Tympanostomy Tubes or Medical Management for Recurrent Acute Otitis Media.

BACKGROUND: Official recommendations differ regarding tympanostomy-tube placement for children with recurrent acute otitis media. METHODS: We randomly assigned children 6 to 35 months of age who had had at least three episodes of acute otitis media within 6 months, or at least four episodes within 12 months with at least one episode within the preceding 6 months, to either undergo tympanostomy-tube placement or receive medical management involving episodic antimicrobial treatment. The primary outcome was the mean number of episodes of acute otitis media per child-year (rate) during a 2-year period. RESULTS: In our main, intention-to-treat analysis, the rate (±SE) of episodes of acute otitis media per child-year during a 2-year period was 1.48±0.08 in the tympanostomy-tube group and 1.56±0.08 in the medical-management group (P = 0.66). Because 10% of the children in the tympanostomy-tube group did not undergo tympanostomy-tube placement and 16% of the children in the medical-management group underwent tympanostomy-tube placement at parental request, we conducted a per-protocol analysis, which gave corresponding episode rates of 1.47±0.08 and 1.72±0.11, respectively. Among secondary outcomes in the main analysis, results were mixed. Favoring tympanostomy-tube placement were the time to a first episode of acute otitis media, various episode-related clinical findings, and the percentage of children meeting specified criteria for treatment failure. Favoring medical management was children's cumulative number of days with otorrhea. Outcomes that did not show substantial differences included the frequency distribution of episodes of acute otitis media, the percentage of episodes considered to be severe, and antimicrobial resistance among respiratory isolates. Trial-related adverse events were limited to those included among the secondary outcomes of the trial. CONCLUSIONS: Among children 6 to 35 months of age with recurrent acute otitis media, the rate of episodes of acute otitis media during a 2-year period was not significantly lower with tympanostomy-tube placement than with medical management. (Funded by the National Institute on Deafness and Other Communication Disorders and others; ClinicalTrials.gov number, NCT02567825.).

Intelligence quotient testing in children with hearing loss: A systematic review.

OBJECTIVE: The objective of the current study is to perform a systematic review of the research literature to evaluate the impact of hearing loss on intelligence quotient (IQ) scores in pediatric patients. DATA SOURCES: Ovid MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched from their inception up to December 21st, 2021. REVIEW METHODS: Studies evaluating neurocognitive testing and hearing loss in children aged 21 years old or younger who had not undergone auditory rehabilitation were included in the study. Two independent reviewers evaluated titles, abstracts, and full texts for all included studies. RESULTS: The literature search yielded 3199 studies of which 431 studies underwent full-text screening. 21 studies were ultimately selected for inclusion and contained a total of 1716 pediatric patients assessed through 13 different validated tests of intelligence. Six studies included both hearing impaired (HI) and normal hearing (NH) patients, and IQ testing results. CONCLUSION: The results of this large systematic review demonstrate that hearing impaired children may perform lower than their age-matched normal hearing peers on IQ testing across a battery of IQ testing modalities.

Practice trends in pediatric sudden sensorineural hearing loss management: An unresolved diagnosis.

PURPOSE: Assess practice patterns amongst pediatric otolaryngologist for the management of children with SSNHL. MATERIALS AND METHODS: A cross-sectional online survey of members of the American Society of Pediatric Otolaryngology (ASPO) was performed; 135 responded. Patterns in treatment modalities, ancillary tests, and timing of treatment and follow-up were evaluated. These patterns were compared between respondents with different characteristics (number of years in practice, clinic location, and number of pediatric SSNHL cases within the last year) using ordered logistic regression, Kruskal-Wallis, Wilcoxon rank-sum, and Fisher's exact tests. RESULTS: Mean time from onset of hearing loss to presentation to a pediatric otolaryngologist was 10 days (range 1-60 days). The most cited reasons for delay in care were 'patient not seeking any healthcare evaluation' (65 %) and 'lack of access to obtain an audiogram' (54 %). The most ordered blood work was complete blood count (14 %) and herpes simplex testing (15 %). Complete blood count was ordered more frequently by physicians in practice for >10 years compared with those in practice 1-10 years, P = 0.03. Most respondents reported treating with systemic steroids (86/92, 93 %), including intratympanic steroids (32/92, 35 %). Treatment with systemic steroids was more common in academic compared with private practice, P = 0.03. Antivirals were the most common additional agent prescribed (14/89, 16 %). Most patients were seen in follow-up 1-4 weeks after diagnosis (63/85, 74 %). CONCLUSIONS: Most pediatric otolaryngologists treat SSNHL with systemic steroids. The remainder of the diagnostic and management paradigm varies significantly, highlighting the need to systematically define which treatment optimizes outcomes in this population.

