The Influence of Vasopressors on Free Flap Outcomes in Head and Neck Cancer Patients.

OBJECTIVE: To compare free flap outcomes between those who received and did not receive vasopressors (VPs) at the time of free flap reconstruction. STUDY DESIGN: This retrospective cohort study includes patients from January 2013 to January 2023. SETTING: This multicenter cohort study utilized data from the TriNetX Research Network which includes 80 health care organizations. METHODS: Head and neck cancer patients older than 18 years who underwent free flap reconstruction were separated into those who received or did not receive VPs on the day of surgery. The primary outcomes were flap failure defined by need for secondary free flap procedures, blood vessel repair, and other flap revision procedures. RESULTS: After propensity score matching, 7446 patients were analyzed. The VP group included 3723 patients (mean age [SD], 62.9 [11.4] years; 2511 males [67.4%]). The non-VP group included 3723 patients (mean age [SD], 63.0 [11.2] years; 2479 males [66.6%]). Free flap outcomes were not statistically different between groups (secondary free flap: 166 [4.5%] VP vs 155 [4.2%] non-VP, P = .04; vessel repair: 314 [8.4%] vs 319 [8.6%], P = .06; other flap revision procedures: 416 [11.2%] vs 449 [12.1%], P = .02). Bony flaps were found to have decreased rates of vessel repair in the VP group (47 [6.1%] vs 69 [9.0%], P = .003]. For secondary outcomes, pneumonia (173 [4.6%] vs 231 [6.2%], P = .0002), urinary tract infection (34 [1.0%] vs 59 [1.6%], P = .0007), and deep vein thrombosis (93 [2.5%] vs 122 [3.3%], P = .004) were significantly different. CONCLUSION: VP use is not significantly associated with free flap complications. These results imply that VP use on the same day as surgery may be safe if clinically necessary.

Surgical Thromboprophylaxis in Patients With Head and Neck Cancer: An Economic Model.

Objective: To quantify postoperative venous thromboembolism (VTE) incidence in head and neck cancer (HNC) patients, and assess the economic implications of chemoprophylaxis. Study Design: Retrospective cost-effective analysis. Setting: Fifty-three health care organizations. Methods: The TriNetX Research Network was queried to identify the 1-month VTE rate in HNC patients undergoing neck dissection from 2012 to 2022. A literature search provided additional postsurgical VTE rates in HNC patients. Costs of prophylactic heparin and enoxaparin were obtained from a drug wholesaler, and VTE-associated medical costs were sourced from the literature. A break-even analysis determined the absolute risk reduction (ARR) in the VTE rate necessary for a medication to break-even on cost. Results: In TriNetX, 8193 HNC surgical patients underwent neck dissection, and an additional 1640 patients underwent neck dissection plus free flap reconstruction without chemoprophylaxis. Respective 1-month VTE rates were 1.3% (n = 103) and 2.5% (n = 41). Four additional studies of 1546 postoperative HNC patients not prescribed chemoprophylaxis reported a mean VTE rate of 3.8% (n = 59), ranging from 1.9% to 13.0%. At $8.40 per week, heparin resulted in cost savings if it decreased the VTE rate by an ARR of at least 0.05%, while enoxaparin, at $23.66 per week, needed to achieve a 0.14% ARR. Considering potential added costs from bleeding complications, heparin, and enoxaparin remained cost-effective if chemoprophylaxis did not increase bleeding complications by an absolute risk of more than 2.86% and 2.79%, respectively. Conclusion: Postoperative VTE rates varied in HNC patients. Despite this, achievable ARRs suggested the potential cost-effectiveness of routine chemoprophylaxis with heparin and enoxaparin.

Impact of COVID-19 on facial plastic surgery volumes: A large database analysis of pre- and post-pandemic trends.

