Implementing a Protocol to Reduce Opioid Prescriptions in Military Otolaryngology: A Quality Improvement Initiative.

INTRODUCTION: To compare pain medication refill rates for adult septoplasty and rhinoplasty patients before and after initiating a multimodal analgesic protocol for reducing opioid prescriptions (PROP). MATERIALS AND METHODS: Data from 58 adult patients were retrieved by retrospective chart review (19 septoplasties and 10 rhinoplasties before initiating PROP in September 2018 and 21 septoplasties and 8 rhinoplasties after PROP). We selected consecutive septoplasties and rhinoplasties, at which time a new discharge order set was implemented. The new order set consisted of 10 oxycodone tabs (5 mg), 100 acetaminophen tabs (325 mg), and 28 celecoxib tabs (200 mg). The primary outcome variable was the number of initial opioid prescriptions and refills filled by any provider. RESULTS: Among the septoplasties, there was a 46% decrease in total morphine milligram equivalent (MME) prescribed, from a mean of 202.0 mg in the non-PROP group (95% CI, 235.4, 174.6) to 108.6 mg in the PROP group (95% CI, 135.8, 81.4), with no difference in refill rates. Among the rhinoplasties, there was a 51% decrease in total MME prescribed, from a mean of 258.8 mg in the non-PROP group (95% CI, 333.4, 184.1) to 126.6 mg in the PROP group (95% CI, 168.1, 85.0) with no difference in refill rates. CONCLUSIONS: The outcomes after PROP implementation for septoplasty and rhinoplasty at our institution suggest that opioid prescription rates can be significantly decreased to manage postoperative pain, with no difference in opioid refill rates. The results also warrant further investigation into patient pain, satisfaction, provider efficiency, and healthcare costs.

Supraglottoplasty surgery types 1-3: A practical classification system for laryngomalacia surgery.

OBJECTIVE: The objective of this study is to review the published literature on supraglottoplasty techniques for correcting laryngomalacia, and to subsequently provide a standardized classification system. METHODS: Three authors independently and systematically searched Pubmed/MEDLINE and six additional databases for all studies that included descriptions of supraglottoplasty techniques for correcting laryngomalacia. Sub-sites operated on and specific technique descriptions were reviewed, cataloged and subsequently categorized. This data was then used to develop a new classification system. RESULTS: 231 articles were identified, downloaded and reviewed in full text. 53 articles with 1669 patients from the included articles described in detail the supraglottoplasty procedure. 84 articles with 5731 patients had to be excluded secondary to not providing detail about the supraglottoplasty procedure. The resultant data identifies the need for a more standardized reporting of the supraglottoplasty procedure in order to more accurately evaluate technique specific outcomes. Currently 77% of the patients in the literature cannot be assessed for outcomes as they did not describe the details for the procedures. Eight variations of supraglottoplasty and four variations of epiglottis surgery were described. Based on the literature, we consolidated the surgery into the following types: Type 1: Debulking of arytenoids, Type 2: Division of aryepiglottic folds, Type 3: Epiglottis surgery. CONCLUSION: This descriptive review identified 53 articles with 1669 patients from the included articles detailing multiple variations of supraglottoplasty techniques. The new classification supplements a previously established system describing laryngomalacia, and simplifies the supraglottoplasty into three descriptive and logical types of categories. Our classification system would give surgeons a universal language to describe the supraglottoplasty performed, which could improve reporting of techniques, and facilitate future communication and research.

The Impact of the Veteran's Affairs Medical System on an Otolaryngology Residency Training Program.

Introduction: The field of otolaryngology has become the leading specialty in the management of head and neck pathology and trauma. Graduate medical education programs tasked to train military head and neck surgeons within the Department of Defense (DoD) maintain certification by ensuring adequate surgical case volume and training. In recent years, surgical case numbers have declined due to an overall healthy active duty patient population and deployments of residency faculty. As such, a novel initiative between the San Antonio Military Medical Center and the South Texas Veteran's Healthcare system was developed to provide seamless care among active duty service members, dependents, retirees, and veterans. The goal of this study is to review the impact on Otolaryngology Key Indicator Procedures (KIP), as defined by the Accreditation Council for Graduate Medical Education (ACGME), following integration of a Veterans Affairs health care population into a military otolaryngology residency program. Further, we aim to assess the potential secondary benefits of an integrated health care initiative between the DoD and the Veteran's Affairs (VA) systems. Materials and Methods: Otolaryngology key indicator procedures, as defined by the ACGME, were reviewed at an academic military medical center before and after implementation of an ENT Federal Healthcare Consortium integrating care of VA patients at a military hospital. The surgical scheduling system at our institution was queried for cases within the KIP categories of "Head & Neck" and "Otology" from 2011 to 2015. Results: Case data was reviewed from the San Antonio Military Medical Center before (2011-2012) and following integration of VA patient care (2013-2015). A total of 520 "Head & Neck" and 532 "Otology" KIP were performed following development of an ENT Federal Consortium. One hundred and sixty-five KIPs were performed on patients referred from the VA. The range of VA-generated cases contributing to total KIPs for "Head & Neck" and "Otology" ranged from 6.8% to 59.5% and 0% to 18.9% per year. Conclusions: The establishment of a Federal Healthcare Consortium and integration of VA patient population provided a tangible and quantifiable increase in otolaryngology KIPs. Development of a training relationship with VA patients is beneficial in reaching outcome-oriented goals for otolaryngology residents.

Stromal contributions to the carcinogenic process.

Tumor-associated stromal cells are dynamic characters that endorse the carcinogenic process in a multitude of ways. The tumor microenvironment plays a crucial role throughout the tumor progression, which includes initiation, growth, invasion, and metastasis. The tumor microenvironment consists of cellular and non-cellular components. Tumor-associated stromal cell types include the microbiome, immune cells including macrophages, dendritic and T-cells, cells associated with blood and lymphatic vessels including pericytes and endothelial cells, fibroblasts, neuronal cells, and adipocytes. The non-cellular components of the microenvironment include matrix proteins and secreted factors. The development of therapies that target the mechanisms by which stromal cells contribute to successful tumorigenesis is major goal of upcoming cancer research. The purpose of this review is to present a comprehensive discussion of the role of each of the tumor-associated stromal cell types in the carcinogenic process with a special focus on target development and therapeutic intervention. © 2016 Wiley Periodicals, Inc.