Otolaryngology-head and neck surgery resident and medical school characteristics: Current paradigm amidst changing application criteria.

PURPOSE: To determine the characteristics of current US Otolaryngology-Head and Neck Surgery (Oto-HNS) residents and their medical school. METHODS: Data were manually collected between Dec 2022 and Jan 2023 for 1649 residents attending 163 US-based ACGME accredited Oto-HNS residency programs, reflecting the 2018-2022 cohort. All data were collected from publicly available sources including residency and medical school program websites, web of science, and professional networking sites (ex: LinkedIn, Doximity). Data were analyzed to determine the "feeder" schools which contributed the greatest number and percent of residents. Using univariable linear regression models, we characterized factors which were associated with feeder school status. RESULTS: Of 1649 residents analyzed, 364 (22 %) matched to their home program and 918 (56 %) stayed in the region of their medical school. The median [IQR] number of published papers and abstracts was 5 [3, 9] with an h-index of 2 [1,4]. Factors associated with producing a greater percent of Oto-HNS residents include presence of an interest group, presence of a home program, USNWR research rank of the medical school, Doximity reputation rank of the home residency program, average pre-residency h-index of the school's graduates, and total NIH research funding (each p < 0.001). CONCLUSIONS: In the changing landscape of residency applications after the USMLE Step 1 exam's transition in January 2022 to pass/fail scoring, it is important to objectively characterize current Oto-HNS residents. Findings from this study will inform prospective residents and residency programs seeking to improve access to Oto-HNS. Future small-scale studies may help further identify driving factors within medical school curricula.

Prolonged Gastrointestinal Manifestations After Recovery From COVID-19.

BACKGROUND & AIMS: Acute enteric infections are well known to result in long-term gastrointestinal (GI) disorders. Although COVID-19 is principally a respiratory illness, it demonstrates significant GI tropism, possibly predisposing to prolonged gut manifestations. We aimed to examine the long-term GI impact of hospitalization with COVID-19. METHODS: Nested within a large-scale observational cohort study of patients hospitalized with COVID-19 across North America, we performed a follow-up survey of 530 survivors 12-18 months later to assess for persistent GI symptoms and their severity, and for the development of disorders of gut-brain interaction (DGBIs). Eligible patients were identified at the study site level and surveyed electronically. The survey instrument included the Rome IV Diagnostic Questionnaire for DGBI, a rating scale of 24 COVID-related symptoms, the Gastrointestinal Symptoms Rating Scale, and the Impact of Events-Revised trauma symptom questionnaire (a measure of posttraumatic stress associated with the illness experience). A regression analysis was performed to explore the factors associated with GI symptom severity at follow-up. RESULTS: Of the 530 invited patients, 116 responded (52.6% females; mean age, 55.2 years), and 73 of those (60.3%) met criteria for 1 or more Rome IV DGBI at follow-up, higher than the prevalence in the US general population (P < .0001). Among patients who experienced COVID-related GI symptoms during the index hospitalization (abdominal pain, nausea, vomiting, or diarrhea), 42.1% retained at least 1 of these symptoms at follow-up; in comparison, 89.8% of respondents retained any (GI or non-GI) COVID-related symptom. The number of moderate or severe GI symptoms experienced during the initial COVID-19 illness by self-report correlated with the development of DGBI and severity of GI symptoms at follow-up. Posttraumatic stress disorder (Impact of Events-Revised score ≥33) related to the COVID-19 illness experience was identified in 41.4% of respondents and those individuals had higher DGBI prevalence and GI symptom severity. Regression analysis revealed that higher psychological trauma score (Impact of Events-Revised) was the strongest predictor of GI symptom severity at follow-up. CONCLUSIONS: In this follow-up survey of patients 12-18 months after hospitalization with COVID-19, there was a high prevalence of DGBIs and persistent GI symptoms. Prolonged GI manifestations were associated with the severity of GI symptoms during hospitalization and with the degree of psychological trauma related to the illness experience.

User-Centered Design of a Clinical Tool for Shared Decision-making About Diet in Primary Care.

