Otolaryngology resident familiarity with surgical instruments and preoperative setup: A pilot study.

OBJECTIVE: This study was designed to determine otolaryngology (ORL) residents' ability to prepare the operating room independently for ORL surgical cases and their familiarity with ORL surgical instruments and related equipment. METHODS: A 24-question, one-time, anonymous survey was distributed to otolaryngology-head and neck surgery program directors for distribution among their residents in the United States in November 2022. Residents in every post-graduate year were surveyed. Spearman's ranked correlation and Mann-Whitney U test were used. RESULTS: The response rate among program directors was 9.5 % (11/116 programs), while the response rate among residents was 51.5 % (88/171 residents). A total of 88 survey responses were completed. 61 % of ORL residents who responded were able to name most instruments used in surgical cases. The most recognized surgical instruments by ORL residents were microdebrider (99 %) and alligator forceps (98 %); the least recognized were bellucci micro scissors (72 %) and pituitary forceps (52 %); and all instruments except the microdebrider showed significantly increased recognition with increasing post graduate training year (PGY), p ≤ 0.05. ORL residents were most able to set up independently the electrocautery (77 %) and laryngoscope suspension (73 %), while they were least able to set up the robot laser (6.8 %) and coblator (26 %) independently. All instruments showed significant positive correlations with increasing PGY; the strongest correlation was found in laryngoscope suspension, r = 0.74. 48 % of ORL residents reported that there were times when surgical techs and nurses were not available. Only 54 % of ORL residents reported being able to set up instruments when alone in the operating room, including 77.8 % of PGY-5 residents. Only 8 % of residents reported receiving education related to surgical instruments from their residency program, while 85 % thought that ORL residencies should have courses or educational materials about surgical instruments. CONCLUSION: ORL residents' familiarity with surgical instruments and preoperative setup improved throughout their training. However, specific instruments had much lower recognition than others and a lower ability for independent setup. Nearly half of ORL residents reported being unable to set up surgical instruments in the absence of surgical staff. Implementation of surgical instrument education may improve these deficiencies.

An in situ inferior vena cava ligation-stenosis model to study thrombin generation rates with flow.

BACKGROUND: Blood flow-induced shear stress affects platelet participation in coagulation and thrombin generation. We aimed to develop an in vivo model to characterize thrombin generation rates under flow. METHODS: An in situ inferior vena cava (IVC) ligation-stenosis model was established using C57BL/6 mice. Wild type C57BL/6 mice were fed normal chow diet for two weeks before experiments. On the day of experiments, mice were anesthetized, followed by an incision through the abdominal skin to expose the IVC, which was then ligated (followed by reperfusion through a stenosis for up to 2 h). IVC blood flow rate was monitored using a Transonic ultrasound flow meter. In sham animals, the IVC was exposed following the same procedure, but no ligation was applied. Thrombin generation following IVC ligation was estimated by measuring mouse plasma prothrombin fragment 1-2 concentration. Mouse plasma factor Va concentration was measured using phospholipids and a modified prothrombinase assay. Blood vessel histomorphology, vascular wall ICAM-1, von Willebrand Factor, tissue factor, and PECAM-1 expression were measured using immunofluorescence microscopy. RESULTS: IVC blood flow rate increased immediately following ligation and stenosis formation. Sizable clots formed in mouse IVC following ligation and stenosis formation. Both plasma factor Va and prothrombin fragment 1-2 concentration reduced significantly following IVC ligation/stenosis, while no changes were observed with ICAM-1, von Willebrand Factor, tissue factor and PECAM-1 expression. CONCLUSION: Clot formation was successful. However, the prothrombin-thrombin conversion rate constant in vivo cannot be determined as local thrombin and FVa concentration (at the injury site) cannot be accurately measured. Modification to the animal model is needed to further the investigation.

How Do Patients With Predominant Neck Pain Improve After Anterior Cervical Discectomy and Fusion for Cervical Radiculopathy?