Objective: During the COVID-19 pandemic, elective surgeries faced cancelations due to quarantine measures. The objective of this study was to assess facial plastic and reconstructive surgery (FPRS) volume before, during, and after the height of the pandemic on a national scale. Methods: The TriNetX Research Network identified 68,101,098 individuals aged 18+ with healthcare interactions from 2017 to 2022. Rates of common FPRS surgeries and procedures were compared during March-August of each year, aligning with the pandemic lockdown. Results: Compared to immediately before the pandemic in 2019, the 2020 pandemic peak saw an overall surgical volume reduction of -36.8%, with specific surgeries decreasing significantly: rhinoplasty (-28.6%), septoplasty (-34.0%), rhytidectomy (-54.9%), blepharoplasty (-40.7%), brow lift (-43.8%), ectropion/entropion repair (-35.6%), repair of blepharoptosis (-45.6%), correction of lagophthalmos (-29.9%), correction of lid retraction (-36.8%), and lipectomy (-41.8%) (p < .001). The procedural volume also decreased by 28.6%, encompassing reductions in various procedures: botulinum toxin A (-18.7%), facial filler (-40.7%), dermabrasion (-62.3%), chemical peel (-36.6%), and intralesional injection (-33.3%) (p < .001). In contrast to 2020, 2021 witnessed an increase of +75.0% in total surgical and +61.3% procedural volume: rhinoplasty (+81.0%), septoplasty (+74.7%), rhytidectomy (+143.4%), blepharoplasty (+81.7%), brow lift (+64.5%), ectropion/entropion repair (+55.2%), repair of blepharoptosis (+62.7%), correction of lagophthalmos (+39.0%), correction of lid retraction (+73.0%), lipectomy (+121.2%), botulinum toxin A (+52.4%), filler (+59.6%), dermabrasion (+91.8%), chemical peel (+78.8%), and intralesional injection (+67.3%) (p < .001). In 2022, rates of total surgeries (+8.5%) and procedures (+12.8%) surpassed pre-pandemic levels from 2019 (p < .001). Conclusions: FPRS experienced significant pandemic-induced decreases, followed by a notable recovery in subsequent years, with certain surgeries and procedures surpassing pre-pandemic levels. Level of Evidence: 4.

Charcot Neuroarthropathy Is Associated With Higher Rates of Phantom Limb After Lower Extremity Amputation.

BACKGROUND: The incidence of phantom limb pain in patients with Charcot neuroarthropathy who undergo major amputation is not well described. The purpose of this study was to determine whether patients with Charcot neuroarthropathy and diabetes who underwent either a below-knee amputation (BKA) or above-knee amputation (AKA) had an increased rate of phantom limb pain compared with those with a diagnosis of diabetes alone. METHODS: Using international classification of disease (ICD) and common procedural terminology (CPT) codes, the TriNetX research database identified 10 239 patients who underwent BKA and 6122 who underwent AKA between 2012 and 2022. Diabetic patients with and without Charcot neuroarthropathy were compared in terms of demographics and relative risk of developing phantom limb pain after AKA or BKA. RESULTS: Age, sex, ethnicity, and race did not significantly differ between groups. Charcot neuroarthropathy was associated with significantly increased risk of phantom limb pain following both BKA (risk ratio [RR]: 1.2, 95% confidence interval [CI]: 1.1-1.3, P < .01) and AKA (RR: 1.6, 95% CI: 1.2-2.3, P < .0068). CONCLUSION: Our results indicate that patients with a coexisting diagnosis of Charcot neuroarthropathy who require BKA or AKA may have an increased risk of developing phantom limb pain. LEVELS OF EVIDENCE: Level III.

Preoperative Serum Albumin as Predictor of Outcomes After Thyroidectomy.