BACKGROUND: Health information technology is a leading cause of clinician burnout and career dissatisfaction, often because it is poorly designed by nonclinicians who have limited knowledge of clinicians' information needs and health care workflow. OBJECTIVE: Describe how we engaged primary care clinicians and their patients in an iterative design process for a software application to enhance clinician-patient diet discussions. DESIGN: Descriptive study of the steps followed when involving clinicians and their at-risk patients in the design of the content, layout, and flow of an application for collaborative dietary goal setting. This began with individual clinician and patient interviews to detail the desired informational content of the screens displayed followed by iterative reviews of intermediate and final versions of the program and its outputs. PARTICIPANTS: Primary care clinicians practicing in an urban federally qualified health center and two academic primary care clinics, and their patients who were overweight or obese with diet-sensitive conditions. MAIN MEASURES: Descriptions of the content, format, and flow of information from pre-visit dietary history to the display of evidence-based, guideline-driven suggested goals to final display of dietary goals selected, with information on how the patient might reach them and patients' confidence in achieving them. KEY RESULTS: Through three iterations of design and review, there was substantial evolution of the program's content, format, and flow of information. This involved "tuning" of the information desired: from too little, to too much, to the right amount displayed that both clinicians and patients believed would facilitate shared dietary goal setting. CONCLUSIONS: Clinicians' well-founded criticisms of the design of health information technology can be mitigated by involving them and their patients in the design of such tools that clinicians may find useful, and use, in their everyday medical practice.

Interdisciplinary assessment of tracheostomy care knowledge: An opportunity for quality improvement.

PURPOSE: A 2013 AAOHNS consensus statement called for reduced variation in tracheostomy care. Multidisciplinary approaches and standardized protocols have been shown to improve tracheostomy outcomes. This study aims to identify inconsistencies in knowledge in order to design standardized education targeting these areas to improve quality of care. MATERIALS AND METHODS: An online, multiple-choice tracheostomy care knowledge assessment was administered to nurses and respiratory therapists in ICUs, stepdown units, and regular nursing floors, as well as residents in otolaryngology, general surgery, and thoracic surgery. The survey was administered and data were recorded using the Select Survey online platform. RESULTS: 173 nurses, respiratory therapists, and residents participated in this study. Over 75 % of respondents identified correct answers to questions addressing basic tracheostomy care, such as suctioning and humidification. Significant variation was observed in identification and management of tracheostomy emergencies, and appropriate use of speaking valves. Only 47 % of all respondents identified all potential signs of tracheostomy tube displacement. Respiratory therapists with over 20 years of experience (p = 0.001), were more likely to answer correctly than those with less. Nurses were less likely than respiratory therapists to have received standardized tracheostomy education (p = 0.006) and were less likely than others to choose the appropriate scenario for speaking valve use (p = 0.042), highlighting the need for interdisciplinary education. CONCLUSIONS: An interdisciplinary assessment of tracheostomy care knowledge demonstrates variation, especially in identification and management of tracheostomy emergencies and appropriate use of speaking valves. Design of a standardized educational program targeting these areas is underway.

Methods for development and application of data standards in an ontology-driven information model for measuring, managing, and computing social determinants of health for individuals, households, and communities evaluated through an example of asthma.

OBJECTIVE: To describe methods to approach application of data standards to integrate social determinants of health (SDoH) into EHRs through evaluation of a case of clinical decision support for pediatric asthma. MATERIALS AND METHODS: We identified a list of environmental factors important for managing pediatric asthma. We identified and integrated data from local outdoor air quality monitors with elements available from the clinic's EHR and self-reported indoor air quality questionnaire data. We assessed existing SDoH frameworks, assessment tools, and terminologies to identify representative data standards for these environmental SDoH measures. RESULTS: We found many-to-many relationships between the multiple framework domains, the environmental exposure measures collected, and existing standards. The majority of concepts did not accurately align with environmental exposure measurements. We propose an ontology-driven information framework methodology to apply standards for SDoH measurements to support measuring, managing, and computing SDoH data. DISCUSSION: To support methods of integrating SDoH data in the EHR via an ontology-driven information framework, a common SDoH ecosystem should be developed descriptively and prescriptively integrating framework domains, assessment tools, and standard ontologies to support future data sharing, aggregation, and interoperability. A hierarchical object-oriented information model should be adopted to manage SDoH to extend beyond patient-centered orientation of EHRs to orient to households and communities. CONCLUSION: SDoH data pose unique challenges and opportunities in collecting, measuring, and managing health information. Future work is needed to define data standards for implementing SDoH in a hierarchical, object-oriented information model representing multiple units of orientation including individuals, households, and communities.

An institution-wide tracheostomy rounding team: Initial caregiver perceptions.

PURPOSE: To analyze and present the initial findings of provider perceptions regarding the impact of the implementation of a hospital-wide Tracheostomy Rounding Team (TRT) on the delivery of tracheostomy care at the Cleveland Clinic. MATERIALS AND METHODS: Based on prior literature, a novel multidisciplinary TRT was designed and implemented at the Cleveland Clinic in December of 2018. After the TRT began clinical care, a previously validated RedCap survey was administered anonymously to 358 caregivers to assess provider experience, comfort, and prior education regarding tracheostomy management. Survey results were collected, and descriptive statistics were applied. Answers were compared between providers who interacted with the TRT clinically and those who did not. RESULTS: 42.9% of providers who interacted with the TRT clinically reported that the TRT improved hands-on assistance with tracheostomy care, and 36.7% reported that the TRT improved the identification of safety concerns. Similarly, 34.7% reported that the TRT improved the overall quality of tracheostomy care at the Cleveland Clinic. Providers with active exposure to the TRT additionally reported statistically higher comfort with multiple topics surrounding tracheostomy care. CONCLUSIONS: The implementation of this team improved provider comfort in managing patients with tracheostomies both qualitatively and quantifiably. This intervention offered a perceived benefit to patient care at our institution. Further study of the impact of this team on quantitative patient outcomes is forthcoming.