PORP vs. TORP in children: A systematic review and meta-analysis.

OBJECTIVES: To compare the mean pre-operative air-bone gaps (ABG), mean post-operative ABGs, and extrusion rates between pediatric recipients of partial ossicular reconstruction prostheses (PORPs) and pediatric recipients of total ossicular reconstruction prostheses (TORPs) via a systematic review and meta-analysis. METHODS: A quantitative systematic review last updated on September 29, 2021 of PubMed, Scopus, and Embase databases was conducted for studies reporting mean post-operative ABGs or numbers of children with post-operative ABG ≤ 20 dB following PORP and TORP procedures in at least five children aged 0-18 years. Studies were excluded if they were review articles, conference abstracts, or not in English. Studies that primarily reported data on congenital aural atresia, stapedectomy/stapedotomy, congenital stapes fixation, or juvenile otosclerosis were also excluded. NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies was used to assess for risk of bias. Review Manager (RevMan) version 5.4.1 was used to perform the meta-analysis and generate forest plots. RESULTS: Out of 648 unique abstracts retrieved, 11 papers were included in this systematic review with meta-analysis. Data from 449 children (247 TORP recipients and 202 TORP recipients) are represented among the various analyses. Data from nine studies, representing 84.2 % of all children in the systematic review, demonstrated that PORP recipients presented with a pre-operative ABG 6.30 dB less than TORP recipients (mean difference: -6.30, 95 %CI: -7.4, -5.18, p < 0.01). Data from these same children demonstrated that PORP recipients had a 1.80 dB less post-operative ABG compared to TORP recipients (mean difference: -1.80 dB, 95 %CI: -2.84, -0.77, p < 0.001). Data from seven studies, representing 49.4 % of all children in the systematic review, demonstrated that PORP recipients were more likely to have a successful closure of the post-operative ABG to ≤20 dB (OR: 2.12, 95 %CI: 1.18, 3.79, p = 0.01). In these same children, 62.5 % of PORP recipients had a post-operative ABG ≤ 20 dB and 48.3 % of TORP recipients had a post-operative ABG ≤ 20 dB. There was no difference in extrusion rates between PORP recipients compared to TORP recipients (OR: 1.08, 95 %CI: 0.31, 3.78, p = 0.90) from five studies representing 45.9 % children in the systematic review. CONCLUSION: Children who receive a PORP have better pre-operative hearing baselines and post-operative hearing outcomes compared to those who receive TORP with similar rates of extrusion. More pediatric studies should report their mean pre- and post-operative ABGs stratifying by various material types, surgical indications, and surgical details to facilitate future meta-analyses.

A Surgical Framework for the Management of Incomplete Axillary Nerve Injuries.

BACKGROUND: Axillary nerve injury is the most common nerve injury affecting shoulder function. Nerve repair, grafting, and/or end-to-end nerve transfers are used to reconstruct complete neurotmetic axillary nerve injuries. While many incomplete axillary nerve injuries self-resolve, axonotmetic injuries are unpredictable, and incomplete recovery occurs. Similarly, recovery may be further inhibited by superimposed compression neuropathy at the quadrangular space. The current framework for managing incomplete axillary injuries typically does not include surgery. METHODS: This study is a retrospective analysis of 23 consecutive patients with incomplete axillary nerve palsy who underwent quadrangular space decompression with additional selective medial triceps to axillary end-to-side nerve transfers in 7 patients between 2015 and 2019. Primary outcome variables included the proportion of patients with shoulder abduction M3 or greater as measured on the Medical Research Council (MRC) scale, and shoulder pain measured on a Visual Analogue Scale (VAS). Secondary outcome variables included pre- and postoperative Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH) scores. RESULTS: A total of 23 patients met the inclusion criteria and underwent nerve surgery a mean 10.7 months after injury. Nineteen (83%) patients achieved MRC grade 3 shoulder abduction or greater after intervention, compared with only 4 (17%) patients preoperatively (p = 0.001). There was a significant decrease in VAS shoulder pain scores of 4.2 ± 2.5 preoperatively to 1.9 ± 2.4 postoperatively (p < 0.001). The DASH scores also decreased significantly from 48.8 ± 19.0 preoperatively to 30.7 ± 20.4 postoperatively (p < 0.001). Total follow-up was 17.3 ± 4.3 months. CONCLUSION: A surgical framework is presented for the appropriate diagnosis and surgical management of incomplete axillary nerve injury. Quadrangular space decompression with or without selective medial triceps to axillary end-to-side nerve transfers is associated with improvement in shoulder abduction strength, pain, and DASH scores in patients with incomplete axillary nerve palsy.