BACKGROUND: The presence of predominant pain in the arm vs the neck as a predictor of postoperative outcomes after anterior cervical discectomy and fusion (ACDF) has been seldom reported; therefore, the purpose of this study was to determine whether patients with predominant neck pain improve after surgery compared to patients with predominant arm pain or those with mixed symptoms in patients undergoing ACDF for radiculopathy. METHODS: A retrospective cohort study was conducted on patients who underwent ACDF at a single center from 2016 to 2018. Patients were split into groups based on preoperative neck and arm pain scores: neck (N) pain dominant group (visual analog scale [VAS] neck ≥ VAS arm by 1.0 point); neutral group (VAS neck < VAS arm by 1.0 point); or arm (A) pain dominant group (VAS arm ≥ VAS neck by 1.0 point), using a threshold difference of 1.0 point. Subsequently, individuals were substratified into 2 groups based on the arm to neck pain ratio (ANR): non-arm pain dominant defined as ANR ≤1.0 and arm pain dominant (APD) defined as ANR >1.0. Patient-reported outcome measurements including Neck Disability Index (NDI), Physical Component Score-12, and Mental Component Score (MCS-12) were compared between groups. RESULTS: No significant differences between groups when stratifying patients using a threshold difference of 1.0 point. When stratifying patients using the ANR, those in the APD group had significantly higher postoperative MCS-12 (P = 0.008) and NDI (P = 0.011) scores. In addition, the APD group showed a greater magnitude of improvement for MCS-12 and NDI scores (P = 0.043 and P = 0.038, respectively). Multiple linear regression showed that the A and the APD groups were both independent predictors of improvement in NDI. CONCLUSION: Patients with dominant arm pain showed significantly greater improvement in terms of MCS-12 and NDI scores compared to patients with dominant neck pain. CLINICAL RELEVANCE: To compare the impact of ACDF on arm and neck pain in the context of cervical radiculopathy using patient-reported outcome measures as an objective measurement.

High Speed Video Observations of Vocal Fold Kinematics While Playing a Clarinet.

INTRODUCTION: In this pilot study, flexible high-speed video (HSV) technology with synchronized audio is used to visualize vocal fold behavior in a wind instrumentalist. Specifically, this study aims to contribute to describing the vocal fold behavior of a professional clarinet musician playing varying tones and melodies. METHOD: Vocal folds of a healthy 26-year-old professional clarinet musician were recorded utilizing a HSV camera coupled to a flexible endoscope, which allowed the synchronous recording of audio with vocal fold movement at the onset, playing, and offset of playing. Two raters experienced with analyzing vocal folds described vocal fold motion of each sample. Samples were processed through a software model to determine the vocal fold movement relative to their position at rest. Digital kymograms (DKGs) were additionally obtained to visualize vocal fold micromovements throughout each sample. RESULTS: At the onset of playing, the raters observed the vocal folds moving to a paramedian position. Vocal fold adduction varied according to the task performed and ranged from 58% to 77% of the original resting glottis width. The calculated changes in glottis width and DKGs were consistent with the descriptions by the raters. CONCLUSION: This study demonstrates the utility of flexible HSV in observing vocal fold motion before, during, and after events other than sustained phonation. The incomplete adducted vocal fold postures observed while playing the clarinet not only differ from phonation but also differ depending on task. These various postures may contribute to voice fatigue in wind instrumentalists or to various disorders experienced during their careers.

Do Patients with Back Pain-Dominant Symptoms Improve After Lumbar Surgery for Radiculopathy or Claudication?

BACKGROUND: Currently, few studies have examined whether patients with back or leg pain-predominant symptoms fare better clinically after lumbar spine surgery; therefore, the purpose of this study was to determine whether patients with back pain-dominant symptoms improved to a similar degree as patients with mixed or leg pain-dominant symptoms after lumbar surgery. METHODS: A retrospective cohort study was conducted at a single academic center, in which patients were stratified into three groups: (1) back pain-dominant group (B) (visual analog score [VAS] back - VAS leg ≥ 1.0 point), (2) neutral group (N) (VAS back - VAS leg < 1.0 point), or (3) leg pain-dominant group (L) (VAS leg - VAS back ≥ 1.0 point), using a VAS threshold difference of 1.0 point. As a secondary analysis, the VAS leg-to-back pain (LBR) ratio was used to further stratify patients: (1) nonleg pain-dominant (NLPD) group (LBR ≤ 1.0) or (2) leg pain-dominant (LPD) group (LBR > 1.0). Patient outcomes, including physical component score of the short form-12 survey (PCS-12), mental component score of the short form-12 survey (MCS-12), and Oswestry Disability Index (ODI), were identified and compared between groups using univariate and multivariate analysis. RESULTS: There were no significant differences in preoperative, postoperative, or delta scores for PCS-12 or ODI scores between groups. In patients undergoing decompression surgery, those with back pain-dominant or mixed symptoms (B, N, or NLPD groups) did not improve with respect to MCS-12 scores after surgery (P > .05), and those with leg pain-dominant symptoms (LPD group) had greater delta MCS-12 scores (P = .046) and greater recovery rates (P = .035). Multiple linear regression did not find LPD to be an independent predictor of PCS-12 or ODI scores. CONCLUSION: Patients undergoing lumbar decompression surgery and leg pain-dominant symptoms noted a greater improvement in MCS-12 scores; however, there were no differences in PCS-12 or ODI scores. LEVEL OF EVIDENCE: 3. CLINICAL RELEVANCE: Patients undergoing lumbar decompression surgery demonstrate no major clinically significant differences when split up by pain-dominance groups.