Objective: Albumin is considered to be a surrogate marker for inflammation and nutritional status. Levels usually decrease after surgery but little is known about the predictive value of preoperative albumin levels in patients undergoing thyroidectomy. This study aimed to investigate the 30-day incidence of postoperative outcomes in thyroidectomy patients with and without preoperative hypoalbuminemia. Study Design: Retrospective cohort study. Setting: TriNetX Database. Methods: TriNetX, a federated deidentified database, was retrospectively queried to identify patients who underwent thyroidectomy. Postoperative outcomes within 30 days of thyroidectomy, based on International Classification of Disease, 10th Revision and Current Procedural Terminology codes, in patients with preoperative hypoalbuminemia (≤3.4 g/dL) (cohort 1) were analyzed and compared to patients without hypoalbuminemia (cohort 2). Results: After propensity score matching, 2398 patients were identified in each cohort. Hypoalbuminemia patients were more likely to have postoperative pneumonia (odds ratio, OR: 3.472, 95% confidence interval, CI [2.016-5.978]), acute renal failure (OR: 3.872, 95% CI [2.412-6.217]), venous thromboembolism (OR: 1.766, 95% CI [1.016-2.819]), and surgical site infection (OR: 2.353, 95% CI [1.282-4.32]). Rates of recurrent laryngeal nerve injury were comparable between cohorts. Conclusion: Patients undergoing thyroidectomy with preoperative hypoalbuminemia have a higher prevalence of postoperative complications compared to patients without preoperative hypoalbuminemia. While not routinely assessed, preoperative evaluation of serum albumin levels may help guide expectations and optimal management of thyroidectomy patients.

Current and Emerging Diagnostic, Prognostic, and Predictive Biomarkers in Head and Neck Cancer.

Head and neck cancers (HNC) are a biologically diverse set of cancers that are responsible for over 660,000 new diagnoses each year. Current therapies for HNC require a comprehensive, multimodal approach encompassing resection, radiation therapy, and systemic therapy. With an increased understanding of the mechanisms behind HNC, there has been growing interest in more accurate prognostic indicators of disease, effective post-treatment surveillance, and individualized treatments. This chapter will highlight the commonly used and studied biomarkers in head and neck squamous cell carcinoma.

Telemedicine in Otolaryngology in the Context of the End of the COVID-19 Public Health Emergency.

At the onset of the COVID-19 pandemic, the US Department of Health and Human Services implemented a range of flexibilities to expedite the adoption of telehealth. As our specialty moved past the height of the pandemic and the use of telehealth transitioned from a necessity to a convenience, numerous health care providers (physicians, advanced practice providers, speech-language pathologists, and audiologists) recognized its benefits and continued to offer these services. In May 2023, the current administration terminated the COVID-19 public health emergency declaration, with some telehealth guidelines in effect until December 31, 2023, and others extended through December 31, 2024. Amidst the changing telehealth landscape, the objective of this commentary is to explain policy implications on Otolaryngology-Head and Neck Surgery and provide insight into how to best implement telehealth under these new guidelines.

Association of Systemic Hormonal Contraceptives With Reconstruction Procedures for Patellar Instability.

Background: Previous research suggests that estrogen plays a role in increased ligamentous laxity observed within the female population. Whereas many studies have sought to evaluate the impact of exogenous estrogen on anterior cruciate ligament injuries, research has not yet explored its impact on the medial patellofemoral ligament. Furthermore, less is known about the role of exogenous progesterone on ligamentous structures. Purpose: To determine whether women prescribed systemic estrogen (ethinyl estradiol) or progesterone (norgestimate or etonogestrel) hormonal contraceptives had an increased risk of undergoing reconstruction surgery for patellar instability compared with women without a prescription for systemic hormonal contraceptives. Study Design: Cross-sectional study; Level of evidence, 3. Methods: The TriNetX Research Network database was queried using International Classification of Disease and Common Procedural Terminology codes for women aged 15 to 26 years who underwent reconstruction procedures for patellar instability between 2012 and 2022. Women were grouped according to whether they had a coded prescription for a systemic hormonal contraceptive containing either ethinyl estradiol or etonogestrel; controls were matched by age, sex, race, and ethnicity. The relative risk (RR) of undergoing reconstruction for patellar instability was determined for each contraceptive. Results: After 1-to-1 propensity score matching, 0.054% (525/980,878) of women prescribed a systemic contraceptive containing ethinyl estradiol underwent reconstruction procedures for patellar instability compared with 0.043% (417/980,878) of controls (RR, 1.3; 95% CI, 1.1-1.4; P = .0004). Likewise, 0.058% (67/116,260) of women prescribed a form of systemic contraceptive containing only etonogestrel underwent reconstruction procedures for patellar instability compared with 0.026% (30/116,260) of controls (RR, 2.2; 95% CI, 1.5-3.4; P = .0002). Conclusion: Female patients prescribed systemic contraceptives containing estrogen or progesterone had an increased rate of reconstruction procedures for patellar instability.