Estrogen receptor signaling is reprogrammed during breast tumorigenesis.

Limited knowledge of the changes in estrogen receptor (ER) signaling during the transformation of the normal mammary gland to breast cancer hinders the development of effective prevention and treatment strategies. Differences in estrogen signaling between normal human primary breast epithelial cells and primary breast tumors obtained immediately following surgical excision were explored. Transcriptional profiling of normal ER+ mature luminal mammary epithelial cells and ER+ breast tumors revealed significant difference in the response to estrogen stimulation. Consistent with these differences in gene expression, the normal and tumor ER cistromes were distinct and sufficient to segregate normal breast tissues from breast tumors. The selective enrichment of the DNA binding motif GRHL2 in the breast cancer-specific ER cistrome suggests that it may play a role in the differential function of ER in breast cancer. Depletion of GRHL2 resulted in altered ER binding and differential transcriptional responses to estrogen stimulation. Furthermore, GRHL2 was demonstrated to be essential for estrogen-stimulated proliferation of ER+ breast cancer cells. DLC1 was also identified as an estrogen-induced tumor suppressor in the normal mammary gland with decreased expression in breast cancer. In clinical cohorts, loss of DLC1 and gain of GRHL2 expression are associated with ER+ breast cancer and are independently predictive for worse survival. This study suggests that normal ER signaling is lost and tumor-specific ER signaling is gained during breast tumorigenesis. Unraveling these changes in ER signaling during breast cancer progression should aid the development of more effective prevention strategies and targeted therapeutics.

Complete Foot Drop With Normal Electrodiagnostic Studies: Sunderland "Zero" Ischemic Conduction Block of the Common Peroneal Nerve.

ABSTRACT: Common peroneal neuropathy is a peripheral neuropathy of multifactorial etiology often left undiagnosed until foot drop manifests and electrodiagnostic abnormalities are detected. However, reliance on such striking symptoms and electrodiagnostic findings for diagnosis stands in contrast to other commonly treated neuropathies, such as carpal tunnel and cubital tunnel syndrome. Poor recognition of common peroneal neuropathy without foot drop or the presence of foot drop with normal electrodiagnostic studies thus often results in delayed or no surgical treatment. Our cases document 2 patients presenting with complete foot drop who had immediate resolution after decompression. The first patient presented with normal electrodiagnostic studies representing an isolated Sunderland Zero nerve ischemia. The second patient presented with severe electrodiagnostic studies but also had an immediate improvement in their foot drop representing a Sunderland VI mixed nerve injury with a significant contribution from an ongoing Sunderland Zero ischemic conduction block. In support of recent case series, these patients demonstrate that common peroneal neuropathy can present across a broad diagnostic spectrum of sensory and motor symptoms, including with normal electrodiagnostic studies. Four clinical subtypes of common peroneal neuropathy are presented, and surgical decompression may thus be indicated for these patients that lack the more conventional symptoms of common peroneal neuropathy.

Estrogen-regulated feedback loop limits the efficacy of estrogen receptor-targeted breast cancer therapy.

Endocrine therapy resistance invariably develops in advanced estrogen receptor-positive (ER+) breast cancer, but the underlying mechanisms are largely unknown. We have identified C-terminal SRC kinase (CSK) as a critical node in a previously unappreciated negative feedback loop that limits the efficacy of current ER-targeted therapies. Estrogen directly drives CSK expression in ER+ breast cancer. At low CSK levels, as is the case in patients with ER+ breast cancer resistant to endocrine therapy and with the poorest outcomes, the p21 protein-activated kinase 2 (PAK2) becomes activated and drives estrogen-independent growth. PAK2 overexpression is also associated with endocrine therapy resistance and worse clinical outcome, and the combination of a PAK2 inhibitor with an ER antagonist synergistically suppressed breast tumor growth. Clinical approaches to endocrine therapy-resistant breast cancer must overcome the loss of this estrogen-induced negative feedback loop that normally constrains the growth of ER+ tumors.

Identifying barriers and considerations for cochlear implantation in Amish children.

