Alcohol-related posterior reversible encephalopathy syndrome: a case report of a patient managed with a benzodiazepine-sparing regimen for alcohol withdrawal.

We report a case of posterior reversible encephalopathy syndrome (PRES) during treatment for alcohol withdrawal syndrome with gabapentin and clonidine. The patient developed severe hypertension, confusion and tremor, culminating in bilateral vision loss and a seizure. Imaging revealed posterior cerebral edema. Treatment with benzodiazepines, antihypertensives, and anti-seizure medications led to resolution. One year later, imaging showed resolution of the findings. We review the associated literature and propose the recognition of a PRES sub-entity, Alcohol-Related PRES (ARPRES), which can appear in the setting of alcohol withdrawal syndrome, chronic alcohol use, and acute alcohol intoxication, with or without hypertension.

Personalized Approach to Olfactory Neuroblastoma Care.

Olfactory neuroblastoma (ONB) is an uncommon neuroendocrine malignancy arising from the olfactory neuroepithelium. ONB frequently presents with nonspecific sinonasal complaints, including nasal obstruction and epistaxis, and diagnosis can be obtained through a combination of physical examination, nasal endoscopy, and computed tomography and magnetic resonance imaging. Endoscopic resection with negative margins, with or without craniotomy, as necessary, is the standard of care for definitive treatment of ONB. Regional metastasis to the neck is often detected at presentation or may occur in a delayed fashion and should be addressed through elective neck dissection or radiation. Adjuvant radiotherapy should be considered, particularly in the case of high grade or tumor stage, as well as positive surgical margins. Systemic therapy is an area of active investigation in both the neoadjuvant and adjuvant setting, with many advocating in favor of induction chemotherapy for significant orbital or intracranial involvement prior to surgical resection. Various targeted immunotherapies are currently being studied for the treatment of recurrent or metastatic ONB. Prolonged locoregional and distant surveillance are indicated following definitive treatment, given the tendency for delayed recurrence and metastasis.

Machine Learning for Predictive Analysis of Otolaryngology Residency Letters of Recommendation.

INTRODUCTION: Letters of recommendation (LORs) are a highly influential yet subjective and often enigmatic aspect of the residency application process. This study hypothesizes that LORs do contain valuable insights into applicants and can be used to predict outcomes. This pilot study utilizes natural language processing and machine learning (ML) models using LOR text to predict interview invitations for otolaryngology residency applicants. METHODS: A total of 1642 LORs from the 2022-2023 application cycle were retrospectively retrieved from a single institution. LORs were preprocessed and vectorized using three different techniques to represent the text in a way that an ML model can understand written prose: CountVectorizer (CV), Term Frequency-Inverse Document Frequency (TF-IDF), and Word2Vec (WV). Then, the LORs were trained and tested on five ML models: Logistic Regression (LR), Naive Bayes (NB), Decision Tree (DT), Random Forest (RF), and Support Vector Machine (SVM). RESULTS: Of the 337 applicants, 67 were interviewed and 270 were not interviewed. In total, 1642 LORs (26.7% interviewed) were analyzed. The two best-performing ML models in predicting interview invitations were the TF-IDF vectorized DT and CV vectorized DT models. CONCLUSION: This preliminary study revealed that ML models and vectorization combinations can provide better-than-chance predictions for interview invitations for otolaryngology residency applicants. The high-performing ML models were able to classify meaningful information from the LORs to predict applicant interview invitation. The potential of an automated process to help predict an applicant's likelihood of obtaining an interview invitation could be a valuable tool for training programs in the future. LEVEL OF EVIDENCE: N/A Laryngoscope, 2024.

Is maxillary sinusitis and radiographic maxillary sinus opacification associated with an altered microbiology of MRONJ?

