An early experience on the effect of solid organ transplant status on hospitalized COVID-19 patients.

We compared the outcome of COVID-19 in immunosuppressed solid organ transplant (SOT) patients to a transplant naïve population. In total, 10 356 adult hospital admissions for COVID-19 from March 1, 2020 to April 27, 2020 were analyzed. Data were collected on demographics, baseline clinical conditions, medications, immunosuppression, and COVID-19 course. Primary outcome was combined death or mechanical ventilation. We assessed the association between primary outcome and prognostic variables using bivariate and multivariate regression models. We also compared the primary endpoint in SOT patients to an age, gender, and comorbidity-matched control group. Bivariate analysis found transplant status, age, gender, race/ethnicity, body mass index, diabetes, hypertension, cardiovascular disease, COPD, and GFR <60 mL/min/1.73 m2 to be significant predictors of combined death or mechanical ventilation. After multivariate logistic regression analysis, SOT status had a trend toward significance (odds ratio [OR] 1.29; 95% CI 0.99-1.69, p = .06). Compared to an age, gender, and comorbidity-matched control group, SOT patients had a higher combined risk of death or mechanical ventilation (OR 1.34; 95% CI 1.03-1.74, p = .027).

Effect of Remdesivir vs Standard Care on Clinical Status at 11 Days in Patients With Moderate COVID-19: A Randomized Clinical Trial.

Importance: Remdesivir demonstrated clinical benefit in a placebo-controlled trial in patients with severe coronavirus disease 2019 (COVID-19), but its effect in patients with moderate disease is unknown. Objective: To determine the efficacy of 5 or 10 days of remdesivir treatment compared with standard care on clinical status on day 11 after initiation of treatment. Design, Setting, and Participants: Randomized, open-label trial of hospitalized patients with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and moderate COVID-19 pneumonia (pulmonary infiltrates and room-air oxygen saturation >94%) enrolled from March 15 through April 18, 2020, at 105 hospitals in the United States, Europe, and Asia. The date of final follow-up was May 20, 2020. Interventions: Patients were randomized in a 1:1:1 ratio to receive a 10-day course of remdesivir (n = 197), a 5-day course of remdesivir (n = 199), or standard care (n = 200). Remdesivir was dosed intravenously at 200 mg on day 1 followed by 100 mg/d. Main Outcomes and Measures: The primary end point was clinical status on day 11 on a 7-point ordinal scale ranging from death (category 1) to discharged (category 7). Differences between remdesivir treatment groups and standard care were calculated using proportional odds models and expressed as odds ratios. An odds ratio greater than 1 indicates difference in clinical status distribution toward category 7 for the remdesivir group vs the standard care group. Results: Among 596 patients who were randomized, 584 began the study and received remdesivir or continued standard care (median age, 57 [interquartile range, 46-66] years; 227 [39%] women; 56% had cardiovascular disease, 42% hypertension, and 40% diabetes), and 533 (91%) completed the trial. Median length of treatment was 5 days for patients in the 5-day remdesivir group and 6 days for patients in the 10-day remdesivir group. On day 11, patients in the 5-day remdesivir group had statistically significantly higher odds of a better clinical status distribution than those receiving standard care (odds ratio, 1.65; 95% CI, 1.09-2.48; P = .02). The clinical status distribution on day 11 between the 10-day remdesivir and standard care groups was not significantly different (P = .18 by Wilcoxon rank sum test). By day 28, 9 patients had died: 2 (1%) in the 5-day remdesivir group, 3 (2%) in the 10-day remdesivir group, and 4 (2%) in the standard care group. Nausea (10% vs 3%), hypokalemia (6% vs 2%), and headache (5% vs 3%) were more frequent among remdesivir-treated patients compared with standard care. Conclusions and Relevance: Among patients with moderate COVID-19, those randomized to a 10-day course of remdesivir did not have a statistically significant difference in clinical status compared with standard care at 11 days after initiation of treatment. Patients randomized to a 5-day course of remdesivir had a statistically significant difference in clinical status compared with standard care, but the difference was of uncertain clinical importance. Trial Registration: ClinicalTrials.gov Identifier: NCT04292730.