OBJECTIVE: To determine if barriers to cochlear implantation (CI) exist with respect to Amish children and to describe unique considerations associated with CI and subsequent otologic care in the Amish population. METHODS: Out of all patients who underwent CI at a tertiary care pediatric hospital from 2008 to 2019, Amish children were age-matched to the remainder of the cohort to compare demographics and care-related metrics including etiology of hearing loss, age at time of initial hearing-related appointment and at CI, total number of pre- and post-operative audiologic and otologic appointments, and post-operative complications. Social considerations that may pose barriers to care were collected for descriptive analysis. RESULTS: Since 2008, 232 children underwent CI, of which 8 implants were performed on Amish children. Six (75%) Amish children underwent newborn hearing screening and 3(38%) were found to have syndromic etiology for hearing loss. While Amish patients had a lower number of both audiologic (15 vs 33.5, p<.001) and otologic (4.5 vs 8.5, p=.028) appointments when compared to age-matched controls, median age at the time of implantation for the whole sample was not different between groups (2.5 vs 2.0 years, p=.211). From a social standpoint, limitations in transportation, telephone communication, and ability to recharge processor batteries must be considered in the Amish population. CONCLUSION: Amish children undergoing CI face unique barriers to care including transportation and technologic limitations, leading to overall fewer hearing-related appointments when compared to an age-matched cohort. Understanding societal differences is important to facilitate optimal care for Amish children with hearing loss.

Natural Killer Cell Phenotype and Functionality Affected by Exposure to Extracellular Survivin and Lymphoma-Derived Exosomes.

The inherent abilities of natural killer (NK) cells to recognize and kill target cells place them among the first cells with the ability to recognize and destroy infected or transformed cells. Cancer cells, however, have mechanisms by which they can inhibit the surveillance and cytotoxic abilities of NK cells with one believed mechanism for this: their ability to release exosomes. Exosomes are vesicles that are found in abundance in the tumor microenvironment that can modulate intercellular communication and thus enhance tumor malignancy. Recently, our lab has found cancer cell exosomes to contain the inhibitor of apoptosis (IAP) protein survivin to be associated with decreased immune response in lymphocytes and cellular death. The purpose of this study was to explore the effect of survivin and lymphoma-derived survivin-containing exosomes on the immune functions of NK cells. NK cells were obtained from the peripheral blood of healthy donors and treated with pure survivin protein or exosomes from two lymphoma cell lines, DLCL2 and FSCCL. RNA was isolated from NK cell samples for measurement by PCR, and intracellular flow cytometry was used to determine protein expression. Degranulation capacity, cytotoxicity, and natural killer group 2D receptor (NKG2D) levels were also assessed. Lymphoma exosomes were examined for size and protein content. This study established that these lymphoma exosomes contained survivin and FasL but were negative for MHC class I-related chains (MIC)/B (MICA/B) and TGF-ß. Treatment with exosomes did not significantly alter NK cell functionality, but extracellular survivin was seen to decrease natural killer group 2D receptor (NKG2D) levels and the intracellular protein levels of perforin, granzyme B, TNF-α, and IFN-γ.

Plastic Surgery in the Time of COVID-19.

BACKGROUND: The novel coronavirus disease 2019 (COVID-19) has swept the world in the last several months, causing massive disruption to existing social, economic, and health care systems. As with all medical fields, plastic and reconstructive surgery has been profoundly impacted across the entire spectrum of practice from academic medical centers to solo private practice. The decision to preserve vital life-saving equipment and cancel elective procedures to protect patients and medical staff has been extremely challenging on multiple levels. Frequent and inconsistent messaging disseminated by many voices on the national stage often conflicts and serves only to exacerbate an already difficult decision-making process. METHODS: A survey of relevant COVID-19 literature is presented, and bioethical principles are utilized to generate guidelines for plastic surgeons in patient care through this pandemic. RESULTS: A cohesive framework based upon core bioethical values is presented here to assist plastic surgeons in navigating this rapidly evolving global pandemic. CONCLUSION: Plastic surgeons around the world have been affected by COVID-19 and will adapt to continue serving their patients. The lessons learned in this present pandemic will undoubtedly prove useful in future challenges to come.

En Bloc Capsulectomy for Breast Implant Illness: A Social Media Phenomenon?

