderate-to-severe OSA before surgery (0.65 95 % CI 0.45, 0.93 p = 0.017) and be admitted postoperatively (0.73, 0.55-0.96, p < 0.01), while more likely to have postoperative follow-up phone calls (1.57, 1.19-2.09, p < 0.01) and visits (1.53, 1.22-1.92, p < 0.01). Increased income was associated with decreased rehospitalizations within three months of surgery (0.98, 0.97-1.00, p < 0.01). CONCLUSION: This study suggests SES significantly affects adenotonsillectomy outcomes. Further studies are warranted to provide better care for all pediatric patients.

"Does My Kid Have an Ear Infection?" An Analysis of Pediatric Acute Otitis Media Videos on TikTok.

INTRODUCTION: With the rise of social media, online platforms have become a common way to access healthcare information. This study examines the quality of pediatric acute otitis media (AOM) videos on TikTok, a popular short-form video social media platform. METHODS: A TikTok search was conducted between 8/18 and 8/19/2023 using pediatric AOM hashtags: #pediatric acute otitis media management, #kid ear infections remedy, #child ear infections treatment, and #kid ear infection. Data collected include number of views/shares per day, uploader type (nonmedical influencer, lay individual, and medical professional), and content categories. The Patient Education Materials Assessment Tool for Audiovisual Material (PEMAT-AV) and DISCERN questionnaire measured understandability, actionability, and quality of videos. Multivariable linear regression models were used (significance set at ≤0.05). RESULTS: Of 166 videos, 38.6% (64) of uploaders were medical professionals, and 32.5% (54) were nonmedical influencers. Nonmedical influencer videos were viewed and shared significantly more than those by medical professionals (p < 0.05). Controlling for covariates, physicians were more likely to produce more beneficial and higher quality videos as compared with nonmedical influencers (ß = 2.4 and 1.3, p < 0.01, respectively). However, physicians did not have significantly different ratings for understandability compared with nonmedical influencers (ß = 0.45, p > 0.05). DISCUSSION: AOM content on TikTok is often geared toward caretakers of symptomatic children. Although physician-created AOM content was significantly higher quality, these videos reached a statistically smaller audience than those from nonmedical influencers. Addressing misinformation on social media platforms requires physicians to reach larger audiences by producing more actionable and understandable content. LEVEL OF EVIDENCE: NA Laryngoscope, 2024.