Is metformin poised for a second career as an antimicrobial?

Metformin, a widely used antihyperglycaemic, has a good safety profile, reasonably manageable side-effects, is inexpensive, and causes a desirable amount of weight loss. In 4 studies of patients with tuberculosis (1 prospective and 3 retrospective), metformin administration resulted in better outcomes. In mice with several models of endotoxemia, metformin diminished levels of proinflammatory cytokines and improved survival. Laboratory studies showed effectiveness of the drug on multiple pathogens, including Trichinella spiralis, Staphylococcus aureus, Pseudomonas aeruginosa, hepatitis B virus, hepatitis C virus, and human immunodeficiency virus. Metformin administration in humans and mice produced major changes in the composition of the gut microbiota. These recently discovered microbe-modulating properties of the drug have led investigators to predict wide therapeutic utility for metformin. The recent easing in United States Food and Drug Administration (FDA) guidelines regarding administration of metformin to patients with kidney disease, and reduced anxiety about patient safety in terms of lactic acidosis, increase the probability of broadening of metformin's usage as a treatment of infectious agents. In this text we review articles pertinent to metformin's effects on microorganisms, both pathogens and commensals. We highlight the possible role of metformin in a wide range of infectious diseases and a possible expansion of its therapeutic profile in this field. A systematic review was done of PubMed indexed articles that examined the effects of metformin on a wide range of pathogens. Metformin was found to have efficacy as an antimicrobial agent in patients with tuberculosis. Mice infected with Trypanosomiasis cruzi had higher survival when also treated with metformin. The drug in vitro was active against T. spiralis, S. aureus, P. aeruginosa, and hepatitis B virus. In addition there is emerging literature on its role in sepsis. We conclude that metformin may have a potential role in the therapy for multiple infectious diseases. Metformin, in addition to its traditional effects on glucose metabolism, provides anti-microbial benefits in patients with tuberculosis and in a very wide range of other infections encounters in vitro and in vivo.

Impact of Respiratory Viral Panel Polymerase Chain Reaction Assay Turnaround Time on Length of Stay and Antibiotic Use in Patients With Respiratory Viral Illnesses.

Background: Respiratory viral illnesses account for many hospitalizations and inappropriate antibiotic use. Respiratory viral panels by polymerase chain reaction (RVP-PCR) provide a reliable means of diagnosis. In 2015, the RVP-PCR assay at our institution was switched from respiratory viral panel (RVP) to rapid respiratory panel (rapid RP), which has a faster turnaround time (24 hours vs 12 hours, respectively). The purpose of this study was to evaluate the effect of RVP-PCR tests on duration of antibiotic use and length of stay (LOS) in hospitalized patients. Methods: We performed a retrospective chart review of patients who had a RVP-PCR ordered within a 1-year time period before and after the assay switch. Patients who were pregnant, had received antibiotics within 30 days prior to admission, were not discharged, or had not completed antibiotics by end of study period were excluded. Results: Data were obtained from a total of 140 patients (70 in each group). Of these, 25 (35.7%) in the RVP group and 28 (40.0%) in the rapid RP group had a positive result. The median LOS was 4.5 days (IQR, 3-9 days) in the RVP group and 5 days (IQR, 3-9 days) in the rapid RP group (P = .78). The median duration of antibiotic use was 4 days (IQR, 2-7 days) in the RVP group and 5 days (IQR, 1-7 days) in the rapid RP group (P = .8). Conclusion: Despite faster turnaround time, there was no significant difference in duration of antibiotic use, or LOS between the RVP and rapid RP groups.

Clinical Features of Respiratory Viral Infections Among Inpatients at a Major US Tertiary Care Hospital.

