Low-Cost Ear Procedure Simulator With Syringe and Tuning Fork: Training Course and Results.

INTRODUCTION: Medical simulation is a continuously expanding field. In surgical specialties, in particular, simulation can provide an alternative avenue for learning. The objective of this process improvement project was to evaluate the effectiveness and practicality of adding simulation-based training to our educational curriculum regarding common otologic procedures. MATERIALS AND METHODS: A low-cost, novel ear procedure simulator was designed and constructed from readily available clinic supplies. Participants were asked to fill out a pre-simulator survey to assess their own comfort and skill level before undergoing the simulation course. A pre-simulation PowerPoint training course was then administered to participants. The participants then underwent the simulation training course and were again asked to fill out a post-simulator training exercise survey to reassess their own comfort and skill level. Institutional review board approval was not required by Tripler Army Medical Center. RESULTS: A total of 15 participants consisting of junior residents in otolaryngology, third- and fourth-year medical students rotating on an otolaryngology clinical clerkship, and one physician assistant in otolaryngology were included in the study. There was a significant improvement in both provider comfort with the procedure and clinical performance of the procedure among participants after training on the simulation-based model. CONCLUSIONS: Simulation-based training provides a safe, effective, and cost-friendly alternative to clinical medical education. Future studies are needed to address the wide-scale applicability of these results to other forms of surgical training.

Impact of a pediatric anesthesiologist on operating room efficiency during pediatric tonsillectomies and adenotonsillectomies.

We conducted a retrospective case review to determine if the presence of an Accreditation Council for Graduate Medical Education (ACGME) fellowship-trained pediatric anesthesiologist improves efficiency during pediatric tonsillectomies and adenotonsillectomies in hospitals that do not have dedicated pediatric operating rooms and, if so, to determine which specific anesthesia practices might account for such a difference. We reviewed the charts of all patients aged 12 years and younger who had undergone a tonsillectomy or adenotonsillectomy from Jan. 1, 2008, through Aug. 1, 2013, at San Francisco General Hospital. A total of 75 cases met our eligibility criteria. We compiled information on patient demographics, surgical time, anesthesia time, and anesthesia practices. Our primary study outcome was the amount of anesthesia-controlled time (ACT), which is the sum of time spent in induction and emergence. Cases were grouped according to whether the operation was staffed by an ACGME fellowship-trained pediatric anesthesiologist or a general anesthesiologist. Data were analyzed for 1 pediatric anesthesiologist and 23 general anesthesiologists. We found that ACT was significantly shorter during the cases staffed by the ACGME fellowship-trained pediatric anesthesiologist, although there were no major differences in anesthesia practices between the types of anesthesiologist. We suggest that staffing pediatric tonsillectomy operations with a fellowship-trained pediatric anesthesiologist may be an effective strategy for increasing operating room efficiency.

Nasal Dilators (Breathe Right Strips and NoZovent) for Snoring and OSA: A Systematic Review and Meta-Analysis.

Objective. To systematically review the international literature for studies evaluating internal (NoZovent) and external (Breathe Right Strips) nasal dilators as treatment for obstructive sleep apnea (OSA). Study Design. Systematic review with meta-analysis. Methods. Four databases, including PubMed/MEDLINE, were searched through September 29, 2016. Results. One-hundred twelve studies were screened, fifty-eight studies were reviewed, and fourteen studies met criteria. In 147 patients, the apnea-hypopnea index (AHI) was reported, and there was an improvement from a mean ± standard deviation (M ± SD) of 28.7 ± 24.0 to 27.4 ± 23.3 events/hr, p value 0.64. There was no significant change in AHI, lowest oxygen saturation, or snoring index in OSA patients when using nasal dilators. However, a subanalysis demonstrated a slight reduction in apnea index (AI) with internal nasal dilators (decrease by 4.87 events/hr) versus minimal change for external nasal dilators (increase by 0.64 events/hr). Conclusion. Although nasal dilators have demonstrated improved nasal breathing, they have not shown improvement in obstructive sleep apnea outcomes, with the exception of mild improvement in apnea index when internal nasal dilators were used.

Stapedectomy Effects on Tinnitus: Relationship of Change in Loudness to Change in Severity.