OBJECTIVE: Maxillary sinusitis can be a sequela of medication-related osteonecrosis of the jaw (MRONJ). This study aims to characterize the microbiome of maxillary MRONJ with concurrent maxillary sinusitis and radiographic maxillary sinus opacification to determine if there is a relationship between the microbiome of MRONJ and sinus disease. STUDY DESIGN: This retrospective case series was conducted using electronic health records from the University of Pennsylvania and affiliated hospitals. The target population was surgically managed maxillary MRONJ patients. The primary predictor variables were tissue culture results. The primary outcomes were maxillary sinusitis or maxillary sinus opacification. Statistical analysis was performed using chi-squared tests at the 95% confidence interval. RESULTS: Thirty-nine subjects were selected: 25 had sinus opacification and 11 had sinusitis. Resident bacteria were present in 90% of subjects, nonresident bacteria in 74%, and opportunistic organisms in 15%. There were significantly more subjects with chronic sinusitis microbes (79%) than without. There were significantly more gram-positive anaerobes, specifically Propionibacterium, as well as the gram-negative facultative anaerobe, Capnocytophaga, in subjects with concurrent sinusitis. CONCLUSIONS: Maxillary MRONJ with concurrent maxillary sinusitis may be associated with gram-positive anaerobic species, Propionibacterium, and Capnocytophaga colonization. Maxillary MRONJ patients may benefit from sinus evaluation and concurrent surgical intervention.

Utilizing Histopathology to Predict Success with Macrolide Therapy in CRS Patients.

There is currently interest regarding CRSsNP patients with refractory symptomatology following functional endoscopic sinus surgery, and which of these patients can derive benefit from low-dose macrolide therapy. In the present study, we analyze a cohort of over fifty CRSsNP patients on macrolide therapy; structured histopathological findings at the time of surgery were analyzed against the success of macrolide treatment. Independently, fibrosis, absence of squamous metaplasia, absence of eosinophilia, presence of neutrophilic infiltrate, and lymphoplasmocytic predominance were all associated with objective success of macrolide treatment; these findings may allow clinicians to more appropriately select patients for this therapy.

5-Aminolevulinic Acid Fluorescence-Guided Surgery in Head and Neck Squamous Cell Carcinoma.

OBJECTIVES: To determine the utility of 5-aminolevulinic acid (5-ALA) fluorescence for resection of head and neck carcinoma. METHODS: In this prospective pilot trial, 5-ALA was administered as an oral suspension 3-5 h prior to induction of anesthesia for resection of head and neck squamous cell carcinoma (HNSCC). Following resection, 405 nm blue light was applied, and fluorescence of the tumor as well as the surgical bed was recorded. Specimen fluorescence intensity was graded categorically as none (score = 0), mild (1), moderate (2), or robust (3) by the operating surgeon intraoperatively and corroborated with final pathologic diagnosis. RESULTS: Seven patients underwent resection with 5-ALA. Five (83%) were male with an age range of 33-82 years (mean = 60). Sites included nasal cavity (n = 3), oral cavity (n = 3), and the larynx (n = 1). All specimens demonstrated robust fluorescence when 5-ALA was administered 3-5 h preoperatively. 5-ALA fluorescence predicted the presence of perineural invasion, a positive margin, and metastatic lymphadenopathy. Two patients had acute photosensitivity reactions, and one patient had a temporary elevation of hepatic enzymes. CONCLUSIONS: 5-ALA induces robust intraoperative fluorescence of HNSCC, capable of demonstrating a positive margin, perineural invasion, and metastatic nodal disease. Although no conclusions are there about the safety of this drug in the head and neck cancer population, our study parallels the extensive safety data in the neurosurgical literature. Future applications may include intraoperative assessment of margin status, diagnostic accuracy, and impacts on survival. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:741-748, 2024.

Gabapentin and postoperative pain and opioid consumption: A double-blind randomized controlled trial of perioperative pain management for sinus surgery.

BACKGROUND: The link between post-operative narcotic prescription and opioid misuse has spurred a nationwide effort to reduce perioperative opioid use. Previous work has suggested that perioperative gabapentin may reduce post-operative pain and opioid consumption across different procedures, although the optimal regimen remains to be defined. METHODS: Chronic rhinosinusitis (CRS) patients undergoing functional endoscopic sinus surgery (FESS) with or without septoplasty were randomized to receive a 7-day pre- and post-operative course of placebo or gabapentin, starting at 300 mg daily and titrated to 300 mg three times daily, in a double-blind fashion. Primary endpoint was pain level using a validated visual analog scale (VAS). Secondary endpoints included post-operative opioid consumption and side effects, as well as modified Lund-Kennedy endoscopy, Lund-Mackay, and SNOT-22 scores. RESULTS: Analysis of 35 patients (20 gabapentin, 15 control) showed no significant difference in mean postoperative VAS (p = 0.18) or postoperative opioid consumption between the placebo and gabapentin groups (2.3 and 4.8 oxycodone tablets respectively, p = 0.18). 15 of 35 patients did not require any post-operative oxycodone tablets, and only two patients required more than six tablets. CONCLUSION: Preliminary results show no significant change in pain after FESS with or without septoplasty in patients taking 7-day pre- and post-operative gabapentin versus placebo. Results also showed no significant difference in opioid consumption between the treatment and placebo groups. Post-operative pain scores and opioid requirements are both quite low following FESS. Many patients do not need opioids at all, suggesting that routine initial post-operative opioid prescriptions can be limited accordingly.