OBJECTIVES: Respiratory viral illnesses (RVI) are reliably diagnosed by respiratory viral panel using polymerase chain reaction (RVP-PCR); however, owing to the scant data, clinical presentation alone is unreliable in establishing viral etiology. The primary objective of this study was to characterize signs and symptoms of RVI among inpatients in a major tertiary care hospital. METHODS: Between 2013 and 2015, adult inpatients with RVI undergoing RVP-PCR were prospectively enrolled in our study. Clinical data were collected by interviews and electronic medical record reviews. Data analysis was performed using χ(2) testing, analysis of variance for continuous variables, and logistic regression modeling. RESULTS: Of 421 patients analyzed, 175 (41.7%) had a positive RVP-PCR. Patients were evenly matched at baseline except for renal disease. Multivariate logistic regression modeling demonstrated the following positive correlations: positive RVP-PCR with renal disease (odds ratio [OR] 2.08), cough (OR 2.28), and wheezing (OR 1.8); influenza with cough (OR 5.04), and renal disease (OR 2.17); metapneumovirus with age older than 65 (OR 3.24); respiratory syncytial viruses with wheezing (OR 3.42) and immunosuppression (OR 3.11); and parainfluenza with smoking (OR 3.16). Negative correlations included influenza with anosmia (OR 0.41); rhinovirus/enterovirus with feeling confined to bed (OR 0.3); metapneumovirus with smoking (OR 0.29); and parainfluenza with male sex (OR 0.22). CONCLUSIONS: In this descriptive study, we noted specific viral associations with clinical signs and symptoms among 421 inpatients with RVIs. With increasing RVP-PCR use, studies similar to ours may be able to better define the clinical presentation of RVIs and lead to evidence-based, clinical presentation-guided diagnostic and management algorithms.

Successful Treatment of Peritoneal Dialysis Catheter-Related Polymicrobial Peritonitis Involving Clostridium difficile.

Clostridium difficile is one of the most common nosocomial pathogens and the cause of pseudomembranous colitis in cases of prior antimicrobial exposure. Extraintestinal manifestations of C. difficile are uncommon and rarely reported. We report the first successfully treated case of catheter-related C. difficile peritonitis in a patient undergoing peritoneal dialysis.

Study protocol for Hear Me Read (HMR): A prospective clinical trial assessing a digital storybook intervention for young children who are deaf or hard of hearing.

Since the early 2000's, digital reading applications have enhanced the language and literacy skills of typically hearing young children; however, no digital storybook intervention currently exists to scaffold the early language and literacy skills of their peers who are deaf or hard of hearing. To address this gap, our research team developed a novel digital storybook intervention called Hear Me Read with the aim of enhancing the therapeutic, language, and literacy benefits of speech-language therapy. This prospective clinical trial (registered at clinicaltrials.gov, NCT#: 05245799) aims to determine the efficacy of adding Hear Me Read to in-person speech-language therapy for children aged three to five years who are deaf or hard of hearing. Fifty caregivers, their child, and their child's treating speech-language pathologist participate in the trial for 12 months. In the first six months, children attend standard-of-care speech-language therapy sessions. In the second six months, children continue to attend standard-of-care speech-language therapy sessions and use the Hear Me Read application, via a study supplied iPad. The primary outcome of this trial is that, compared to in-person speech-language therapy alone, in-person speech-language therapy with Hear Me Read will improve vocabulary, speech, and language outcomes in children aged three to five years who are deaf or hard of hearing. The secondary outcome is that, compared to in-person speech-language therapy alone, in-person speech-language therapy with Hear Me Read will improve literacy outcomes in children aged three to five years who are deaf or hard of hearing. The goal of this intervention is to help children who are deaf or hard of hearing achieve their vocabulary, speech, language, and literacy goals through interactive digital storybook reading.

Evidence for validity of the epidemic-pandemic impacts inventory (brief healthcare module): Internal structure and association with other variables.

The COVID-19 pandemic has subjected healthcare workers to enormous stress. Measuring the impact of this public health emergency is essential to developing strategies that can effectively promote resilience and wellness. The Epidemic-Pandemic Impacts Inventory Supplemental Healthcare Module-Brief Version (EPII-SHMb) was developed to measure impacts among occupational cohorts serving on the front lines of healthcare. While this instrument has been utilized in COVID-19 related studies, little is known about its psychometric properties. This study collects evidence for validity of the EPII-SHMb by evaluating its internal structure and how its scores associate with other variables. Physicians and nursing staff across a large New York health system were cross-sectionally surveyed using an online questionnaire between June and November 2020. Exploratory factor analysis resulted in a 3-factor solution, identifying factors Lack of Workplace Safety (7 items), Death/Dying of Patients (3 items), and Lack of Outside Support (2 items). Internal consistency was high overall and within physician/nursing and gender subgroups (Cronbach's alpha: 0.70 - 0.81). Median scores on Death/Dying of Patients were higher among those who directly cared for COVID-19 patients or worked in COVID-19 hospital units. These results are promising. Additional studies evaluating other dimensions of validity are necessary.

