Longer Times to Delivery of Otolaryngology Care for Patients With Limited English Proficiency.

OBJECTIVE: Limited English proficiency (LEP) is known to contribute to poorer health outcomes and delays in management. However, to our knowledge, no other studies have explored the impact of LEP on delays to care within otolaryngology. This study aims to investigate the relationship between LEP and the time to delivery of otolaryngology care. METHODS: We retrospectively reviewed 1125 electronic referrals to an otolaryngologist from primary care providers at 2 health centers in the greater Boston area, between January 2015 and December 2019. Multivariable logistic regression analyses were conducted to determine if patient LEP status (preferred language non-English and language interpreter use) has an impact on total time to appointment (TTTA). RESULTS: Patients with non-English preferred languages were 2.6 times more likely to experience extended TTTA (odds ratio [OR] = 2.61, 95% confidence interval [CI] = 1.99-3.42, p < .001) relative to English-speaking patients. Patients who required interpreter use were 2.4 times more likely to experience extended TTTA (OR = 2.42, 95% CI = 1.84-3.18, p < .001) relative to patients who did not require an interpreter. There was no difference in age, sex, insurance type, education level, or marital status. TTTA did not vary by diagnosis category (p = .09). DISCUSSION: LEP is an important factor that influences the time to appointment in our cohort. Notably, the impact of LEP on appointment wait times was independent of diagnosis. IMPLICATIONS FOR PRACTICE: Clinicians should recognize LEP as a factor that can impact the overall delivery of care in otolaryngology. Specifically, mechanisms to streamline care for LEP patients should be considered.

Inequities in Thyroid Cancer Care: Populations Most at Risk for Delays in Diagnosis and Treatment.

Background: Delays in treatment for thyroid cancer (TC) have been associated with higher overall mortality rates. However, few studies have explored the impact of health disparities on delayed presentation and treatment for TC. This study aims to investigate what patient sociodemographic factors contribute to delays in presentation and treatment of TC. Methods: Using the National Cancer Database, we identified patients diagnosed with well-differentiated TC between 2004 and 2016 who underwent thyroidectomy. Multivariable regression analyses were conducted to examine the impact of race, insurance status, income, and distance from treatment facility on time to surgical treatment, stage, the presence of distant metastases, and tumor size. Results: We identified 89,105 patients diagnosed with well-differentiated TC who underwent thyroidectomy. Nonwhite patients who were uninsured or had Medicare or Medicaid insurance were more likely to experience delays in care, present with higher stages at diagnosis, and have distant metastases and larger tumors at presentation. Distance from treatment facility was associated with delays in surgical treatment and higher stage at presentation. Conclusion: Delays in TC presentation and surgical treatment vary by race, insurance status, and patient location. Health care policies should focus on targeting at-risk individuals to reduce health care disparities in this disease.

Facial Paresis and Pulsatile Middle Ear Mass.

SIGNIFICANCE STATEMENT: Head and neck paragangliomas are uncommon pathologies that present with common symptoms such as pulsatile tinnitus and aural pressure. This article highlights an unusual presentation of a patient with facial paresis who was found to have a jugular paraganglioma. Emphasis is placed on how the otologic examination showed a pulsatile middle ear mass that led to the diagnosis. This case illustrates the importance of maintaining a healthy degree of clinical suspicion when encountering common complaints.

Functional connectivity associated with improvement in emotion management after cognitive enhancement therapy in early-course schizophrenia.

BACKGROUND: The ability to manage emotions is an important social-cognitive domain impaired in schizophrenia and linked to functional outcome. The goal of our study was to examine the impact of cognitive enhancement therapy (CET) on the ability to manage emotions and brain functional connectivity in early-course schizophrenia. METHODS: Participants were randomly assigned to CET (n = 55) or an enriched supportive therapy (EST) control group (n = 45). The resting-state functional magnetic resonance imaging scans and measures of emotion management performances were collected at baseline, 9, and 18 months follow-up. The final sample consisted of 37 CET and 25 EST participants, including 19 CET and 12 EST participants with imaging data. Linear mixed-effects models investigated the impact of treatment on emotion management and functional connectivity from the amygdala to ventrolateral and dorsolateral prefrontal cortex (dlPFC). RESULTS: The CET group showed significant improvement over time in emotion management compared to EST. Neither functional connectivity changes nor main group differences were observed following treatment. However, a significant between-group interaction showed that improved emotion management ability was associated with increased functional connectivity between the left amygdala and the left dlPFC in the CET group exclusively. CONCLUSION: Our results replicate the previous work demonstrating that CET is effective at improving some aspects of social cognition in schizophrenia. We found evidence that improvement in emotion management may be associated with a change in amygdala-dlPFC connectivity. This fronto-limbic circuit may provide a mechanistic link between the biology of emotion management processes that can be enhanced in individuals with schizophrenia.