Cerebrospinal fluid leaks secondary to dural tears: a review of etiology, clinical evaluation, and management.

OBJECTIVE: Damage to the dura mater often occurs in trauma cases of the head and spine, surgical procedures, lumbar punctures, and meningeal diseases. The resulting damage from dural tears, or durotomy, causes cerebrospinal fluid (CSF) to leak out into the surrounding space. The CSF leak induces intracranial hypotension, which can clinically present with a range of symptoms not limited to positional headaches which can confound accurate diagnosis. Current methods of evaluation and management of dural tears are discussed herewith, as well as the present understanding of its etiology, which may be classified as related to surgery, procedure, trauma, or connective tissue disorder. METHODS: We piloted a MEDLINE® database search of literature, with emphasis on the previous five years, combining keywords such as "cerebrospinal fluid leak," "surgery," "procedure," and "trauma" to yield original research articles and case reports for building a clinical profile. RESULTS: Patients with suspected dural tears should be evaluated based on criteria set by the International Headache Society, radiological findings, and a differential diagnosis to accurately identify the tear and its potential secondary complications. Afflicted patients may be treated promptly with epidural blood patches, epidural infusions, epidural fibrin glue, or surgical repair. At this time, epidural blood patches are the first line of treatment. Dural tears can be prevented to an extent by utilizing minimally invasive techniques and certain positions for lumbar puncture. Surgical, trauma, lumbar puncture, and epidural injection patients should be observed very carefully for dural tears and CSF leaks as the presenting clinical manifestations can be highly individualized and misguiding. CONCLUSION: Because studies have demonstrated a high frequency of dural tears, particularly in spinal surgery patients, there is a need for prospective studies so that clinicians can develop an elaborate prevention strategy and response to avoid serious, unseen complications.

Neuro-urological sequelae of lumbar spinal stenosis.

PURPOSE: Lumbar spinal stenosis is characterized by the narrowing of the spinal canal, which subsequently induces impingement of neural elements in the lumbar spine. Thus, symptoms of lumbar spinal stenosis are typically associated with damage to those neural elements. Herewith, we target the genitourinary symptoms of lumbar spinal stenosis and the importance of differentiating these symptoms from other genitourinary pathologies, namely benign prostatic hyperplasia. MATERIALS AND METHODS: MeSH and keywords relevant to lumbar spinal stenosis and the organs of the urinary tract were used to a guide a literature search on MEDLINE. RESULTS: Bladder dysfunction, lower urinary tract symptoms (e.g. urinary incontinence, detrusor overactivity and underactivity, as well as frequent urinary tract infections), renal osteodystrophy and sexual dysfunction (e.g. erectile dysfunction and priapism) are implicated in lumbar spinal stenosis. CONCLUSIONS: It is imperative for urologists to conduct a thorough history and physical examination so that they will not misdiagnose secondary genitourinary manifestations of lumbar spinal stenosis as primary problems or misunderstand secondary problems. Urological consultations are also integral to prioritizing patients with the highest risk of bladder damage for corrective spinal surgery.

Global patterns of marine mammal, seabird, and sea turtle bycatch reveal taxa-specific and cumulative megafauna hotspots.

Recent research on ocean health has found large predator abundance to be a key element of ocean condition. Fisheries can impact large predator abundance directly through targeted capture and indirectly through incidental capture of nontarget species or bycatch. However, measures of the global nature of bycatch are lacking for air-breathing megafauna. We fill this knowledge gap and present a synoptic global assessment of the distribution and intensity of bycatch of seabirds, marine mammals, and sea turtles based on empirical data from the three most commonly used types of fishing gears worldwide. We identify taxa-specific hotspots of bycatch intensity and find evidence of cumulative impacts across fishing fleets and gears. This global map of bycatch illustrates where data are particularly scarce--in coastal and small-scale fisheries and ocean regions that support developed industrial fisheries and millions of small-scale fishers--and identifies fishing areas where, given the evidence of cumulative hotspots across gear and taxa, traditional species or gear-specific bycatch management and mitigation efforts may be necessary but not sufficient. Given the global distribution of bycatch and the mitigation success achieved by some fleets, the reduction of air-breathing megafauna bycatch is both an urgent and achievable conservation priority.