Recognition and Management of Nonaccidental Esophageal Perforation.

Nonaccidental trauma is a common pediatric concern that often goes unrecognized. Although most patients present with bruising, burns, fractures, and head trauma, it is critical that physicians be able to diagnose and treat atypical presentations such as pharyngeal and esophageal trauma. In this report, we describe the presentation and management of a 5-week-old girl with an inflicted esophageal perforation.

The impact of cochlear implantation on speech and language outcomes in children with asymmetric sensorineural hearing loss.

INTRODUCTION: Cochlear implantation (CI) is considered in children with asymmetric sensorineural hearing loss (ASHL), or severe to profound sensorineural hearing loss in one ear, and better hearing contralaterally. The benefits of a CI in these children are not well established. This study investigated the impact of unilateral CI on speech and language outcomes in pediatric patients with ASHL. METHODS: The retrospective chart review identified pediatric patients who underwent cochlear implantation for ASHL at a tertiary single center institution between 2014 and 2017. Children who underwent cochlear implantation in the poorer ear and maintained a hearing aid in the better ear were included, while children with cognitive impairment or prior cochlear nerve deficiency and auditory neuropathy were excluded. Speech and language measures were evaluated prior to implantation and at regular six-month intervals postoperatively. Ear specific Audiometry was evaluated at every visit and varied developmentally appropriate speech recognition tasks, including questionnaires, closed-set, and open-set measures, accounted for advancing childhood milestones. Specific measures of speech articulation, expressive and receptive language, and vocabulary were assessed including: Goldman Fristoe Test of Articulation (GFTA-3), Clinical Evaluation of Language Fundamentals (CELF-P2 or CELF-5), Receptive One-Word Picture Vocabulary Test (ROWPVT) and Expressive One Word Picture Vocabulary Test (EOWPVT). The mean difference and standard deviation of speech and language outcomes at preoperative and postoperative evaluations were calculated. The change in outcomes were further assessed over each post-operative time point. RESULTS: Twenty-six children with asymmetric sensorineural hearing loss were included in the analysis, with 11 (42%) having bilateral enlarged vestibular aqueducts (EVA). At time of CI, unaided mean Pure Tone Average (PTA-4) for the better ear was 62Db HL, and worse ear was 92Db HL. There was an improvement in speech recognition in the implanted ear as expected. All preoperative speech and language evaluations were conducted within 7 months of cochlear implantation. Twenty-three patients had at least 1 postoperative re-evaluation. Fourteen children had preoperative and postoperative assessments with the same tool, with 13 patients (93%) showing improvement in at least 1 domain. For patients with repeated assessment within 12 months of surgery, we observed an average improvement in standard scores of: GFTA-3 (+11.2), CELF-P2 Core Language (+10.3), CELF-5 Core Language (+7.0), ROWPVT (+2.8) and EOWPVT (+4.5). Individual results are described. CONCLUSION: Improvement in speech and language measures can be demonstrated in children undergoing unilateral cochlear implantation for asymmetric sensorineural hearing losses. These children, who are not typical CI candidates, can benefit from a CI in the poorer ear.

The Impact of Physicians' COVID-19 Pandemic Occupational Experiences on Mental Health.

