A novel simulation module for segmental mandibulectomy and mandible reconstruction using 3D models.

INTRODUCTION: Mandibular resection and reconstruction are common but complex procedures in head and neck surgery. Resection with adequate margins is critical to the success of the procedure but technical training is restricted to real case experience. Here we describe our experience in the development and evaluation of a mandibular resection and reconstruction simulation module. METHODS: 3D printed (3DP) models of a mandible with a pathologic lesion were developed from imaging data from a patient with an ameloblastoma. During an educational conference, otolaryngology trainees participated in a simulation in which they reviewed a CT scan of the pathologic mandible and then planned their osteotomies before and after handling a 3DP model demonstrating the lesion. The adequacy of the osteotomy margins was assessed and components of the simulation were rated by participants with pre- and post-training surveys. RESULTS: 52 participants met criteria. After reviewing the CT scan, 34 participants (65.3 %) proposed osteotomies clear of the lesion. This proportion improved to 48 (92.3 %, p = 0.001) after handling the 3D model. Among those with initially adequate margins (n = 33), 45.5 % decreased their margins closer to the ideal, 27.2 % made no revision, 21.2 % widened their margins. 92 % of participants found the simulation beneficial for surgical planning and technical training. After the exercise, the majority of participants had increased confidence in conceptualizing the boundaries of the lesion (69.2 %) and their abilities to ablate (76.5 %). CONCLUSIONS: The structured mandibulectomy simulation using 3DP models was useful in the development of trainee experience in segmental mandible resection. LAY SUMMARY: This study presents the first mandibulectomy simulation module for trainees with the use of 3DP models. The use of a 3DP model was also shown to improve the quality of surgical training.

Effect of the Law Enforcement Duty Belt on Muscle Activation during Hip Hinging Movements in Young, Healthy Adults.

Sixty percent of all law enforcement officers (LEOs) experience low back pain (LBP), with the LEO duty belt (LEODB) commonly reported to be a contributing factor. The primary purpose of the study was to investigate the LEODB's effect on muscular activity and compare it to a tactical vest, which is a commonly used alternative to an LEODB. In total, 24 participants (13 male, 11 female; mass, 73.0 ± 11.1 kg; height, 169.0 ± 10.0 cm; age, 24.0 ± 5.8 years) completed a progressive series of hip hinge tasks in a single testing session. All participants completed four conditions (no belt, leather belt, nylon belt, and weight VEST) in a randomized order. Surface electromyography (sEMG) sensors were placed bilaterally on the rectus abdominus, multifidus, biceps femoris, and rectus femoris. Across all tasks, no significant effects of load on muscle activity were found for any of the muscles. Participants rated the VEST condition as more comfortable (p < 0.05) and less restrictive (p < 0.05) than either LEODB. The findings suggest an LEODB does not alter muscle activity during bodyweight hip hinging or lifting objects from the ground. Future research should examine whether changes in muscle activity occur with durations of LEODB wear more similar to an actual work shift duration for LEOs (≥8 h).

Common law enforcement load carriage systems have limited acute effects on postural stability and muscle activity.

Law enforcement officers are inherently at a high risk of injury and the loads they must carry during their occupational duties further increase their injury risk. It is unknown how different methods of carrying a law enforcement officer's load influence factors related to injury risk. This study assessed the effects of common law enforcement load carriage systems on muscular activity and postural stability while standing. Twenty-four participants performed single and dual-task (i.e. concurrent performance of cognitive tasks) standing while wearing a duty belt, tactical vest, and no load. The postural stability and muscle activity were measured and effects of condition and task examined. Dual task standing decreased postural stability and increased muscular activity. The belt and vest (7.2 kg each) increased muscle activity compared to control for the right abdominals, low back, right thigh. The duty belt resulted in less muscle activity in the right abdominals but more muscle activity in the left multifidus compared to the control. The findings indicate that common law enforcement load carriage systems increase muscular activity but do not affect postural stability. However, the lack of differences between the duty belt and tactical vest did not provide clear support for one load carriage system versus the other.

Flipping the Otolaryngology Didactics Curriculum: Results of a Novel Resident Course Structure.