BACKGROUND: En bloc capsulectomy has recently increased in prominence as a potential surgical therapy for patients with breast implant illness (BII). However, this procedure has chiefly been recommended for treating breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). OBJECTIVES: This study aimed to review the current literature and evaluate the public understanding of treatment options for BII via social media to characterize any potential communication disconnect between clinicians and patients. METHODS: An electronic literature review was performed to identify all available publications mentioning evidence-based support for en bloc capsulectomy as treatment for BII and BIA-ALCL. Twitter social media posts referencing BII or BIA-ALCL were analyzed from 2010 to 2019. Author identity and any mention of surgical treatment were assessed. RESULTS: A total of 115 publications on the subject of BII and 315 articles on BIA-ALCL were identified. En bloc resection was recommended only for patients with a diagnosis of BIA-ALCL. A total of 6419 tweets referencing BII and 6431 tweets referencing BIA-ALCL were identified. Tweets referencing BIA-ALCL were significantly more likely to be authored by physicians (25.9% vs 5.3%, P < 0.001), and tweets referencing BII were significantly more likely to mention any surgical treatment (7.8% vs 1.9%, P < 0.001) and en bloc capsulectomy (1.4% vs 0.3%, P < 0.001). CONCLUSIONS: This study demonstrates that a communication disconnect exists between the scientific literature and social media regarding treatment options for BII and BIA-ALCL. Physicians should be aware of these potential misconceptions to empathetically address patient concerns in a patient-centered manner.

Follow-up after failed newborn hearing screening: Parental and primary care provider awareness.

PURPOSE: The current loss to follow-up rate after failed newborn hearing screening (NBHS) is 34.4%. Previous studies have found that lack of parental and primary care provider (PCP) awareness of NBHS results are significant contributors to loss to follow-up. The objective of this study was to identify factors associated with parental and PCP awareness of NBHS results. MATERIALS AND METHODS: Retrospective cohort study. A survey asking about demographics and knowledge of NBHS testing and results was offered to parents in the waiting room of an urban pediatric primary care office. Included were biological parents ≥18 years of age of children ≤10 years of age born in Pennsylvania. Each child's chart was reviewed for PCP documentation of NBHS results. The odds of knowing NBHS results were evaluated using logistic regression. RESULTS: The survey was completed by 304 parents. 74.0% were aware of their child's NBHS results. Child age ≥1 year old (OR: 0.49, 95%CI[0.29, 0.82], P = 0.007) and Hispanic ethnicity (OR: 0.38, 95%CI[0.16, 0.89], P = 0.03) were associated with decreased odds of a parent knowing NBHS results. In addition, fewer fathers knew the results of their child's NBHS compared with mothers (OR: 0.33, 95%CI[0.18, 0.62], P < 0.001). However, parental awareness was not associated with birthing facility or insurance type. 222 charts were reviewed for NBHS documentation, revealing PCP awareness in 95.5% of cases and no associations with any of the factors examined. CONCLUSIONS: Factors associated with parents not knowing NBHS results included being the parent of an older child, Hispanic, or the father.

Comparative Effectiveness of Transversus Abdominis Plane Blocks in Abdominally Based Autologous Breast Reconstruction: A Systematic Review and Meta-analysis.

BACKGROUND: The abdomen is the most common donor site in autologous microvascular free flap breast reconstruction and contributes significantly to postoperative pain, resulting in increased opioid use, length of stay, and hospital costs. Enhanced Recovery After Surgery (ERAS) protocols have demonstrated multiple clinical benefits, but these protocols are widely heterogeneous. Transversus abdominis plane (TAP) blocks have been reported to improve pain control and may be a key driver of the benefits seen with ERAS pathways. METHODS: A systematic review and meta-analysis of studies reporting TAP blocks for abdominally based breast reconstruction were performed. Studies were extracted from 6 public databases before February 2019 and pooled in accordance with the PROSPERO registry. Total opioid use, postoperative pain, length of stay, hospital cost, and complications were analyzed using a random effects model. RESULTS: The initial search yielded 420 studies, ultimately narrowed to 12 studies representing 1107 total patients. Total hospital length of stay (mean difference, -1.00 days; P < 0.00001; I = 81%) and opioid requirement (mean difference, -133.80 mg of oral morphine equivalent; P < 0.00001; I = 97%) were decreased for patients receiving TAP blocks. Transversus abdominis plane blocks were not associated with any significant differences in postoperative complications (P = 0.66), hospital cost (P = 0.22), and postoperative pain (P = 0.86). CONCLUSIONS: Optimizing postoperative pain management after abdominally based microsurgical breast reconstruction is invaluable for patient recovery. Transversus abdominis plane blocks are associated with a reduction in length of stay and opioid use, representing a safe and reasonable strategy for decreasing postoperative pain.

