A quiet place: The impact of the word "quiet" on clinical workload.

Purpose: This study aimed to determine the impact of uttering the word "quiet" on clinical workload during the overnight otolaryngology call shift and understand the factors contributing to resident busyness. Materials and Methods: A multicenter, single-blind, randomized-controlled trial was conducted. A total of 80 overnight call shifts covered by a pool of 10 residents were randomized to the quiet or to the control group. At the start of shift, residents were asked to state aloud, "Today will be a quiet night" (quiet group) or "Today will be a good night" (control group). Clinical workload, as measured by number of consults, was the primary outcome. Secondary measures included number of sign-out tasks, unplanned inpatient and operating room visits, number of phone calls and hours of sleep, and self-perceived busyness. Results: There was no difference in the number of total (P = 0.23), nonurgent (P = 0.18), and urgent (P = 0.18) consults. Tasks at signout, total phone calls, unplanned inpatient visits, and unplanned operating room visits did not differ between the control and quiet groups. While there were more unplanned operating room visits in the quiet group (29, 80.6%) compared to the control group (34, 94.4%), this was not found to be significant (P = 0.07). The majority of residents reported feeling "not busy" during control nights (18, 50.0%) compared to feeling "somewhat busy" during quiet nights (17, 47.2%; P = 0.42). Conclusion: Contrary to popular belief, there is no clear evidence that uttering the word "quiet" significantly increases clinical workload.

Thyroid Lobectomy for T1 Papillary Thyroid Carcinoma in Pediatric Patients.

Importance: The current recommendation for pediatric patients with papillary thyroid cancer (PTC) is a total thyroidectomy. This recommendation applies to all stages of PTC, including papillary thyroid microcarcinoma (≤1 cm, T1a) tumors. Objective: To evaluate the characteristics of American Joint Committee on Cancer T1 PTC tumors in a large pediatric population and to identify a subgroup of patients who may benefit from a thyroid lobectomy instead of a total thyroidectomy. Design, Setting, and Participants: This retrospective cohort study was conducted from January 1, 2009, to May 31, 2020. The study took place at a tertiary care medical center and included 102 patients who were surgically treated for T1 PTC: 52 with stage T1a (≤1 cm) tumors and 50 with stage T1b (>1 cm but ≤2 cm) tumors. Main Outcomes and Measures: Primary outcomes included the presence of bilateral disease and lymph node metastasis. Results: A total of 102 patients (mean age, 15.3 years [range, 9.7-18.9 years]; 84 girls [82.4%]) were included in the analysis. Among 52 patients with T1a tumors, 10 (19.2%) had bilateral disease, and 15 (28.8%) had central neck lymph node (N1a) metastasis. Among 50 patients with T1b tumors, 10 (20%) had bilateral and 13 (26%) had N1a disease. Of those with T1a, unilateral multifocality was associated with bilateral disease (odds ratio [OR], 2.1; 95% CI, 1.3-3.4) and N1a disease (OR, 5.1; 95% CI, 1.5-17.6). Both N1a disease (OR, 20.0; 95% CI, 3.5-115.0) and ≥4 positive lymph nodes (OR, 8.6; 95% CI, 1.2-60.9) were associated with bilateral disease. In patients with no pathologic evidence of lymph node metastasis (N0), there was a 95% rate of unilateral PTC. In patients with T1b tumors, unilateral multifocality was also associated with bilateral disease (OR, 1.8; 95% CI, 1.3-2.7). Patients with T1b tumors had an increased risk of lateral (N1b) neck lymph node metastasis when compared with those with T1a tumors (OR, 3.7; 95% CI, 1.0-14.5). Conclusions and Relevance: The findings of this cohort study suggest that, in patients with unifocal T1a PTC without clinically evident nodal disease on preoperative ultrasonography, a thyroid lobectomy and central neck dissection may be considered. If there is no evidence of unilateral multifocality or if there are fewer than 4 positive lymph nodes on postoperative pathology, then close observation may be considered. These findings have substantial clinical implications and may result in practice changes regarding the extent of thyroid surgery on low-stage pediatric PTC.

Orbital Floor Reconstruction: A Comparison of Outcomes between Absorbable and Permanent Implant Systems.

There are distinct advantages and disadvantages between bioresorbable and permanent implants in orbital floor reconstruction. Our aim was to compare the outcomes and complications of resorbable implants and permanent implants in orbital floor fracture repair. A retrospective chart review was performed on all patients who underwent orbital floor fracture repair at a rural, tertiary care center from 2011 through 2016. Main outcome measures included improvement in diplopia, ocular motility, enophthalmos, hypoglobus, and infraorbital nerve sensation. A total of 87 patients underwent orbital floor reconstruction. After exclusion criteria were applied, 22 patients were included in the absorbable implant cohort, and 20 patients in the nonabsorbable implant cohort. All absorbable implants were composed of poly L-lactide/poly glycolide/poly D-lactide (PLL/PG/PDL), and nonabsorbable implants included both titanium/porous polyethylene (Ti/PPE) composite and titanium (Ti) mesh. Mean fracture surface area was 2.1 cm 2 (standard deviation [SD]: ± 0.9 cm 2 , range: 0.4-3.6 cm 2 ) for the absorbable implant group and 2.3 cm 2 (SD: ± 1.1 cm 2 , range: 0.6-4.4 cm 2 ) for the nonabsorbable implant group ( p = 0.58). There were no significant differences in diplopia, ocular motility, enophthalmos, hypoglobus, and infraorbital nerve sensation between absorbable and nonabsorbable implant groups. The mean follow-up time for absorbable and nonabsorbable implant groups was 622 (SD ± 313) and 578 (SD ± 151) days respectively ( p = 0.57). For moderate-size orbital floor fracture repairs, there is no difference in outcomes between absorbable implants consisting of PLL/PG/PDL and nonabsorbable implants consisting of Ti mesh or Ti/PPE combination.