Predictors of Quality of Life for Head and Neck Cancer Patients at an Academic Institution.

Objective: Quality of life (QOL) is an important consideration in head and neck cancer (HNC) due to lasting disease and treatment-related toxicities. We performed a comprehensive review of predictors of QOL in this population, including distance to care. Study Design: Retrospective cohort study from 2017 to 2022. Setting: Academic medical center. Methods: QOL was quantified in patients treated for HNC utilizing the University of Washington Quality of Life and 20-Item Short Form surveys completed at subsequent clinic visits. Distance to treatment center and other demographic, socioeconomic, disease-specific, and behavioral data were analyzed. Results: There were 176 patients in the cohort (69% male; mean age, 64 ± 10.8 years). There was no association between miles traveled and any of the QOL subscales. Marital status was the strongest predictor of QOL, significantly associated with 7/8 QOL domains and favoring those who were married. Other significant predictors of decreased QOL included emotional/physical abuse, current tobacco use, documented religious affiliation, and treatment involving surgery plus adjuvant therapy. A significant positive trend over time existed for multiple QOL subscales. Conclusion: QOL is unchanged in patients who travel greater distances for care. QOL is more closely linked to factors such as marital status, physical/emotional abuse, tobacco use, religious affiliation, treatment intensity, and time following surgery. This highlights the importance of a strong support structure and the influence of certain socioeconomic and lifestyle factors on patients, with opportunities for screening and intervention throughout their cancer care.

Letter to the Editor of Journal of Otolaryngology regarding "Risk of diabetes in patients with sleep apnea: comparison of surgery versus CPAP in a long-term follow-up study".

Obstructive sleep apnea (OSA) is associated with multiple chronic comorbidities with treatments including continuous positive airway pressure (CPAP), upper airway surgery (UAS), and hypoglossal nerve stimulation (HNS). Given the complexity of the condition and multiple treatment options, there is an ongoing debate to determine the best management. O'Connor-Reina et al. recently published a paper titled "Risk of diabetes in patients with sleep apnea: comparison of surgery versus CPAP in a long-term follow-up study." In their study, the authors stated that OSA patients who received surgery had a 50% less chance of developing diabetes compared to patients who only received CPAP treatment. However, we would like to point out some limitations that warrant attention and caution interpretation of the findings by physicians and patients.

Use of Thromboprophylaxis after Autologous Breast Reconstruction: A Cost-Effective Break-Even Analysis.

PURPOSE: Post-operative venous thromboembolism (VTE) is a major source of morbidity and mortality. The use of thromboprophylaxis amongst surgeons is not well studied in autologous breast reconstruction. The purpose of this study was to determine the rate of VTE in breast cancer patients undergoing autologous breast reconstruction and to compare the cost-effectiveness of postoperative chemoprophylactic agents. METHODS: The TriNetX LLC. National Health Research Network database was used to identify patients with breast cancer who underwent autologous breast reconstruction surgery between 2002-2022. The incidence of occurrence of VTE within the first 30 days of surgery was calculated. Then a break-even analysis was performed to determine the break-even rate of VTE at which the chemoprophylactic agent would be cost effective. RESULTS: A cohort of 8,221 patients was identified in this study. The rate of VTE was significantly higher in those without anticoagulation (4.0%) compared to those who received anticoagulation (2.6%) (*p=0.0008). The break-even analysis for heparin and enoxaparin's cost-effectiveness yielded ARRs of 0.73% and 1.63% for high risk patients requiring 30 days of therapy and 0.20% and 0.43% for moderate risk patients requiring 7 days of therapy, respectively. CONCLUSION: The use of thromboprophylaxis significantly lowered the risk of VTE within 30 days after autologous breast reconstruction. Heparin appeared to be more cost-effective at preventing VTE compared to enoxaparin for both high and moderate risk patients. The presented model holds potential for other institution-specific variables that can be easily applied by plastic surgeons to determine the cost-effectiveness of any therapy of their choice.

Facial plating industry payments: An analysis of the open payments database.