The Influence of Connective Tissue Disease in Breast Reconstruction: A National Database Analysis.

BACKGROUND: Patients with connective tissue diseases (CTD), or collagen vascular diseases, are at risk of potentially higher morbidity after surgical procedures. We aimed to investigate the complication profile in CTD versus non-CTD patients who underwent breast reconstruction on a national scale. METHODS: A retrospective analysis of the Healthcare Cost and Utilization Project NIS Database between 2010 and 2014 was conducted for patients 18 years or older admitted for immediate autologous or implant breast reconstruction. Connective tissue disease was defined as systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis, scleroderma, Raynaud phenomenon, psoriatic arthritis, or sarcoidosis. Independent t test/Wilcoxon-Mann-Whitney was used to compare continuous variables and Pearson χ/Fischer exact test was used for categorical variables. Outcomes of interest were assessed using multivariable linear regressions for continuous variables and multivariable logistic regressions for categorical variables. RESULTS: There were 19,496 immediate autologous breast reconstruction patients, with 357 CTD and 19,139 non-CTD patients (2010-2014). The CTD patients had higher postoperative complication rates for infection (2.8% vs 0.8%, P < 0.001), wound dehiscence (1.4% vs 0.4%, P = 0.019), and bleeding (hemorrhage and hematoma) (6.7% vs 3.5%, P < 0.001). After multivariable analysis, CTD remained an independent risk factor for bleeding (odds ratio [OR], 1.568; 95% confidence interval [CI], 1.019-2.412). There were a total of 23,048 immediate implant breast reconstruction patients, with 431 CTD and 22,617 non-CTD patients (2010-2014). The CTD patients had a higher postoperative complication rate for wound dehiscence/complication (2.3% vs 0.6%, P < 0.001). They also experienced a longer length of stay (2.31 days vs 2.07 days, P < 0.001). After multivariable analysis, CTD remained an independent risk factor for wound dehiscence (OR, 4.084; 95% CI, 2.101-7.939) and increased length of stay by 0.050 days (95% CI, -0.081 to 0.181). CONCLUSIONS: Connective tissue disease patients who underwent autologous breast reconstruction had significantly higher infection, wound dehiscence, and bleeding rates, and those who underwent implant breast reconstruction had significantly higher wound dehiscence rates. Connective tissue diseases appear to be an independent risk factor for bleeding and wound dehiscence in autologous and implant breast reconstruction, respectively. This information may help clinicians be aware of this increased risk when determining patients for reconstruction.

Drivers of Hospital Costs in the Self-Pay Facelift (Rhytidectomy) Patient: Analysis of Hospital Resource Utilization in 1890 Patients.

INTRODUCTION: Rhytidectomy is one of the most commonly performed cosmetic procedures by plastic surgeons. Increasing attention to the development of a high-value, low-cost healthcare system is a priority in the USA. This study aims to analyze specific patient and hospital factors affecting the cost of this procedure. METHODS: We conducted a retrospective cohort study of self-pay patients over the age of 18 who underwent rhytidectomy using the Healthcare Utilization Cost Project National Inpatient Sample database between 2013 and 2014. Mean marginal cost increases patient characteristics, and outcomes were studied. Generalized linear modeling with gamma regression and a log-link function were performed along with estimated marginal means to provide cost estimates. RESULTS: A total of 1890 self-pay patients underwent rhytidectomy. Median cost was $11,767 with an interquartile range of $8907 [$6976-$15,883]. The largest marginal cost increases were associated with postoperative hematoma ($12,651; CI $8181-$17,120), West coast region ($7539; 95% CI $6412-$8666), and combined rhinoplasty ($7824; 95% CI $3808-$11,840). The two risk factors associated with the generation of highest marginal inpatient costs were smoking ($4147; 95% CI $2804-$5490) and diabetes mellitus ($5622; 95% CI $3233-8011). High-volume hospitals had a decreased cost of - $1331 (95% CI - $2032 to - $631). CONCLUSION: Cost variation for inpatient rhytidectomy procedures is dependent on preoperative risk factors (diabetes and smoking), postoperative complications (hematoma), and regional trends (West region). Rhytidectomy surgery is highly centralized and increasing hospital volume significantly decreases costs. Clinicians and hospitals can use this information to discuss the drivers of cost in patients undergoing rhytidectomy. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Resource Utilization and Risk Factors for Esophageal Injury in Pediatric Esophageal Foreign Bodies.