OBJECTIVE: To assess the impact of a novel flipped-classroom (FC) otolaryngology resident didactic curriculum on resident learning. METHODS: Based on the preferences elicited in a survey of preferred learning styles of residents, a hybrid web-based and in-person FC otolaryngology didactic curriculum was implemented over a 6-month period in 2020-2021. Resident reactions to the new curriculum were assessed via a second survey. Kruskal Wallis tests were used to compare mean stanine scores on the Otolaryngology Training Examination (OTE) exam for topics taught in the new format with topics delivered in the old format. RESULTS: After instituting the curriculum reform, engagement in at least a moderate amount of the pre-didactic work and synchronous case discussions was reported by 67% and 88% of the residents, respectively. After the curriculum change, residents in years PGY2 and above reported statistically significant increases in self-reported ability to retain information from didactics, to feel prepared for the OTE, and to feel confident in fund of knowledge (p < 0.001, p = 0.004, and p = 0.004, respectively). Compared to the prior year, mean stanine increased on OTE scores for residents in years PGY2-PGY5 to a statistically significant degree (5.45 vs. 4.41, p = 0.001) for the topics delivered in the new format compared to topics delivered in the traditional format (5.13 vs. 4.70, p = 0.07). CONCLUSION: By organizing a didactic curriculum through online modules that incorporate pre-recorded lectures and external resources, residents reported and demonstrated improved knowledge retention. LEVEL OF EVIDENCE: NA Laryngoscope, 133:2129-2134, 2023.

Effects of load carriage on measures of postural sway in healthy, young adults: A systematic review and meta-analysis.

Load carriage (LC) is a contributing factor to musculoskeletal injury in many occupations. Given that falls are a common mechanism of injury for those frequently engaging in LC, understanding the effects of LC on postural stability (PS) is necessary. A systematic review and meta-analysis was conducted to examine effects of LC on PS. Sixteen and 9 studies were included in the qualitative and quantitative synthesis, respectively. In most studies, it was found that LC leads to a decrease in PS with significant effects on center of pressure (COP) sway area (standardized mean difference = 0.45; p < 0.005) and COP anterior-posterior excursion (standardized mean difference = 0.52; p < 0.05). Furthermore, load magnitude and load placement are factors which can significantly affect COP measures of PS. It is recommended to minimize load magnitude and equally distribute load when possible to minimize LC effects on PS. Future research should examine additional factors contributing to differences in individual PS responses to LC such as changes in muscle activation and prior LC experience.

Upper body push to pull ratios in law enforcement officer recruits.

BACKGROUND: Law enforcement recruits (LER) often encounter shoulder injuries, which may cause attrition from academies. Investigating required upper body muscular fitness may inform of muscular balance around shoulder joints through anterior and posterior ratios in LER. OBJECTIVE: To investigate push to pull ratios (P2P) and factors related with P2P in LER. METHODS: LER (95 males; 12 females) completed testing during a single session in the academy's first week: body mass, one-repetition maximum (1RM) bench press, push-up repetitions (reps) to failure, and pull-up reps to failure. Calculations were: estimated pull-up 1RM=body mass+0.033*(body mass x pull-ups); endurance P2P (eP2P)=push-ups / pull-ups; strength P2P (sP2P)=bench press 1RM / estimated pull-up 1RM. Pearson correlation coefficients assessed relationships among tests and P2P (p < 0.05). RESULTS: The sP2P was positively correlated with bench press 1RM and push-ups. The eP2P was negatively associated with pull-up reps and 1RM. Females had similar eP2P, but lower sP2P than male recruits (p < 0.05). CONCLUSION: Practitioners may benefit from examining eP2P and sP2P as they should not be used interchangeably. Future research should examine whether the P2P ratios are associated with injury and subsequent inability to successfully complete law enforcement training academies.

Competitive Wetting: A New Approach to Prevent Liquid Penetration through Porous Materials with Superior Synergistic Effect.

Blocking liquid penetration in porous materials is a key function for several applications including chemical protective clothing (CPC), wound healing, and hygiene products. Enormous efforts are made to prevent liquid penetration through porous media by the modification of materials. CPC is used as an example to demonstrate the effect of the synergistic effect on liquid penetration. A common strategy to achieve liquid protection is the use of liquid-repellent surfaces with the aid of a liquid absorption liner layer. However, this strategy demonstrates limited success for low surface energy liquids. Herein, a novel approach is reported to prevent the permeation of liquid across porous materials by a synergistic effect. Both fabrics are individually susceptible to be wetted by low surface tension liquids. However, when they are assembled, they can prevent low surface tension liquids from penetrating because of the wettability gap between the two fabrics. The fabric assembly demonstrates an increase in the liquid prevention capacity by 70-1000 times compared with a commercial CPC material. This novel synergistic effect may offer a breakthrough in the development of various applications including protective clothing baby nappies, hygiene products, food preparation, soil water retention, and sporting/camping/ski equipment and clothing.