Objective: To compare industry payments from facial plating companies to plastic surgery, oral and maxillofacial surgery (OMFS), and otolaryngology (OHNS). Methods: The Open Payments Database was queried from 2016 to 2021 to identify all industry disbursements related to facial plating products from Stryker, Zimmer Biomet, Depuy Synthes Products, Acumed, and KLS Martin. Total dollars, number of payments, and specialists paid were compared between plastic surgery, OMFS, and OHNS. Funding was correlated to estimated case volume and number of licensed surgeons determined by literature review. Results: From 2016 through 2021, OMFS received an average of $786,497 annually, followed by plastic surgery ($765,482), and OHNS ($184,484). On average, facial plating companies distributed 2256, 963, and 917 yearly payments to 699 oral and maxillofacial surgeons, 378 plastic surgeons, and 354 otolaryngologists, respectively. Total dollars, number of payments, and specialists paid were significantly different between specialties (p < .05). Facial trauma coverage is 39.6% by plastic surgery, 36.6% by OMFS, and 23.3% by OHNS. There are 7560 licensed oral and maxillofacial surgeons, 4948 plastic surgeons, and 11,778 otolaryngologists in the United States. Decreased payment to OHNS was more than could be accounted for by case volume alone. Conclusions: The facial plating industry allocates more funding dollars to OMFS and plastic surgery compared to OHNS. OMFS receives the greatest number of payments to the most specialists compared to plastic surgery and OHNS. Engagement between OHNS and the facial plating industry is a potential area of growth in the future.Level of evidence: Level 4.

Comparison of Voice Therapy Outcomes: Clinic vs Telehealth.

BACKGROUND: Voice therapy provides patients with valuable exercises and techniques to optimize vocal behaviors and improve their ability to communicate effectively and efficiently. These sessions were typically held by speech-language pathologists (SLPs) in clinic. During the COVID-19 pandemic, SLPs were provisionally able to provide billable voice therapy services in telehealth format. There is a lack of existing research studies comparing outcomes based on the format of voice therapy. METHODS: A retrospective chart review was performed on 101 patients who underwent voice therapy at a large academic institution in order to compare outcomes between clinic, telehealth, and mixed voice therapy formats. Demographics, dysphonia etiology, duration of symptoms, number of therapy sessions, and pre- and postvoice therapy scores using reflux symptom index (RSI), voice handicap index (VHI-10), consensus auditory-perceptual evaluation of voice (CAPE-V), and Grade, Roughness, Breathiness, Asthenia, Strain (GRBAS) scoring were collected. Statistical comparisons were performed using Fisher's exact test and analysis of covariance. RESULTS: There were no statistically significant differences in pre- to postvoice therapy RSI, VHI-10, CAPE-V, or GRBAS scores based on format of voice therapy, after adjustment for number of therapy sessions received. There were no differences in these outcomes when comparing voice therapy by etiology of dysphonia. CONCLUSIONS: Overall, these data support the effectiveness of the telehealth voice therapy format. It is a promising platform for greater patient access to therapy. All formats of voice therapy were effective in improving key measures of voice perception.

Update on adherence to guidelines for time to initiation of postoperative radiation for head and neck squamous cell carcinoma.

BACKGROUND: A prior study reported that over half of patients with HNSCC initiated PORT after 6 weeks from surgery during 2006-2014. In 2022, the CoC released a quality metric for patients to initiate PORT within 6 weeks. This study provides an update on time to PORT in recent years. METHODS: The NCDB and TriNetX Research Network were queried to identify patients with HNSCC who received PORT during 2015-2019 and 2015-2021, respectively. Treatment delay was defined as initiating PORT beyond 6 weeks after surgery. RESULTS: In NCDB, PORT was delayed for 62% of patients. Predictors of delay included age >50, female sex, black race, nonprivate insurance/uninsured status, lower education, oral cavity site, negative surgical margins, increased postoperative length of stay, unplanned hospital readmissions, IMRT radiation modality, treatment at an academic hospital or in the Northeast, and surgery and radiation at different facilities. In TriNetX, 64% experienced treatment delay. Additional associations with prolonged time to treatment included never married/divorced/widowed marital status, major surgery (neck dissection/free flaps/laryngectomy), and gastrostomy/tracheostomy dependence. CONCLUSIONS: There continue to be challenges to timely initiation of PORT.

