Is mandibular osteomyelitis a sequela of SSRI-induced dental implant failure? A systematic review & case report.

BACKGROUND: To determine if the utilization of selective serotonin reuptake inhibitors (SSRIs) increases the risk of osteomyelitis as a sequela of dental implant failure. We also report the case of a patient on long-term SSRIs who presented with dental implant failure and subsequently developed mandibular osteomyelitis. METHODS: We performed a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) in PubMed, Google Scholar and Embase, for all records pertaining to SSRIs, dental implants, and mandibular osteomyelitis. RESULTS: SSRIs are associated with increased risk of dental implant failure, and our results suggest that they may be independently associated with mandibular osteomyelitis in the setting of implant failure. Though there was no evidence of mandibular osteomyelitis specifically following SSRI-related dental implant failure, there were a few case reports on osteomyelitis resulting from failed dental implant osseointegration. CONCLUSIONS: In the context of long-term SSRI utilization, our findings suggest that osteomyelitis should be considered in the differential diagnosis of patients with recent dental implant placement or failure.

Effects of Cross-Training on Medical Teams' Teamwork and Collaboration: Use of Simulation.

Previous research in the US Navy demonstrated that cross-training enhances teamwork and interpersonal collaboration. Limited data exists on cross-training effectiveness in medical education. This research aimed to assess whether cross-training would have similar effects on medical teams. A multidisciplinary pair of resident participants-consisting of one physician and one pharmacist-was randomly assigned to cross-training or current training condition. The training experience involved one video-based content module (training a pharmacist's task of pharmacokinetic dosing and a physician's task of intubation) and one simulation-based practice scenario (collaborative treatment of an unstable critically ill simulated patient). Interprofessional pairs randomized to cross-training condition participated in both the content module and practice scenario in the alternative professional role whereas pairs randomized to current training condition participated in their own professional role. Pairs also participated in pre- and post- training assessment scenarios in their own professional role. Teamwork and interprofessionalism were measured immediately following assessment scenarios. Knowledge assessments were conducted at the start and end of the scenario sequence. Multidisciplinary pairs experiencing cross-training showed a significant improvement in teamwork (increased by 6.11% vs. 3.24%, p < 0.05). All participants demonstrated significant improvement in knowledge scores (increase of 14% cross-training, p < 0.05, and increase of 13.9% control, p < 0.05). Our project suggests that cross-training can improve teamwork in interprofessional medical teams.

Novel minimally invasive transoral surgery bleeding model implemented in a nationwide otolaryngology emergencies bootcamp.

Post-operative hemorrhage is the most concerning complication after minimally invasive transoral surgery, as can result in airway compromise. Simulation-based medical education provides trainees with structured learning in an intensive and immersive environment allowing deliberate practice of skills and behaviors in the management of real-life situations. We implemented a novel post-oropharyngeal surgery bleeding model in a nationwide otolaryngology emergencies bootcamp, to teach and evaluate technical and non-technical skills required to competently manage this clinical scenario. 28 Otolaryngology residents from 11 programs in Canada participated in the annual Otolaryngology Emergencies Bootcamp of Western University in London, Ontario. After teaching technical aspects of emergency surgical airways in models, the course culminated with a complex scenario of a post-minimally invasive transoral surgery bleeding model using a fresh cadaver. The Non-Technical Skills for Surgeons (NOTSS) rating scale was applied to video analysis and a scenario-specific Medical Expert Checklist was implemented. The model design in a cadaveric torso is described for use in a simulation of a high-volume oropharyngeal bleed after a minimally invasive approach. Participants agreed that the model evoked an elevated degree of realism and conveyed the emotion of a life-threatening event. NOTSS analysis identified a marginal score in the domains of decision-making and communication and teamwork. Critical action checklist analysis highlighted the early mobilization of available resources and time to decision for surgical airway. We present the first report of a post-minimally invasive transoral surgery bleeding model. It was successful in recreating with high fidelity such a high-stake event and to teach technical and non-technical skills.

Using Voogle to Search Within Patient Records in the VA Corporate Data Warehouse.

The VA has developed a tool to search its Corporate Data Warehouse, which provides easy access to patient data for better clinical decision making.

The Emerging Field of Geriatric Otolaryngology.