Resident Safety Huddles: Our Department's Experience in Improving Safety Culture.

OBJECTIVE/HYPOTHESIS: Our department sought to develop a quality improvement initiative in the interest of promoting resident involvement within the departmental safety culture. Specifically, we aimed to identify any barriers to incident reporting among residents and to create an approach to rectify this problem. STUDY DESIGN: Patient Safety/Quality Improvement. METHODS: This is a descriptive, qualitative study taking place at a large teaching hospital. A brief survey was administered to all Otorhinolaryngology residents and based on feedback a two-pronged approach to creating a patient safety and quality improvement curriculum was undertaken. This entailed implementation of 1) a formalized online curriculum and 2) a resident-driven forum for discussion of safety concerns termed a "Resident Safety Huddle." RESULTS: The survey identified three main barriers to incident reporting among residents, including increased workload, the punitive nature of the system, and fear of retribution. During the study period, the residents completed the curriculum required to obtain the Institute for Healthcare Improvement Basic Certificate of Quality and Safety and participated in 10 Resident Safety Huddles. Each huddle was dedicated to discussion of a unique safety concern and frequently led to sustainable solutions. After implementation of this curriculum, an increase in the number of safety events reported by residents was recognized. CONCLUSIONS: In building an educational foundation for incident reporting and further bolstering it with a resident-driven forum for discussion of safety concerns, we were able to achieve a recognizable and meaningful impact on our residents and the greater departmental safety culture. LEVEL OF EVIDENCE: 4 (single descriptive or qualitative study) Laryngoscope, 131:E1811-E1815, 2021.

Airway management of angioedema patients during the COVID-19 pandemic.

IMPORTANCE: The COVID-19 pandemic is characterized by high transmissibility from patients with prolonged minimally- or asymptomatic periods, with a particularly increased risk of spread during aerosol-generating procedures, including endotracheal intubation. OBSERVATIONS: All patients presenting with upper airway obstruction due to angioedema during this time should be carefully managed in a way that is safest for both patient and provider. CONCLUSIONS: For patients requiring emergent airway management during the COVID-19 pandemic, minimization of aerosols while taking the necessary precautions to protect healthcare workers should are critical principles for their management.

Outcomes After Tracheostomy in COVID-19 Patients.

OBJECTIVE: To determine the outcomes of patients undergoing tracheostomy for COVID-19 and of healthcare workers performing these procedures. BACKGROUND: Tracheostomy is often performed for prolonged endotracheal intubation in critically ill patients. However, in the context of COVID-19, tracheostomy placement pathways have been altered due to the poor prognosis of intubated patients and the risk of transmission to providers through this highly aerosolizing procedure. METHODS: A prospective single-system multi-center observational cohort study was performed on patients who underwent tracheostomy after acute respiratory failure secondary to COVID-19. RESULTS: Of the 53 patients who underwent tracheostomy, the average time from endotracheal intubation to tracheostomy was 19.7 days ±â€Š6.9 days. The most common indication for tracheostomy was acute respiratory distress syndrome, followed by failure to wean ventilation and post-extracorporeal membrane oxygenation decannulation. Thirty patients (56.6%) were liberated from the ventilator, 16 (30.2%) have been discharged alive, 7 (13.2%) have been decannulated, and 6 (11.3%) died. The average time from tracheostomy to ventilator liberation was 11.8 days ±â€Š6.9 days (range 2-32 days). Both open surgical and percutaneous dilational tracheostomy techniques were performed utilizing methods to mitigate aerosols. No healthcare worker transmissions resulted from performing the procedure. CONCLUSIONS: Alterations to tracheostomy practices and processes were successfully instituted. Following these steps, tracheostomy in COVID-19 intubated patients seems safe for both patients and healthcare workers performing the procedure.

The Influence of Social Modeling, Gender, and Empathy on Treatment Side Effects.