Hypocalcemia after parathyroidectomy in patients with a history of bariatric surgery.

PURPOSE: A growing body of literature has suggested that a history of bariatric surgery increases the risk of hypocalcemia after subsequent thyroidectomy, however little is known about the risk after parathyroidectomy. The purpose of this study was to determine the incidence of hypocalcemia after parathyroidectomy in patients with prior bariatric surgery. METHODS: The TriNetX Research Network was queried using diagnosis and procedure codes to identify patients with a history of bariatric surgery who were subsequently diagnosed with primary hyperparathyroidism (PHP) and underwent parathyroidectomy between 2012 and 2022. The rate of hypocalcemia after parathyroidectomy was compared between those with a history of bariatric surgery and controls who underwent parathyroidectomy alone, matched for demographics, body mass index (BMI) ≥ 30 kg/m2, and history of calcium or vitamin D supplementation. RESULTS: There were 34,483 included patients diagnosed with PHP who underwent parathyroidectomy. Of this cohort, 1.4% (n = 472) had prior bariatric surgery. There were 90% females and 10% males in this subset of patients, and the average age was 58 years. Compared to matched controls who underwent parathyroidectomy alone, these patients had a significantly increased risk of hypocalcemia within 0-1 month (RR, 95% CI, P) (17.2% vs. 9.3%; 1.8, 1.3-2.6, P < 0.001), 1-6 months (8.5% vs. 2.5%; 3.3, 1.8-6.3, P < 0.001) and 6-12 months (6.8% vs. 2.3%; 2.9, 1.5-5.7, P < 0.001) following surgery. CONCLUSION: The current study is the first to indicate that patients with a history of bariatric surgery are at increased risk for short-term and permanent hypocalcemia after parathyroidectomy. Further research is required to determine optimal prevention and treatment strategies to decrease associated morbidity in this subset of patients.

Iatrogenic Pneumothorax During Hypoglossal Nerve Stimulator Implantation: A Large Database Analysis.

OBJECTIVE: There have been case reports of adverse events of hypoglossal nerve stimulator (HNS) implantation not seen in previous clinical trials, including pneumothorax and pleural effusion. The purpose of this study was to determine the rates of these complications and potential risk factors. STUDY DESIGN: Retrospective case-control study during 2014 to 2021. SETTING: Twenty-five health care organizations across the United States. METHODS: The TriNetX Research Network was queried by using disease codes to retrospectively identify patients with obstructive sleep apnea who underwent HNS implantation. Rates of pneumothorax, pleural effusion, other complications, and need for revision/replacement or explant were determined. RESULTS: We identified 1813 patients from 25 health care organizations who underwent HNS implantation. The average age was 60 years, and there were 68% males and 32% females. Of the cohort, 2.4% (n = 44 from 7 implant centers) experienced a pneumothorax, and 0.6% (n = 11) were diagnosed with a pleural effusion on the day of surgery. Patients who experienced pneumothorax were more likely to have a history of chronic lower respiratory diseases when compared with those who did not (odds ratio, 2.2; 95% CI, 1.1-4.1; P = .02). CONCLUSION: The incidence of intraoperative pneumothorax and pleural effusion during HNS implantation may be greater than initially thought. Patients with chronic lower respiratory diseases may be at increased risk. This should be communicated with patients during the informed consent process.

Hypocalcemia after parathyroidectomy in patients taking proton pump inhibitors.