Expanding Access: Cost-effectiveness of Cochlear Implantation and Deaf Education in Asia.

OBJECTIVE: To determine the cost-effectiveness of cochlear implantation (CI) with mainstream education and deaf education with sign language for treatment of children with profound sensorineural hearing loss in low- and lower-middle income countries in Asia. STUDY DESIGN: Cost-effectiveness analysis. SETTING: Bangladesh, Cambodia, India, Indonesia, Nepal, Pakistan, Philippines, and Sri Lanka participated in the study. SUBJECTS AND METHODS: Costs were obtained from experts in each country with known costs and published data, with estimation when necessary. A disability-adjusted life-years model was applied with 3% discounting and 10-year length of analysis. A sensitivity analysis was performed to evaluate the effect of device cost, professional salaries, annual number of implants, and probability of device failure. Cost-effectiveness was determined with the World Health Organization standard of cost-effectiveness ratio per gross domestic product (CER/GDP) per capita <3. RESULTS: Deaf education was cost-effective in all countries except Nepal (CER/GDP, 3.59). CI was cost-effective in all countries except Nepal (CER/GDP, 6.38) and Pakistan (CER/GDP, 3.14)-the latter of which reached borderline cost-effectiveness in the sensitivity analysis (minimum, maximum: 2.94, 3.39). CONCLUSION: Deaf education and CI are largely cost-effective in participating Asian countries. Variation in CI maintenance and education-related costs may contribute to the range of cost-effectiveness ratios observed in this study.

Prehospital Predictors of Emergent Intervention After Helicopter Transfer for Spontaneous Intraparenchymal Hemorrhage.

OBJECTIVE: Helicopter transport may shorten transportation times for emergent neurosurgical intervention. The usefulness of helicopter transport after spontaneous intraparenchymal hemorrhage is not well studied. This study seeks to clarify factors that are associated with urgent surgical intervention in patients with spontaneous intracerebral hemorrhage following helicopter transport. METHODS: Records were reviewed for patients with spontaneous intraparenchymal hemorrhage transported by helicopter to Dartmouth-Hitchcock Medical Center between January 2008 and December 2011. Records were evaluated for factors associated with emergent tertiary-level care intervention during the first 24 hours of admission. RESULTS: A total of 107 patients met inclusion criteria, with a mean age of 67.2 years. At presentation, 79 (75.24%) were hypertensive, 22 (21.57%) had an increased international normalized ratio, and 47 (45.19%) were intubated. Thirty-three patients (30.8%) underwent 1 or more neurosurgical interventions within 24 hours of arrival, with an additional 6 (5.6%) patients undergoing neurosurgical intervention after 24 hours after admission. On univariate analysis, age, Glasgow Coma Scale (GCS) score, and clot volume were significant predictors of neurosurgical intervention within 24 hours of interfacility helicopter transport. A lobar clot, presence of intraventricular hemorrhage, and presence of >1 cm of midline shift were also associated with neurosurgical intervention within 24 hours. On multivariate analysis, younger age, GCS score of 3-8, and lobar hemorrhage were independent predictors of neurosurgical intervention within 24 hours. CONCLUSIONS: Two thirds of patients did not undergo any surgical intervention during the first 24 hours of admission after interfacility helicopter transfer. Factors associated with urgent neurosurgical intervention included younger age, low GCS score, and presence of lobar hemorrhage.

Diagnostic Value of Lingual Tonsillectomy in Unknown Primary Head and Neck Carcinoma Identification After a Negative Clinical Workup and Positron Emission Tomography-Computed Tomography.

OBJECTIVE: Diagnostic rates of unknown primary head and neck carcinoma (UPHNC) using lingual tonsillectomy (LT) are highly variable. This study sought to determine the diagnostic value of LT in UPHNC identification using strict inclusion criteria and definitions to produce a more accurate estimate of diagnosis rate. METHODS: In this retrospective chart review, records of patients who underwent LT for UPHNC were reviewed. Inclusion criteria included absence of suspicious findings on physical exam and positron emission tomography-computed tomography as well as negative biopsies after panendoscopy and palatine tonsillectomy. Following inclusion criteria, 16 patients were reviewed. A systematic literature review on LT for the workup of CUP was also performed. RESULTS: LT was performed using transoral robotic surgery (TORS), transoral laser microsurgery (TLM), or transoral microsurgery with cautery (TMC). Following LT, primary tumor was identified in 4 patients out of 16. Detection rate by technique was 1/6, 2/7, and 1/3 for TORS, TLM, and TMC respectively. Postoperative bleeding occurred in three patients (19%); however, this was not related to the LT. Following literature review, 12 studies were identified; however, only 3 had enough data to compare against. All three studies had a cohort with suspicious findings on clinical exam. A total of 34 patients had a negative workup, with no suspicious findings on clinical exam and subsequently received an LT. CONCLUSION: This study suggests that LT should be considered initially in the diagnostic algorithm for UPHNC. This study can increase the patient size in this cohort by approximately 47%.