Sub-specialization within otolaryngology, like other specialties, is driven by accumulation of new knowledge and technology. For a variety of reasons, the establishment of a new subspecialty of geriatric otolaryngology is unlikely. Education of all otolaryngologists in the basic principles of gerontology and geriatric otolaryngology is achievable and represents a preferred strategy.

Balance Disorders in Older Adults.

Balance disorders are common in the elderly and can lead to falls, with resultant severe morbidity and even mortality. Progressive loss of vestibular function begins in middle age and is affected by multiple disease processes. Polypharmacy impacts many disease processes in the elderly, with balance function being one of the most susceptible. Evaluation of the older patient with a balance disorder is critical for the well-being of these patients, as it may drive intervention. This article reviews balance disorders often encountered in older patients and makes recommendations regarding education of nonotolaryngologists.

Geriatric Dysphagia.

Geriatric dysphagia is an unrecognized and underdiagnosed problem with significant morbidity and potential mortality. It requires diligence by the clinician and a team approach for successful management. Careful history-taking is the key in the treatment of these patients and determines further workup, as well as treatment.

Frailty and Polypharmacy in Older Patients with Otolaryngologic Diseases.

Frailty and Polypharmacy commonly impact disease processes and treatment of patients with otolaryngologic disorders. Although well known to geriatricians, the 2 concepts often elude other physicians, including otolaryngologists. This article reviews the common manifestations likely to be encountered in otolaryngology patients, reviews frailty measures in surgical patients, and makes recommendations regarding education of nongeriatricians.

Teach the teacher: Training otolaryngology fellows to become academic educators.

OBJECTIVES/HYPOTHESIS: Fellowship is the capstone of academic training and serves as preparation for an academic career. Fellows are expected to educate medical students and residents during and long after fellowship. However, little time is typically spent teaching fellows to become effective educators. We investigate a formal curriculum addressing teaching skills among fellows in otolaryngology-head and neck surgery (OHNS). STUDY DESIGN: E-mail survey. METHODS: We developed and implemented an educational program called Teach the Teacher to build skills as educators for fellows in OHNS. We conducted a survey of fellows from 2014 to 2017 in OHNS who participated in the course. The survey evaluated demographics, teaching experiences, and teaching limitations structured as yes/no and Likert-style questions (1 = strongly disagree, 5 = strongly agree). RESULTS: Thirty fellows were surveyed with a response rate was 80%. Fellowship was rated highly as an experience that will make fellows a better academic educator (mean ± standard deviation: 4.54 ± 0.64). The most important components of teaching during fellowship were role modeling (4.67 ± 0.62), followed by teaching psychomotor skills in the operating room (4.29 ± 0.89), diagnostic reasoning (4.25 ± 0.66), and evidence-based medicine (4.25 ± 0.83). The Teach the Teacher course specifically was rated as a helpful experience (4.00 ± 0.90). The primary limitations to developing teaching skills during fellowship identified were lack of time, patient safety, and inexperience with hospital culture. CONCLUSIONS: Fellowship is a key time to improve skills as academic educators. Fellows value formal efforts to teach academic skills. LEVEL OF EVIDENCE: NA. Laryngoscope, 128:2034-2048, 2018.

Assessing Use Errors Related to the Interface Design of Electrosurgical Units.

Medical device use errors, such as instrument connection errors made with electrosurgical units (ESUs), can lead to adverse events. Current device acquisition processes at health care facilities do not typically include a proactive evaluation of use-error risk before device purchase. We conducted an evaluation to identify ESU user interface design features that can help prevent or mitigate instrument connection errors during clinical care. Thirty-six current ESU users participated in the evaluation. We used a randomized crossover design in which each participant used two ESU models in a simulated OR scenario. We compared participants' instrument connection accuracy, efficiency, and subjective feedback regarding the user interface design across the two ESU models. Overall, we found that the ESU model that incorporated more user interface design principles resulted in better performance and increased acceptance from users. Based on the results, we designed a decision-support tool to assess the risk of instrument connection errors before ESU purchase.

Label Design Affects Medication Safety in an Operating Room Crisis: A Controlled Simulation Study.