Utility of a LangChain and OpenAI GPT-powered chatbot based on the international consensus statement on allergy and rhinology: Rhinosinusitis.

KEY POINTS: We created a LangChain/OpenAI API-powered chatbot based solely on International Consensus Statement of Allergy and Rhinology: Rhinosinusitis (ICAR-RS). The ICAR-RS chatbot is able to provide direct and actionable recommendations. Utilization of consensus statements provides an opportunity for AI applications in healthcare.

Gummatous Neurosyphilis With Transient Worsening of Neurological Symptoms After Treatment Initiation.

Cerebral syphilitic gumma is an atypical presentation of neurosyphilis, the clinical manifestations of which depend on the size and location of the lesions. It radiologically presents as enhancing nodular lesion(s) in brain parenchyma. We present a case of a patient with cerebral syphilitic gummas who had worsening neurological symptoms a few hours after initiation of anti-syphilitic antibiotic treatment. We aim to illustrate the clinical and radiological characteristics that might be helpful to clinicians when approaching the challenges they might encounter while treating neurosyphilis.

X-Ray Imaging in the Simulated Microgravity Environment of Parabolic Flight.

INTRODUCTION: The advancement of human spaceflight has made urgent the need to develop medical imaging technology to ensure a high level of in-flight care. To date, only ultrasound has been used in spaceflight. Radiography has multiple advantages over ultrasound, including lower operator dependence, more rapid acquisition, typically higher spatial resolution, and characterization of tissue with acoustic impedance precluding ultrasound. This proof-of-concept work demonstrates for the first time the feasibility of performing human radiographs in microgravity.METHODS: Radiographs of a phantom and human subject's hand, knee, chest, cervical spine, and pelvis were obtained aboard a parabolic flight in microgravity and simulated lunar gravity with various subject and operator positions. Control radiographs were acquired with the same system on the ground. These radiographs were performed with a Food and Drug Administration-approved ultra-portable, wireless, battery-powered, digital x-ray system.RESULTS: The radiographs of the phantom acquired in reduced gravity were qualitatively and quantitatively compared to the ground controls and found to exhibit similar diagnostic adequacy. There was no statistically significant difference in contrast resolution or spatial resolution with a spatial resolution across all imaging environments up to the Nyquist frequency of 3.6 line-pairs/mm and an average contrast-to-noise ratio of 2.44.DISCUSSION: As mass, power, and volume limitations lessen over the coming decades and the miniaturization of imaging equipment continues, in-flight implementation of nonsonographic modalities will become practical. Given the demonstrated ease of use and satisfactory image quality, portable radiography is ready to be the new frontier of space medical imaging.Lerner D, Pohlen M, Wang A, Walter J, Cairnie M, Gifford S. X-ray imaging in the simulated microgravity environment of parabolic flight. Aerosp Med Hum Perform. 2023; 94(10):786-791.

Omega-3 Fatty Acid Supplementation for the Treatment of Persistent COVID-Related Olfactory Dysfunction.

OBJECTIVE: To evaluate the efficacy of omega-3 fatty acid (O3FA) supplementation in the treatment of COVID-related olfactory dysfunction (OD). METHODS: Patients with laboratory-confirmed or clinically-suspected COVID-19 infection and new-onset OD from August 2020 to November 2021 were prospectively recruited. Patients with quantitative OD, defined as a brief smell identification test (BSIT) score of 9 or less, were eligible for study inclusion. The experimental group received 2 g of O3FA supplementation, while the control group received an identical placebo to be taken daily for 6 weeks. The primary outcome was a change in BSIT score between the initial and 6-week follow-up tests. RESULTS: One hundred and seventeen patients were included in the analysis, including 57 patients in the O3FA group and 60 in the placebo group. O3FA group patients demonstrated a mean BSIT improvement of 1.12 ± 1.99 compared to 0.68 ± 1.86 in the placebo group (p = 0.221). Seventy-seven patients, 42 within the O3FA group and 35 in the placebo group, completed a follow-up BSIT survey at an average of 717.8 days from study onset. At long-term follow-up, there was an average BSIT score improvement of 1.72 within the O3FA group compared to 1.76 within the placebo group (p = 0.948). CONCLUSION: Among patients with persistent COVID-related OD, our study showed no clear evidence of relative short-term or long-term olfactory recovery among patients receiving high doses of O3FA supplementation.