OBJECTIVE: While management protocols of pediatric esophageal foreign bodies (EFBs) are well-delineated, resource utilization can be improved. This study's objectives were to explore hospital charges/costs for pediatric patients who present with EFBs and to identify patient risk factors associated with esophageal injury. METHODS: A retrospective chart review of patients undergoing aerodigestive foreign body removal at a tertiary-care children's hospital from 2018 to 2021 was conducted. Data collected included demographics, medical history, presenting symptoms, EFB type, surgical findings, and hospital visit charges/costs. RESULTS: 203 patients were included. 178 of 203 (87.7%) patients were admitted prior to operation. Unwitnessed EFB ingestion (p < 0.001, OR = 15.1, 95% CI = 5.88-38.6), experiencing symptoms for longer than a week (p < 0.001, OR = 11.4, 95% CI = 3.66-38.6) and the following presenting symptoms increased the odds of esophageal injury: dysphagia (p = 0.04, OR = 2.45, 95% CI = 1.02-5.85), respiratory distress (p = 0.005, OR = 15.5, 95% CI = 2.09-181), coughing (p < 0.001, OR = 10.1, 95% CI = 3.73-28.2), decreased oral intake (p = 0.001, OR = 6.60, 95% CI = 2.49-17.7), fever (p = 0.001, OR = 5.52, 95% CI = 1.46-19.6), and congestion (p = 0.001, OR = 8.15, 95% CI = 2.42-27.3). None of the 51 asymptomatic patients had esophageal injury. The median total charges during the encounter was $20,808 (interquartile range: $18,636-$24,252), with operating room (OR) (median: $5,396; 28.2%) and inpatient admission (median: $5,520; 26.0%) contributing the greatest percentage. CONCLUSIONS: Asymptomatic patients with EFBs did not experience esophageal injury. The OR and inpatient observation accounted for the greatest percentage of the hospital charges. These results support developing a potential algorithm to triage asymptomatic patients to be managed on a same-day outpatient basis to improve the value of care. LEVEL OF EVIDENCE: Level 3 Laryngoscope, 2024.

Socioeconomic status and pediatric cochlear implant usage during COVID-19.

OBJECTIVE: COVID-19 (COVID) delayed access to speech and hearing services. The objective of this study was to identify interactions between socioeconomic status (SES) and cochlear implant (CI) usage during COVID. METHODS: Consecutive pediatric patients (age 0-17) with CI and audiology visits between 2019 and 2022 at a tertiary care children's hospital were reviewed. Age, sex, race, insurance type, and proxy measures for SES using zip code were recorded. Hours spent with CI on and in different listening environments were compared between pre-COVID (1/1/2019-12/31/2019), COVID (4/1/2020-3/31/2021), and most recent (6/1/2021-5/31/2022) time periods. RESULTS: Most patients were male (32/59, 54 % ears of 48 patients) and White, non-Hispanic (45/59, 76 %). Median age at implant was 2.0 years (range:0.6-12.2). There were no significant differences in hours spent with CI on during COVID compared with pre-COVID. However, children spent more time listening to louder noises (70-79 dB and ≥80 dB) recently compared with during COVID (p = 0.01 and 0.006, respectively). During COVID, children living in areas with greater educational attainment showed smaller reductions in total hours with CI on (ß = 0.1, p = 0.02) and hours listening to speech in noise (ß = 0.03, p = 0.005) compared with pre-COVID. In the most recent time period, children of minority race (ß = -3.94 p = 0.008) and those who were older at implant (ß = -0.630, p = 0.02) were more likely to experience reductions in total hours with CI on compared with during COVID. CONCLUSION: Interventions which mitigate barriers of implant use and promote rich listening home-environments for at risk populations should be implemented during challenging future social and environmental conditions.

Degrees of Inflammation in the Treatment of Subglottic Stenosis in a Rabbit Model: Histopathological Assessment of a Novel Bioabsorbable Ultra-high Ductility Magnesium Alloy Stent.