OBJECTIVE: To relate poststapedectomy change in tinnitus loudness to change in tinnitus severity. STUDY DESIGN: Prospective, within-subjects. SETTING: A single otology and neurotology subspecialty referral practice. SUBJECTS AND METHODS: Forty-nine subjects undergoing stapedectomy completed the study between January 2012 and October 2013. Tinnitus instruments, audiometric data, and demographic information were collected prior to and 1 and 6 months after surgery. Tinnitus loudness was assessed using an 11-point (0 = none; 5 = conversation level; 10 = jet engine) visual analog scale, and severity was measured using the validated Tinnitus Functional Index. The relationship between change in tinnitus loudness and change in tinnitus severity was evaluated using linear regression and receiver operating characteristic (ROC) analyses. RESULTS: A linear regression model of change in tinnitus loudness averaged for both ears on a visual analog scale (ΔVASavg) versus change in Tinnitus Functional Index score (ΔTFI) showed a strong correlation (ΔTFI = 9.35 ×ΔVASavg; R = 0.64; P < .001). An ROC analysis identified ΔVASavg between 1.5 and 2.0 as the optimal threshold for predicting a clinically significant change in tinnitus severity (ΔTFI ≥ 13), with sensitivity and specificity of approximately 0.62 and a positive predictive value (PPV) of 0.64. CONCLUSION: For poststapedectomy patients, a VAS loudness change by 1.5 to 2.0 points averaged for both ears in bilateral tinnitus or ~3 points in unilateral tinnitus has a PPV ~0.64 for a clinically significant change in tinnitus severity.

Attitudes toward Human Papilloma Virus Vaccination and Head and Neck Cancer Prevention in a Diverse, Urban Population.

OBJECTIVE: (1) To understand if awareness of the human papilloma virus (HPV) vaccination's potential to prevent head and neck cancer improves acceptability of the vaccine in a large urban population and (2) to identify characteristics of those in whom such discussions would have the greatest impact. STUDY DESIGN: In-person, anonymous survey. SETTING: Academic public hospital between March 2014 and June 2014. SUBJECTS: Patients aged 12 to 24 years and their parents or guardians awaiting scheduled outpatient pediatric appointments. METHODS: Demographics and modified Carolina HPV Immunization Attitudes and Beliefs Scales data were cross-analyzed, followed by univariate binomial logistic regression to identify predictors for major outcomes of interest. RESULTS: More than 78% of those surveyed indicated they would be more receptive to the HPV vaccine if given strong evidence that it prevented head and neck cancer. Respondents were more likely to increase receptivity to HPV vaccination if they held the belief that they did not have enough information about the vaccine or indicated they preferred to wait because the vaccine was too new. CONCLUSION: Increasing public awareness of head and neck cancer prevention with HPV vaccination could increase HPV vaccination acceptance.

Transcanal blind sac closure of the external auditory canal after skull base surgery to treat CSF leak: technique and results.

OBJECTIVE: To report outcomes of a novel transcanal blind sac closure technique of the external auditory canal (EAC) with obliteration of the Eustachian tube orifice to treat CSF leaks after skull base surgery. STUDY DESIGN: Clinical capsule report. SETTING: University hospital. PATIENTS: Ten patients who have undergone a transcanal blind sac closure of the EAC after skull base surgery to treat CSF leak between 2004 and 2012. INTERVENTIONS: Transcanal blind sac closure of the EAC. MAIN OUTCOME MEASURES: Resolution rate of postoperative CSF leak, time to final resolution of CSF leak, and complications. RESULTS: The CSF leak resolution rate, with subsequent conservative management in some cases, is approximately 80%. One case of postsurgical pseudomeningocele was identified. CONCLUSION: Transcanal blind sac closure of the EAC with obliteration of the Eustachian tube orifice provides a rapid and safe method to treat CSF leak after skull base surgery, without the need to reenter the original surgical wound or mastoid cavity.

Avian cone photoreceptors tile the retina as five independent, self-organizing mosaics.

The avian retina possesses one of the most sophisticated cone photoreceptor systems among vertebrates. Birds have five types of cones including four single cones, which support tetrachromatic color vision and a double cone, which is thought to mediate achromatic motion perception. Despite this richness, very little is known about the spatial organization of avian cones and its adaptive significance. Here we show that the five cone types of the chicken independently tile the retina as highly ordered mosaics with a characteristic spacing between cones of the same type. Measures of topological order indicate that double cones are more highly ordered than single cones, possibly reflecting their posited role in motion detection. Although cones show spacing interactions that are cell type-specific, all cone types use the same density-dependent yardstick to measure intercone distance. We propose a simple developmental model that can account for these observations. We also show that a single parameter, the global regularity index, defines the regularity of all five cone mosaics. Lastly, we demonstrate similar cone distributions in three additional avian species, suggesting that these patterning principles are universal among birds. Since regular photoreceptor spacing is critical for uniform sampling of visual space, the cone mosaics of the avian retina represent an elegant example of the emergence of adaptive global patterning secondary to simple local interactions between individual photoreceptors. Our results indicate that the evolutionary pressures that gave rise to the avian retina's various adaptations for enhanced color discrimination also acted to fine-tune its spatial sampling of color and luminance.