Long-term voice changes after thyroidectomy: Results from a validated survey.

BACKGROUND: Long-term dysphonia may persist after thyroid surgery even in the absence of overt nerve injury. Therefore, we evaluated long-term dysphonia after thyroidectomy using a validated survey. METHODS: Patients undergoing thyroidectomy at a single institution from 1990 to 2018 were surveyed via telephone to complete the Voice Handicap Index-10 Survey. Individuals with documented nerve injury were excluded. RESULTS: In total, 308 patients completed the survey (mean age 51 ± 14 years, 78% female). Median time since surgery was 10.7 (interquartile range 2.3-17.5) years. The mean Voice Handicap Index-10 Survey score was 2.6 ± 5.2. Of the 113 (37%) patients who reported subjective dysphonia, the mean Voice Handicap Index-10 Survey score was 7.1 ± 6.5. Twenty-two (7.1%) patients had a Voice Handicap Index-10 Survey score above the empiric normative cutoff of 11, with a mean score of 17.6 ± 6.8. The most frequent complaints included "The clarity of my voice is unpredictable" (N = 71, 23%), "People have difficulty understanding me in a noisy room" (N = 70, 23%), and "I feel as though I have to strain to produce voice" (N = 65, 21%). CONCLUSION: Long-term follow-up of patients after thyroidectomy suggests that more than 30% without nerve injury report dysphonia. Research to further assess the etiology and impact of these changes on quality of life is needed.

Patient-Reported Financial Burden in Thyroid Cancer.

BACKGROUND: The incidence of thyroid cancer is increasing at a rapid rate. Prior studies have demonstrated financial burden and decreased quality of life in patients with thyroid cancer. Here, we characterize patient-reported financial burden in patients with thyroid cancer over a 28y period. MATERIALS AND METHODS: Patients who underwent thyroidectomy for thyroid cancer from 1990-2018 completed a phone survey assessing financial burden and its related psychological financial hardship. Descriptive statistics were performed to characterize these outcomes and correlation with sociodemographic data was assessed. RESULTS: Respondents (N = 147) were 73% female, 75% white, and had a median follow up of 7 y. The majority had a full-time job (59%) and private insurance (81%) at the time of diagnosis. Overall, 16% of respondents reported financial burden and 50% reported psychological financial hardship. Those reporting financial burden were disproportionately impacted by psychological financial hardship (87% versus 43%, P < 0.001). One in four (25%) respondents reported not being adequately informed about costs. CONCLUSIONS: Financial burdens are important outcomes of thyroid cancer which occur even among patients with protective financial factors, suggesting an even greater impact on the general population of patients with thyroid cancer. Further research is needed to explore the intersection of financial burden, cost, and quality of life.

Time to Surgery and Thyroid Cancer Survival in the United States.

BACKGROUND: Longer time to surgery worsens survival in multiple malignancies, including lung, colorectal, and breast cancers, but limited data exist for well-differentiated thyroid cancer. We sought to investigate the impact of time to surgery on overall survival in patients with papillary thyroid cancer. METHODS: In a retrospective cohort study of the National Cancer Database, we used Cox proportional hazard models to investigate overall survival as a function of time between diagnosis and surgery for adults with papillary thyroid cancer, adjusting for demographic, patient, and cancer-related variables. Time to surgery was investigated both as a continuous variable and as intervals of 0-90 days, 90-180 days, and > 180 days. Subgroup analyses were conducted by T stage. RESULTS: Overall, 103,812 adults with papillary thyroid cancer were included from 2004 to 2016. Median follow-up was 55.2 months (interquartile range 28.4-89.5). Increasing time to surgery was associated with increased mortality: delaying by 91-180 days increased the risk by 30% (adjusted hazard ratio [aHR] 1.30, 95% CI 1.19-1.43) and delaying by over 180 days increased the risk by 94% (aHR 1.94, 95% CI 1.68-2.24). Five-year overall survival was 95.7% for 0-90 days, 93.0% for 91-180 days, and 87.9% for over 180 days. On subgroup analysis, increasing delay was associated with worse overall survival for T1, T2, and T3 tumors, but not T4 tumors. CONCLUSIONS: Increasing time to surgery in papillary thyroid cancer is associated with reduced overall survival. Further research is necessary to assess the impact of surgical delay on disease-specific survival.