The evolution of plasticity at geographic range edges.

Phenotypic plasticity enables rapid responses to environmental change, and could facilitate range shifts in response to climate change. What drives the evolution of plasticity at range edges, and the capacity of range-edge individuals to be plastic, remain unclear. Here, we propose that accurately predicting when plasticity itself evolves or mediates adaptive evolution at expanding range edges requires integrating knowledge on the demography and evolution of edge populations. Our synthesis shows that: (i) the demography of edge populations can amplify or attenuate responses to selection for plasticity through diverse pathways, and (ii) demographic effects on plasticity are modified by the stability of range edges. Our spatially explicit synthesis for plasticity has the potential to improve predictions for range shifts with climate change.

West Nile Virus (WNV) Infection-Associated Acute Flaccid Paralysis With Ophthalmoplegia.

Infection with West Nile virus (WNV) is often characterized by a mild febrile illness, but it can progress to meningitis, encephalitis, flaccid paralysis, and respiratory failure. The neuro-ophthalmological manifestations of this disease are uncommonly discussed. This case describes a 49-year-old undomiciled male who developed WNV flaccid paralysis with ophthalmoplegia. His symptoms began with difficulty in walking and progressed over several days to flaccid paralysis and ophthalmoplegia. Cerebrospinal fluid was positive for WNV immunoglobulin M antibodies and electromyography demonstrated acute denervation in several muscle groups. This is an unusual case of neuro-invasive WNV presenting with flaccid paralysis and ophthalmoplegia.

A biome-dependent distribution gradient of tree species range edges is strongly dictated by climate spatial heterogeneity.

Understanding the causes of the arrest of species distributions has been a fundamental question in ecology and evolution. These questions are of particular interest for trees owing to their long lifespan and sessile nature. A surge in data availability evokes a macro-ecological analysis to determine the underlying forces limiting distributions. Here we analyse the spatial distribution of >3,600 major tree species to determine geographical areas of range-edge hotspots and find drivers for their arrest. We confirmed biome edges to be strong delineators of distributions. Importantly, we identified a stronger contribution of temperate than tropical biomes to range edges, adding strength to the notion that tropical areas are centres of radiation. We subsequently identified a strong association of range-edge hotspots with steep spatial climatic gradients. We linked spatial and temporal homogeneity and high potential evapotranspiration in the tropics as the strongest predictors of this phenomenon. We propose that the poleward migration of species in light of climate change might be hindered because of steep climatic gradients.

A natural language processing approach to uncover patterns among online ratings of otolaryngologists.

BACKGROUND: Patients increasingly use physician rating websites to evaluate and choose potential healthcare providers. A sentiment analysis and machine learning approach can uniquely analyse written prose to quantitatively describe patients' perspectives from interactions with their physicians. METHODS: Online written reviews and star scores were analysed from Healthgrades.com using a natural language processing sentiment analysis package. Demographics of otolaryngologists were compared and a multivariable regression for individual words was performed. RESULTS: This study analysed 18 546 online reviews of 1240 otolaryngologists across the USA. Younger otolaryngologists (aged less than 40 years) had higher sentiment and star scores compared with older otolaryngologists (p < 0.001). Male otolaryngologists had higher sentiment and star scores compared with female otolaryngologists (p < 0.001). 'Confident', 'kind', 'recommend' and 'comfortable' were words associated with positive reviews (p < 0.001). CONCLUSION: Positive bedside manner was strongly reflected in better reviews, and younger age and male gender of the otolaryngologist were associated with better sentiment and star scores.

Implementation of a Streamlined Care Pathway to Reduce Cost and Length of Stay for Patients Undergoing Endoscopic Transsphenoidal Pituitary Surgery.