OBJECTIVE: To examine the association between a number of negative COVID-19 occupational experiences and probable anxiety, depression, and PTSD among physicians. METHODS: Cross-sectional examination of longitudinal registry data consisting of physician personal and occupational well-being. Multivariable logistic regressions were performed to determine the association between negative COVID-19 experiences and outcomes. RESULTS: Of the 620 eligible physicians, approximately half were female (49%), and 71% white with a mean age of 46.51 (SD = 13.28). A one-point increase in negative experience score was associated with a 23% increase in probable anxiety (OR = 1.23, 95% CI: 1.14-1.34), a 23% increase in probable depression (OR = 1.23, 95% CI: 1.13-1.33), and a 41% increase in probable PTSD (OR = 1.41, 95% CI: 1.30-1.52). CONCLUSIONS: Negative pandemic experiences were strongly associated with adverse mental health outcomes while greater resilience was protective.

Evaluating burnout during the COVID-19 pandemic among physicians in a large health system in New York.

PURPOSE: The COVID-19 pandemic has generated significant psychological distress among health care workers worldwide. New York State, particularly New York City and surrounding counties, were especially affected, and experienced over 430,000 COVID-19 cases and 25,000 deaths by mid-August 2020. We hypothesized that physicians and trainees (residents/fellows) who were redeployed outside of their specialty to treat COVID-19 inpatients would have higher burnout. METHODS: We conducted a cross-sectional survey to assess burnout among attending and trainee physicians who provided patient care during the COVID-19 pandemic between March-May 2020 across a diverse health care system in New York. Separate multivariable logistic regressions were performed to determine the association between redeployment and measures of burnout: Emotional Exhaustion (EE) and Depersonalization. Burnout measures were also compared by physician vs trainee status. The differential association between redeployment and outcomes with respect to trainee status was also evaluated. RESULTS: Redeployment was significantly associated with increased odds of EE {OR =1.53, 95% CI: 1.01-2.31} after adjusting for gender and Epidemic-Pandemic Impacts Inventory (EPII) score. Similarly, being a trainee, especially a junior level trainee, was associated with increased odds of EE {OR = 1.59, 95% CI: 1.01-2.51} after adjusting for gender and EPII scores. However, neither redeployment nor trainee status were significantly associated with Depersonalization. Interactions between redeployment and trainee status were not significant for any of the outcomes (p>.05). CONCLUSION: Physicians who were redeployed to treat COVID-19 patients had higher reported measures of EE. Trainees, irrespective of redeployment status, had higher EE as compared with attendings. Additional research is needed to understand the long-term impact of redeployment on burnout among redeployed physicians. Programs to identify and address potential burnout among physicians, particularly trainees, during pandemics may be beneficial.

Isoniazid resistance among Bacillus Calmette Guerin strains: implications on bladder cancer immunotherapy related infections.

Bacillus Calmette Guerin (BCG) immunotherapy is widely used for treatment of superficial bladder transitional cell carcinoma. Infectious complications while rare can be serious and severe disseminated infections as well as sepsis has been reported. There are no standard guidelines to direct therapy of these complications. Isoniazid is a commonly and widely used component of the various treatment regimens. Various strains of BCG are used for treatment of bladder cancer as well as vaccinations. These strains have evolved because of repeated subcultures in various laboratories in the world and have been shown to exhibit phenotypic differences in their immunogenicity as well as recently in susceptibility to various antimycobacterial agents. In this article, we review the resistance of BCG strains to various antimycobacterial agents. Some of these strains including the BCG Connaught strain, which is widely used in the United States, Canada and some other parts of the world for bladder cancer therapy exhibit intrinsic resistance to isoniazid. Although the clinical relevance of these differences is unclear, recent studies have questioned the role of isoniazid in treatment of infections after vaccination with these strains. Also, use of isoniazid in combination therapy for these infections may lead to the development of resistance to other antimycobacterial agents. We conclude that isoniazid may not be a suitable agent for empiric treatment of infections related to intravesical immunotherapy for bladder cancer with these strains and further studies are needed to clarify its role.

Early pediatric Cochlear implantation: An update.