OBJECTIVE: Several factors contribute to medication errors in clinical practice settings, including the design of medication labels. The objective of this study was to quantify the impact of label design on medication safety in a realistic, high-stress clinical situation. METHODS: Ninety-six anesthesia trainee participants were randomly assigned to either the redesigned or the current label condition. Participants were blinded to the study's focus on medication label design and their assigned label condition. Each participant was the sole anesthesia provider in a simulated operating room scenario involving an unexpected vascular injury. The surgeon asked the participant to administer hetastarch to the simulated patient because of hemodynamic instability. The fluid drawer of the anesthesia cart contained three 500-ml intravenous bags of hetastarch and one 500-ml intravenous bag of lidocaine. We hypothesized that redesigned labels would help participants correctly select hetastarch from the cart. If the participants incorrectly selected lidocaine from the cart, we hypothesized that the redesigned labels would help participants detect the lidocaine before administration. RESULTS: The percentage of participants who correctly selected hetastarch from the cart was significantly higher for the redesigned labels than the current labels (63% versus 40%; odds ratio, 2.61 [95% confidence interval, 1.1-6.1]; P = 0.03). Of the participants who incorrectly selected lidocaine from the cart, the percentage who detected the lidocaine before administration did not differ by label condition. CONCLUSIONS: The redesigned labels helped participants correctly select hetastarch from the cart, thus preventing some potentially catastrophic medication errors from reaching the simulated patient.

Complex Malignancies: A Diagnostic and Therapeutic Trilemma.

A patient presented with esophageal adenocarcinoma, pulmonary small-cell carcinoma, and high-grade carcinoma, which is a rare occurrence that required a staged multidisciplinary approach to treatment.

We're not there yet.

Patient injury due to medical error continues to plague health care delivery. Efforts to eliminate errors or mitigate their effects have largely been thwarted, despite enormous investments of human and financial resources. A survey published in this issue of Otolaryngology-Head and Neck Surgery on the status of medical error in otolaryngology finds that the specialty is not exempt. The authors report that relatively little has changed since the original report by the senior authors published a decade ago. Despite this lack of apparent progress, there is growing awareness that improvements in patient safety will be incremental rather than transformational. The author of this commentary identifies a number of fundamental cultural changes that will be required to achieve transformational change.

Commentary on the role of expert opinion in developing evidence-based guidelines.

Evidence-based clinical practice guidelines (CPGs) help guide busy practitioners in clinical decision making. CPGs are evidence-based in that recommendations are based on available knowledge derived from published clinical trials. The challenges presented by the tasks of finding, assessing, interpreting, and assembling the information in these reports are herculean. Missing or imperfect evidence may lead to the publication of suboptimal guidelines, even when the other components of the development process have been flawlessly performed. This commentary highlights the requirement that expert opinion must be explicitly recognized by CPG authoring groups when the published evidence is missing or inadequate.

Perioperative process errors and delays in otolaryngology at a Veterans Hospital: prospective study.

OBJECTIVES/HYPOTHESIS: To understand the leading causes for process errors and delays in the otolaryngology operating room and recognize the impact of process errors and delays on patient safety, operating room resources and hospital costs. STUDY DESIGN: Prospective, observational study. METHODS: A 4-week study was conducted during 1 calendar month in 2012, evaluating 23 elective otolaryngology cases. A standardized data collection tool was developed and refined based on prestudy pilot observations. Two trained observers recorded relevant times and actions from patient check-in time in the preoperative holding area to the "wheels out" time. RESULTS: The mean case observation time was 220.0 ± 167.8 minutes, with mean duration of operation length being 107.0 ± 146.2 minutes. The perioperative period was divided into six stages: patient holding, room preparation, preintubation, postintubation, intraoperative, and postextubation. One hundred process errors were recorded (average of 4.3 per case), 34% of which were due to communication failures. Forty delays were observed, resulting in 336 minutes of standstill delay. Again, communication failures represented the most common etiology, with 17 communication failures resulting in 146 minutes of standstill delay. The preintubation stage was most affected by delay, with 1 in 6 minutes comprising standstill delay. CONCLUSION: Process errors and significant delays were common in cases performed at our institution; communication errors were the most common etiology. There is opportunity for preoperative team discussion and the use of technology to minimize communication-related process errors and standstill delays. Further work is currently being undertaken to study this critical issue across specialties.