BACKGROUND: We implemented a streamlined care pathway for patients undergoing endoscopic transsphenoidal (TSA) pituitary surgery. Select patients are recovered in the postanesthesia care unit and transferred to a step-down unit for intermediate neurologic care (INCU), with clinicians trained to manage cerebrospinal fluid leak, diabetes insipidus (DI), and other complications. METHODS: We evaluated all TSA surgeries performed at 1 academic medical center from 7th January, 2017 to 30th March, 2020, collecting patient factors, tumor characteristics, cost variables, and outcomes. The INCU pathway was implemented on 7th January 2018. Pathway patients were compared with nonpathway patients across the study period. Outcomes were assessed using multivariate regression, adjusting for patient and surgical characteristics, including intraoperative cerebrospinal fluid leak, postoperative DI, and tumor dimensions. RESULTS: One hundred eighty-seven patients were identified. Seventy-nine were on the INCU pathway. Mean age was 53.5 years. Most patients were male (66%), privately insured (62%), and white (66%). Mean total cost of admission was $27,276. Mean length of stay (LOS) was 3.97 days. Use of the INCU pathway was associated with total cost reduction of $6376.33 (P < 0.001, 95% confidence interval [CI]: $3698.21-$9054.45) and LOS reduction by 1.27 days (P = 0.008, 95% CI: 0.33-2.20). In-hospital costs were reduced across all domains, including $1964.87 in variable direct labor costs (P < 0.001, 95% CI: $1142.08-$2787.64) and $1206.52 in variable direct supply costs (P < 0.001, 95% CI: $762.54-$1650.51). Pathway patients were discharged earlier despite a higher rate of postoperative DI (25% vs. 11%, P = 0.011), with fewer readmissions (0% vs. 6%, P = 0.021). CONCLUSIONS: A streamlined care pathway following TSA surgery can reduce in-hospital costs and LOS without compromising patient outcomes.

Differential climatic conditions drive growth of Acacia tortilis tree in its range edges in Africa and Asia.

PREMISE: Tree growth is a fundamental biological process that is essential to ecosystem functioning and water and element cycling. Climate exerts a major impact on tree growth, with tree species often requiring a unique set of conditions to initiate and maintain growth throughout the growing season. Still, little is known about the specific climatic factors that enable tree growth in savannah and desert tree species. Among the global tree species, Acacia tortilis occupies one of the largest distribution ranges (crossing 6500 km and 54 latitudes), spanning large parts of Africa and into the Middle East and Asia. METHODS: Here we collected climate data and monitored Acacia tortilis tree growth (continuous measurements of stem circumference) in its southern and northern range edges in South Africa (SA) and Israel (IL), respectively, to elucidate whether the growth-climate interactions were similar in both edges. RESULTS: Growth occurred during the summer (between December and March) in SA and in IL during early summer and autumn (April-June and October-November, respectively). Surprisingly, annual growth was 40% higher in IL than in SA. Within the wide distribution range of Acacia tortilis, our statistical model showed that climatic drivers of tree growth differed between the two sites. CONCLUSIONS: High temperatures facilitated growth at the hot and arid IL site, while high humidity permitted growth at the more humid SA site. Our results confer an additional understanding of tree growth adaptation to extreme conditions in Acacia's world range edges, a major point of interest with ongoing climate change.

In-Hospital Cost Comparison for Open Versus Endoscopic Endonasal Approach for Meningioma Resection.

OBJECTIVE: To determine the in-hospital cost implications of an endoscopic expanded endonasal approach (EEEA) for meningioma resection relative to the open transcranial approach. METHODS: All anterior skull base meningioma surgeries performed over a period from January 1st, 2015 to October 31th, 2017 were evaluated. The electronic medical record was reviewed for patient factors, tumor characteristics, and cost variables associated with each hospital stay and univariate analysis was performed using R software. All cost data were converted into August 2021-equivalent dollar amounts using the United States Bureau of Labor Statistics consumer price index. RESULTS: Thirty-five patients met study criteria, including 27 patients undergoing an open transcranial approach and 8 undergoing an EEEA. Average length of stay for patients undergoing an open approach was 9.3 days compared to 5.6 within the EEEA group (P = .126). The average total in-hospital cost of patient undergoing an EEEA was $35417.1 compared to $46406.9 among patients undergoing an open transcranial approach (P = .168). On univariate analysis, the cost of an open transcranial approach relative to the EEEA was $10989.8 (P = .411). CONCLUSIONS: The open transcranial approach remained the dominant surgical approach to anterior skull base meningiomas over our study time period. However, despite limited patient numbers the EEEA was associated with decreased total in-hospital costs.