OBJECTIVE: Utilizing a novel histopathological scoring system and subglottic stenosis (SGS) rabbit model, we aimed to compare degrees of inflammation and severity of narrowing in the subglottis between two minimally invasive therapeutic modalities: endoscopic balloon dilation (EBD) alone versus EBD with placement of a bioabsorbable ultra-high ductility magnesium (UHD-Mg) alloy stent. METHODS: SGS was induced endoscopically via microsuspension laryngoscopy in 23 New Zealand white rabbits. The control group (n = 11) underwent EBD alone, the study arm (n = 12) underwent EBD with implantation of bioabsorbable UHD-Mg alloy stents. Rabbits were euthanized at 2-, 3-, and 6-weeks after SGS induction, coinciding with wound healing stages. Using Optical Coherence Tomography (OCT), cross-sectional areas of airways were compared to calculate the mean percentage of intraluminal area at sequential time points. A novel histopathological scoring system was used to analyze frozen sections of laryngotracheal complexes. The degree of inflammation was quantified by scoring changes in inflammatory cell infiltration, epithelial ulceration/metaplasia, subepithelial edema/fibrosis, and capillary number/dilation. Univariate analysis was utilized to analyze these markers. RESULTS: We found rabbits implanted with the bioabsorbable UHD-Mg alloy stent had statistically significantly higher scores in categories of hyperplastic change (stents vs controls: 1.48 vs 0.46 p < 0.001), squamous metaplasia (22 vs 5 p < 0.001), and neutrophils/fibrin in lumen (31 vs 8, p < 0.001). Rabbits who received EBD alone had higher scores of subepithelial edema and fibrosis (2.70 vs 3.49, p < 0.0256). The stented rabbits demonstrated significantly increased mean percent stenosis by intraluminal mean area compared to controls at 2 weeks (88.56 vs 58.98, p = 0.032), however at all other time points there was no significant difference between intraluminal subglottic stenosis by mean percent stenosis area. DISCUSSION: Rabbits with SGS treated with UHD-Mg alloy stents demonstrated histopathologic findings suggestive of lower levels of tracheal fibrosis. This could indicate a reduced tendency towards the development of stenosis when compared to EBD alone. There was not a difference in luminal size between stent and non-stented rabbits at the six-week end point. Histologically, however, overall the use of bioabsorbable UHD-Mg alloy stenting elicited a greater tissue response at the level of the superficial mucosa rather than fibrosis of the lamina propria seen in the stented rabbits. This suggests more favorable healing and less of a tendency towards fibrosis and stenosis even though there may not be a benefit from a luminal size standpoint during this early healing period. Compared to known complications of currently available non-bioabsorbable metal or silicone-based stents, this proof-of-concept investigation highlights the potential use of a novel biodegradable UHD-Mg stent as a therapeutic modality for pediatric SGS.

Escalating Surgical Treatment for Left Ventricular Assist Device Infection and Expected Mortality: Clinical Risk Prediction Score.

BACKGROUND: Left ventricular assist devices (LVAD) improve survival for patients with cardiac failure, but LVAD specific infections (VSI) remain a challenge with poorly understood predictive risk factors. Furthermore, the indications and utility of escalating medical treatment to surgical debridement and potential flap reconstruction are not well-characterized. STUDY DESIGN: A retrospective review of consecutive patients undergoing primary LVAD implantation at a tertiary academic center was performed. The primary outcomes measures were 90-day and overall mortality after VSI. Cox proportional hazards regression was used to generate a risk-prediction score for mortality. RESULTS: Of the 760 patients undergoing primary LVAD implantation, 255 (34%) developed VSI; of these 91 (36%) were managed medically, 134 (52%) with surgical debridement, and 30 (12%) with surgical debridement and flap reconstruction. One-year survival after infection was 85% with median survival of 2.40 years. Factors independently associated with increased mortality were diabetes (hazard ratio (HR) 1.44, p=0.04), methicillin-resistant Staphylococcus aureus infection (HR 1.64, p=0.03), deep space (pump pocket/outflow cannula) involvement (HR 2.26, p<0.001) and extra-corporeal membrane oxygenation after LVAD (HR 2.52, p<0.01. Factors independently associated with decreased mortality were flap reconstruction (HR 0.49, p=0.02) and methicillin-sensitive Staphylococcus aureus infection (HR 0.63, p=0.03). A clinical risk prediction score was developed using these factors and showed significant differences in median survival, which was 5.67 years for low-risk (score 0-1), 3.62 years for intermediate-risk (score 2), and 1.48 years for high-risk (score >3) (p<0.001) patients. CONCLUSIONS: We developed a clinical risk prediction score to stratify VSI patients. In selected cases, escalating surgical treatment was associated with increased survival. Future work is needed to determine if early surgical debridement and flap reconstruction can alter outcomes in select cases of VSI.