Background: Social modeling has the capacity to shape treatment outcomes, including side effects. Purpose: This study investigated the influence of social modeling of treatment side effects, gender, and participant empathy, on side effects of a placebo treatment. Methods: Ninety-six participants (48 females) completed a study purportedly investigating the influence of modafinil (actually placebo) on alertness and fatigue. The participants were randomly seated with a male or female confederate and saw this confederate report experiencing side effects or no side effects. Participant empathy was assessed at baseline. Changes in modeled and general symptoms, and misattribution of symptoms, were assessed during the session and at 24-hr follow-up. Results: During the experimental session, seeing side effect modeling significantly increased modeled symptoms (p = .023, d = 0.56) but not general or misattributed symptoms. Regardless of modeling condition, female participants seated with a female model reported significantly more general symptoms during the session. However, response to social modeling did not differ significantly by model or participant gender. At follow-up, the effect of social modeling of side effects had generalized to other symptoms, resulting in significantly higher rates of modeled symptoms (p = .023, d = 0.48), general symptoms (p = .013, d = 0.49), and misattributed symptoms (p = .022, d = 0.50). The experience of modeled symptoms in response to social modeling was predicted by participants' levels of baseline empathy. Conclusions: Social modeling of symptoms can increase the side effects following treatment, and this effect appears to generalize to a broader range of symptoms and symptom misattribution over time. Higher baseline empathy seems to increase response to social modeling.

Using Simulation to Improve Systems.

Attempts to understand and improve health care delivery often focus on the characteristics of the patient and the characteristics of the health care providers, but larger systems surround and integrate with patients and providers. Components of health care delivery systems can support or interfere with efforts to provide optimal health care. Simulation in situ, involving real teams participating in simulations in real care settings, can be used to identify latent safety threats and improve the work environment while simultaneously supporting participant learning. Thoughtful planning and skilled debriefing are essential.

The economic cost of measles: Healthcare, public health and societal costs of the 2012-13 outbreak in Merseyside, UK.

BACKGROUND: Measles is a highly contagious vaccine-preventable infection that caused large outbreaks in England in 2012 and 2013 in areas which failed to achieve herd protection levels (95%) consistently. We sought to quantify the economic costs associated with the 2012-13 Merseyside measles outbreak, relative to the cost of extending preventative vaccination to secure herd protection. METHODS: A costing model based on a critical literature review was developed. A workshop and interviews were held with key stakeholders in the Merseyside outbreak to understand the pathway of a measles case and then quantify healthcare activity and costs for the main NHS providers and public health team incurred during the initial four month period to May 2012. These data were used to model the total costs of the full outbreak to August 2013, comprising those to healthcare providers for patient treatment, public health and societal productivity losses. The modelled total cost of the full outbreak was compared to the cost of extending the preventative vaccination programme to achieve herd protection. FINDINGS: The Merseyside outbreak included 2458 reported cases. The estimated cost of the outbreak was £ 4.4m (sensitivity analysis £ 3.9 m to £ 5.2m) comprising 15% (£ 0.7 m) NHS patient treatment costs, 40% (£ 1.8m) public health costs and 44% (£ 2.0m) for societal productivity losses. In comparison, over the previous five years in Cheshire and Merseyside a further 11,793 MMR vaccinations would have been needed to achieve herd protection at an estimated cost of £ 182,909 (4% of the total cost of the measles outbreak). INTERPRETATION: Failure to consistently reach MMR uptake levels of 95% across all localities and sectors (achieve herd protection) risks comparatively higher economic costs associated with the containment (including healthcare costs) and implementation of effective public health management of outbreaks. FUNDING: Commissioned by the Cheshire and Merseyside Public Health England Centre.

Percutaneous laryngeal collagen augmentation for treatment of parkinsonian hypophonia.

OBJECTIVE: Our goal was to determine whether percutaneous laryngeal collagen augmentation improves hypophonia in parkinsonian patients. STUDY DESIGN AND SETTING: A retrospective review of 18 patients was performed. Patients and/or caretakers were called on the telephone and asked about their response to the procedure, if any. Videostroboscopic examinations for all patients were reviewed. RESULTS: Of 18 patients, 11 (61%) reported improvement in their hypophonia for a period of at least 2 months. Five of 7 patients without improvement were relatively aphonic both before and after the procedure. Five of 7 patients without improvement had severe dysphagia, which in 3 necessitated gastrostomy tube placement. Four of 7 patients without improvement were not ambulatory at the time of the procedure. CONCLUSIONS: Percutaneous laryngeal collagen augmentation is an effective treatment for parkinsonian hypophonia in a majority of patients. Patients with advanced neurologic disease with aphonia, difficulty with speech initiation, dysphagia, or ambulatory difficulty are less likely to respond to this procedure and should be so informed.