The criteria and candidacy for pediatric cochlear implantation (CI) has significantly transformed over the past few decades and continues to evolve with technological advancements, and recognition of benefit in more diverse populations. Prolonged auditory deprivation among patients with profound sensorineural hearing loss has been shown to cause widespread degeneration in the central auditory system. Thus, there is increasing evidence advocating for earlier implantation within a critical neuroplastic window. However, there is a lack of consensus on this optimal age of implantation. Historically, there were concerns regarding surgical feasibility and safety, anesthesia risk, and logistical considerations in very young infants <12 months. Recent literature has investigated surgical safety and anesthesia risk as well speech and language outcomes with early implantation, resulting in the long-awaited reduction in approved age by the FDA (<9 months for certain devices). This article reviews logistical considerations, surgical safety, anesthesia risk, and language developmental outcomes associated with early CI (<12 months).

Applications of Electrospinning for Tissue Engineering in Otolaryngology.

OBJECTIVE: In tissue engineering, biomaterials create a 3D scaffold for cell-to-cell adhesion, proliferation and tissue formation. Because of their similarity to extracellular matrix and architectural adaptability, nanofibers are of particular interest in tissue engineering. Electrospinning is a well-documented technique for nanofiber production for tissue engineering scaffolds. Here we present literature on the applications of electrospinning in the field of otolaryngology. REVIEW METHODS: A PubMed database search was performed to isolate articles published about applications of electrospun nanofibers for tissue engineering in otolaryngology. Study design, size, material tested, site of application within the head and neck, and outcomes were obtained for each study. RESULTS: Almost all data on electrospinning in otolaryngology was published in the last 6 years (84%), highlighting its novelty. A total of 25 pre-clinical studies were identified: 9 in vitro studies, 5 in vivo animal studies, and 11 combination studies. Sites of application included: tracheal reconstruction (n = 16), tympanic membrane repair (n = 3), cranial nerve regeneration (n = 3), mastoid osteogenesis (n = 1) and ear/nose chondrogenesis (n = 2). IMPLICATIONS FOR PRACTICE: Tissue engineering is a burgeoning field, with recent innovative applications in the field of otolaryngology. Electrospun nanofibers specifically have relevant applications in the field of otolaryngology, due in part to their similarity to native extracellular matrix, with emerging areas of interest being tympanic membrane repair, cranial nerve regeneration and tracheal reconstruction.

A Retrospective Study Analyzing the Lack of Symptom Benefit With Antimicrobials at the End of Life.

BACKGROUND: Infections are common in terminally ill patients (pts), and although antibiotics are frequently prescribed, their benefit for symptom relief is not clear. Antimicrobials at the end of life (EOL) may increase the risk of antimicrobial resistance and Clostrioides difficile infection. Our aim was to determine the frequency of symptom occurrence at the EOL when comparing pts who did or did not receive antibiotics (AB+ or AB-). METHODS: We reviewed electronic medical records of pts admitted to a palliative care unit of a quarternary care hospital between 01/09/2017 and 07/16/2017 and assessed antimicrobial use in the last 14 days of life. Differences in demographics and symptom control between AB+ and AB- pts were analyzed using chi-square analyses; p-values were computed using Mann-Whitney tests. RESULTS: Of a total of 133 pts included, 90 (68%) received antimicrobials (AB+). The indication for antibiotics was documented in only 12% of pts. The AB+ and AB- groups were similar with respect to demographics, including sex, and Charleston Comorbidity Index except for age (p = 0.01) and race (p = 0.03). Documented infections were similar between AB+ and AB- groups, except urinary tract infections. No statistically significant differences were noted in documented symptoms including pain, dyspnea, fever, lethargy, and alteration of mental state or length of stay. CONCLUSION: Our study did not show differences in frequencies of documented symptoms with use of antimicrobials at EOL. Antimicrobial stewardship programs and further research can help with developing EOL care antimicrobial guidelines supporting patients and providers through shared decision-making.

Cooling Blankets in Hospitalized Patients: Time to Reevaluate.