PURPOSE: Long-term use of proton pump inhibitors is associated with metabolic derangements, including hypocalcemia. Hypocalcemia is also a known complication of parathyroidectomy. We sought to determine the rate of hypocalcemia following parathyroidectomy in patients on proton pump inhibitors. MATERIALS AND METHODS: The TriNetX Research Network was queried to identify patients with a history of primary hyperparathyroidism treated with parathyroidectomy between 2012 and 2022. The incidence of short-term (0-6 months following parathyroidectomy) and permanent (6-12 months following parathyroidectomy) postoperative hypocalcemia was compared between patients using proton pump inhibitors and those who were not. RESULTS: Of 34,595 total patients, 19.5 % (n = 6753) were taking proton pump inhibitors prior to surgery. Patients taking proton pump inhibitors were significantly more likely to experience both short-term (RR, 95 % CI, P) (1.5, 1.4-1.6, P < 0.001) and permanent (1.8, 1.6-2.1, P < 0.001) hypocalcemia, and were also more likely to be evaluated in the emergency department after surgery (1.5, 1.4-1.7, P < 0.001). CONCLUSIONS: Our study is the first to indicate an increased risk of hypocalcemia after parathyroidectomy in patients on proton pump inhibitors.

Analysis of Time to Diagnosis and Outcomes Among Adults With Primary Hyperparathyroidism.

Importance: Despite access to routine laboratory evaluation, primary hyperparathyroidism (PHP) remains underdiagnosed and undertreated. Objective: To determine the consequences associated with missed diagnoses and prolonged time to diagnosis and treatment of PHP. Design, Setting, and Participants: This is a retrospective cohort study of patients older than 40 years with 2 instances of hypercalcemia during 2010 to 2020 and 3 years of follow-up. Patients were recruited from 63 health care organizations in the TriNetX Research Network. Data analysis was performed from January 2010 to September 2020. Exposures: Elevated serum calcium. Main Outcomes and Measures: Existing symptoms and diagnoses associated with PHP (osteoporosis, fractures, urolithiasis, major depressive disorder, anxiety, hypertension, gastroesophageal reflux disease, malaise or fatigue, joint pain or myalgias, constipation, insomnia, polyuria, weakness, abdominal pain, headache, nausea, amnesia, and gallstones) compared in patients deemed high-risk and without a diagnosis and matched controls, and those who experienced times from documented hypercalcemia to diagnosis and diagnosis to treatment within or beyond 1 year. Results: There were 135 034 patients analyzed (96 554 women [72%]; 28 892 Black patients [21%] and 88 010 White patients [65%]; 3608 Hispanic patients [3%] and 98 279 non-Hispanic patients [73%]; mean [SD] age, 63 [10] years). Two groups without a documented diagnosis of PHP were identified as high risk: 20 176 patients (14.9%) with parathyroid hormone greater than or equal to 50 pg/mL and 24 905 patients (18.4%) with no parathyroid hormone level obtained or recorded explanation for hypercalcemia. High-risk patients experienced significantly increased rates of all associated symptoms and diagnoses compared with matched controls. Just 9.7% of those with hypercalcemia (13 136 patients) had a diagnosis of PHP. Compared with individuals who received a diagnosis within 1 year of hypercalcemia, those whose workup exceeded 1 year had significantly increased rates of major depressive disorder, anxiety, hypertension, gastroesophageal reflux disease, malaise or fatigue, joint pain or myalgias, polyuria, weakness, abdominal pain, and headache at 3 years. The rate of osteoporosis increased from 17.1% (628 patients) to 25.4% (935 patients) over the study period in the group with delayed diagnosis. Among those with a diagnosis, 5280 patients (40.2%) underwent parathyroidectomy. Surgery beyond 1 year of diagnosis was associated with significantly increased rates of osteoporosis and hypertension at 3 years after diagnosis compared with those treated within 1 year. Conclusions and Relevance: Many patients were at high risk for PHP without a documented diagnosis. Complications in these patients, as well as those who received a diagnosis after prolonged workup or time to treatment, resulted in patient harm. System-level interventions are necessary to ensure proper diagnosis and prompt treatment of PHP.

Venous Thromboembolism Chemoprophylaxis in Knee Arthroscopy: A Break-Even Analysis of Cost.