Resilience of marine turtle regional management units to climate change.

Enhancing species resilience to changing environmental conditions is often suggested as a climate change adaptation strategy. To effectively achieve this, it is necessary first to understand the factors that determine species resilience, and their relative importance in shaping the ability of species to adjust to the complexities of environmental change. This is an extremely challenging task because it requires comprehensive information on species traits. We explored the resilience of 58 marine turtle regional management units (RMUs) to climate change, encompassing all seven species of marine turtles worldwide. We used expert opinion from the IUCN-SSC Marine Turtle Specialist Group (n = 33 respondents) to develop a Resilience Index, which considered qualitative characteristics of each RMU (relative population size, rookery vulnerability, and genetic diversity) and non climate-related threats (fisheries, take, coastal development, and pollution/pathogens). Our expert panel perceived rookery vulnerability (the likelihood of functional rookeries becoming extirpated) and non climate-related threats as having the greatest influence on resilience of RMUs to climate change. We identified the world's 13 least resilient marine turtle RMUs to climate change, which are distributed within all three major ocean basins and include six of the world's seven species of marine turtle. Our study provides the first look at inter- and intra-species variation in resilience to climate change and highlights the need to devise metrics that measure resilience directly. We suggest that this approach can be widely used to help prioritize future actions that increase species resilience to climate change.

Global conservation priorities for marine turtles.

Where conservation resources are limited and conservation targets are diverse, robust yet flexible priority-setting frameworks are vital. Priority-setting is especially important for geographically widespread species with distinct populations subject to multiple threats that operate on different spatial and temporal scales. Marine turtles are widely distributed and exhibit intra-specific variations in population sizes and trends, as well as reproduction and morphology. However, current global extinction risk assessment frameworks do not assess conservation status of spatially and biologically distinct marine turtle Regional Management Units (RMUs), and thus do not capture variations in population trends, impacts of threats, or necessary conservation actions across individual populations. To address this issue, we developed a new assessment framework that allowed us to evaluate, compare and organize marine turtle RMUs according to status and threats criteria. Because conservation priorities can vary widely (i.e. from avoiding imminent extinction to maintaining long-term monitoring efforts) we developed a "conservation priorities portfolio" system using categories of paired risk and threats scores for all RMUs (n = 58). We performed these assessments and rankings globally, by species, by ocean basin, and by recognized geopolitical bodies to identify patterns in risk, threats, and data gaps at different scales. This process resulted in characterization of risk and threats to all marine turtle RMUs, including identification of the world's 11 most endangered marine turtle RMUs based on highest risk and threats scores. This system also highlighted important gaps in available information that is crucial for accurate conservation assessments. Overall, this priority-setting framework can provide guidance for research and conservation priorities at multiple relevant scales, and should serve as a model for conservation status assessments and priority-setting for widespread, long-lived taxa.

Regional management units for marine turtles: a novel framework for prioritizing conservation and research across multiple scales.

BACKGROUND: Resolving threats to widely distributed marine megafauna requires definition of the geographic distributions of both the threats as well as the population unit(s) of interest. In turn, because individual threats can operate on varying spatial scales, their impacts can affect different segments of a population of the same species. Therefore, integration of multiple tools and techniques--including site-based monitoring, genetic analyses, mark-recapture studies and telemetry--can facilitate robust definitions of population segments at multiple biological and spatial scales to address different management and research challenges. METHODOLOGY/PRINCIPAL FINDINGS: To address these issues for marine turtles, we collated all available studies on marine turtle biogeography, including nesting sites, population abundances and trends, population genetics, and satellite telemetry. We georeferenced this information to generate separate layers for nesting sites, genetic stocks, and core distributions of population segments of all marine turtle species. We then spatially integrated this information from fine- to coarse-spatial scales to develop nested envelope models, or Regional Management Units (RMUs), for marine turtles globally. CONCLUSIONS/SIGNIFICANCE: The RMU framework is a solution to the challenge of how to organize marine turtles into units of protection above the level of nesting populations, but below the level of species, within regional entities that might be on independent evolutionary trajectories. Among many potential applications, RMUs provide a framework for identifying data gaps, assessing high diversity areas for multiple species and genetic stocks, and evaluating conservation status of marine turtles. Furthermore, RMUs allow for identification of geographic barriers to gene flow, and can provide valuable guidance to marine spatial planning initiatives that integrate spatial distributions of protected species and human activities. In addition, the RMU framework--including maps and supporting metadata--will be an iterative, user-driven tool made publicly available in an online application for comments, improvements, download and analysis.