BACKGROUND: The therapeutic benefits and rationale for treating fevers with external cooling methods remain unclear. We aimed to describe the clinical settings in which cooling blankets (CBs) are used. DESIGN: We conducted a retrospective chart review of CB use in adult patients admitted to our tertiary care center over a one-year period. We measured how they are used and correlations between clinical variables and their duration of use. RESULTS: 561 patients were included in our study. The mean highest temperature during hospitalization was 39.35 °C (SD, 0.67). Shivering occurred in 176 patients (31.4%) while on a CB although 303 patients (54%) had no data regarding shivering. Discontinuation of CBs was recorded in only 177 (30.5%) cases. Among these, the median duration of use was 33.37 h (IQR: 18.13-80.38) while the median duration of fever was 22.13 h (IQR 6.67-51.98). Duration of CB use was highly correlated with fever duration (Spearman's rho, 0.771, p < .001), moderately with length of stay (LOS) (rho, 0.425, p < .001), LOS after CB initiation (rho, 0.475, p < .001) and antipyretic use (rho, 0.506, p < .001). No other statistically significant correlations were observed. CONCLUSION: Documentation of CB use including temperature set points, time of discontinuation and duration in EMRs was poor. We could not establish benefits of CB use in this study but observed that almost a third of patients developed adverse effects in the form of shivering. Thus, adverse effects of CB use may outweigh potential benefits. Their use should be reevaluated and institutional protocols developed for their use.

Electrocochleography Observations in a Series of Cochlear Implant Electrode Tip Fold-Overs.

OBJECTIVE: Tip fold-over is a rare but serious complication of cochlear implant (CI) surgery. The purpose of this study was to present intraoperative electrocochleography (ECochG) observations in a series of CI electrode tip fold-overs. PATIENTS: Five pediatric subjects undergoing CI surgery through a round window (RW) approach with a perimodiolar electrode array, who were diagnosed with either auditory neuropathy spectrum disorder or enlarged vestibular aqueduct. INTERVENTIONS: Intraoperative RW ECochG during CI surgery: tone burst stimuli were presented from 95 to 110 dB SPL. MAIN OUTCOME MEASURES: Magnitude and phase characteristics of ECochG responses obtained intraoperatively before and immediately after electrode insertion were examined for patients with and without tip fold-over. RESULTS: Three subjects presented with tip fold-over and two formed the control group. Among fold-over cases, one participant exhibited an inversion in the starting phase of the cochlear microphonic response and a decrease in spectral magnitude from pre- to postinsertion. Both subjects who did not exhibit a change in phase had an increase in the ECochG-total response (ECochG-TR) magnitude. No case in the control group exhibited a change in starting phase. In regard to the ECochG-TR, all controls showed a decrease in the magnitude. CONCLUSIONS: Despite the small number of patients, heterogeneous ECochG response patterns were observed within the fold-over group. Though these results are not conclusive, they can serve as a framework to begin to understand ECochG's utility in detecting intraoperative tip fold-over.

Segmentation of Temporal Bone Anatomy for Patient-Specific Virtual Reality Simulation.

OBJECTIVES: Virtual reality (VR) simulation for patient-specific pre-surgical planning and rehearsal requires accurate segmentation of key surgical landmark structures such as the facial nerve, ossicles, and cochlea. The aim of this study was to explore different approaches to segmentation of temporal bone surgical anatomy for patient-specific VR simulation. METHODS: De-identified, clinical computed tomography imaging of 9 pediatric patients aged 3 months to 12 years were obtained retrospectively. The patients represented normal anatomy and key structures were manually segmented using open source software. The OTOPLAN (CAScination AG, Bern, Switzerland) otological planning software was used for guided segmentation. An atlas-based algorithm was used for computerized, automated segmentation. Experience with the different approaches as well as time and resulting models were compared. RESULTS: Manual segmentation was time consuming but also the most flexible. The OTOPLAN software is not designed specifically for our purpose and therefore the number of structures that can be segmented is limited, there was some user-to-user variation as well as volume differences compared with manual segmentation. The atlas-based automated segmentation potentially allows a full range of structures to be segmented and produces segmentations comparable to those of manual segmentation with a processing time that is acceptable because of the minimal user interaction. CONCLUSION: Segmentation is fundamental for patient-specific VR simulation for pre-surgical planning and rehearsal in temporal bone surgery. The automated segmentation algorithm currently offers the most flexible and feasible approach and should be implemented. Further research is needed in relation to cases of abnormal anatomy. LEVEL OF EVIDENCE: 4.