BACKGROUND: Symptomatic venous thromboembolism (VTE) is a serious and costly complication after knee arthroscopy. There continues to be debate regarding the use of VTE prophylaxis after knee arthroscopy, and minimal research has explored its cost-effectiveness. HYPOTHESIS: Both aspirin and enoxaparin would be cost-effective in preventing symptomatic VTE. STUDY DESIGN: Economic and decision analysis; Level of evidence, 3. METHODS: The literature was searched and the TriNetX research database was queried to determine a range of initial rates of VTE. An open-access retail database was used to determine the mean retail price for aspirin (325 mg) and enoxaparin (30 mg and 40 mg). Our institutional records were used to determine the cost of treating VTE. A "break-even" analysis was then performed to determine the absolute risk reduction necessary to make these drugs cost-effective. This value was then used to calculate the number of patients who would need to be treated (NNT) to prevent a single VTE while still breaking even on cost. RESULTS: The cost of treating VTE was $9407 (US Dollars). Aspirin (325 mg), enoxaparin (30 mg), and enoxaparin (40 mg) were found to cost $1.86, $188.72, and $99.99, respectively. The low, TriNetX, and high rates of VTE were 0.34%, 0.86%, and 10.9%, respectively. Aspirin was cost-effective at all 3 rates if the initial rate decreased by 0.02% (NNT = 5058). Both formulations of enoxaparin were cost-effective at the high initial rate if they decreased by 2.01% (NNT = 50) and 1.06% (NNT = 94), respectively. However, at the low and TriNetX rates, the 2 doses of enoxaparin were not cost-effective because their final break-even rate exceeded the initial VTE rate. CONCLUSION: Aspirin and, in some cases, enoxaparin are cost-effective treatments for VTE prophylaxis after knee arthroscopy.

Hypocalcemia After Thyroidectomy in Patients with Prior Bariatric Surgery: A Propensity Score Matched Analysis from a National Administrative Database.

Background: Studies have suggested that patients with prior gastric bypass may be at increased risk for hypocalcemia following thyroidectomy. Unfortunately, most of these studies are limited to case reports and small series. This study represents the largest sample size to date to assess the incidence of post-thyroidectomy hypocalcemia in patients with a history of bariatric surgery. Methods: The TriNetX Research Network was queried to retrospectively identify patients with prior bariatric surgery who underwent total thyroidectomy between 2011 and 2021. The incidence of hypocalcemia following surgery was compared with patients who underwent total thyroidectomy, and hemithyroidectomy with no history of bariatric surgery. Results: We identified 446 patients with a history of bariatric surgery and subsequent thyroidectomy, 29,346 patients with total thyroidectomy, and 19,603 patients with hemithyroidectomy alone. The one-month incidence of hypocalcemia was 54.7% in those with a history of bariatric surgery who underwent thyroidectomy, 43.9% in those with thyroidectomy alone (relative risk, RR = 1.2 [confidence interval, CI 1.1-1.4], p < 0.001), and 8.1% in those with hemithyroidectomy only (RR = 6.8 [CI 6.1-7.4], p < 0.001). Permanent hypocalcemia was documented in 11.4% of patients with prior bariatric surgery who underwent thyroidectomy, 7.7% of those with thyroidectomy only (RR = 1.5 [CI 1.1-1.9], p = 0.003), and 2.9% of patients with hemithyroidectomy alone (RR = 3.9 [CI 3.0-5.2], p < 0.001). Significant differences persisted after matching demographics, prior need for supplementation, and risk factors for hypocalcemia after thyroidectomy. When stratified by bariatric procedure, patients with a history of Roux-en-Y gastric bypass (RYGB) (n = 35) had a greater, although not statistically significant, risk of short-term hypocalcemia (51.4%; RR = 1.2 [CI 0.8-1.6], p = 0.37), and a significantly increased risk of permanent hypocalcemia (20.0%; RR = 2.6 [CI 1.3-5.1], p = 0.005) compared with thyroidectomy alone. Sleeve gastrectomy (SG) (n = 40) was not associated with an increased risk of short-term (40.0%; RR = 0.9 [CI 0.6-1.3], p = 0.62) or permanent (7.5%; RR = 1.0 [CI 0.3-2.9], p = 0.96) hypocalcemia. Conclusions: Prior RYGB, but not SG, may increase the risk of permanent hypocalcemia after thyroidectomy. Additional research is necessary to determine optimal prevention and treatment strategies to reduce morbidity in this population.