A Medical School's Community Engagement Approach to Improve Population Health.

The U.S. spends trillions annually on health care that affects only 16% of health outcomes, with 84% driven by social factors, behaviors, and the physical environment. Medical schools are focusing more on these social determinants of health. We describe an academic community engagement unit with unique methods for partnering with the surrounding community to improve its members' health. Annually, a Call for Ideas asked community members to identify important health problems and propose solutions. A panel of community members and academic researchers reviewed submitted ideas and selects those addressing significant issues, that are also feasible, can be accomplished in a year, and are potentially scalable. Financial, project development, and evaluation support is provided where needed. Three Calls for Ideas generated 268 ideas from 249 individuals: 35% focused on social and behavioral factors, 33% on health behaviors, 16% on health care, and 6% on the physical environment. Half were submitted by individuals and half by community service organizations. Twenty-four (9%) were selected for implementation; 19 have been successfully implemented while 5 are under development. People with lived experience can identify barriers to health in their communities and effective mitigating interventions. By seeking community leadership and mutual benefit, academicians can gain community members' trust and meet both community and academic needs by establishing true partnerships, recognizing power dynamics and structural biases, and using language and approaches that respect the importance and power of lived experiences in identifying approaches to enhancing community health.

Considerations and Management of a Laryngeal Fracture after Sneezing.

Non-traumatic laryngeal fracture is uncommon but should be suspected whenever patients present with dysphonia, odynophagia, dysphagia, neck crepitus, or hemoptysis following a sneeze or coughing episode. Physical examination coupled with computed tomography is essential for making the diagnosis. Management can vary depending on the severity of the case, but the general approach is similar to any trauma. In this report, we describe a non-traumatic laryngeal fracture that occurred following a forceful sneeze. The case was notable for the presence of pneumomediastinum, independent mobility of the thyroid ala, and operative intervention was pursued to repair the fracture.

Surgical management of recurrent Zenker's diverticulum: A multi-institutional cohort study.

OBJECTIVE: This study identifies how recurrent Zenker's diverticula are treated. METHODS: A retrospective chart review was performed from four tertiary referral academic voice and swallowing centers to identify individuals who underwent surgery for recurrent Zenker's diverticulum. Demographic data, surgical modalities for primary and revision surgery, symptoms pre and post revision and complications were recorded. RESULTS: 56 individuals met inclusion criteria. Primary surgery was open in 30.3% (n = 17) and endoscopic in 69.6% (n = 39). Revision surgery was performed via an open approach in 37.5% of cases (N = 21) and via an endoscopic approach in 62.5% of cases (N = 35). Revision surgical technique was based on pouch size, patient age and comorbidities, as well as patient and surgeon preference. There were no major complications and few minor complications. CONCLUSION: Zenker's diverticulum symptoms can recur regardless of primary treatment modality. Both endoscopic and open approaches can safely treat recurrent Zenker's diverticula.

Community engagement as a foundation for improving neighborhood health.

OBJECTIVE: Health inequities and disparities are associated with non-White race/ethnicity, immigrant status, income, and geographic location. Community engagement is essential to identify health and social needs and to plan health care and social services programs. To begin a larger community-based participatory study, the purpose of this study was to explore community residents' perceptions of barriers and facilitators to achieving and maintaining health. DESIGN, SAMPLE, AND MEASUREMENTS: This qualitative descriptive study used focus group interviews. We recruited a convenience sample (n = 50) from community meetings and gathering for five audio-recorded focus groups that used a semi-structured interview guide. Transcripts were coded to identify common topics in each group and major themes across groups. RESULTS: Participants were predominantly women (58%), Hispanic/Latinx, and Spanish-speaking (57%), who rented their homes (69%). Two main themes emerged: (a) social determinants as barriers to health and (b) need for trust to participate in health programs. CONCLUSIONS: Although health care providers are frequently concerned about providing access to care, community members identified a variety of social determinants that affected their health. Listening and responding to community members' priorities are the foundation to improving health in neighborhoods directly affected by inequities.

Development of a health communication campaign to promote the Texas prescription monitoring program.

Given the role opioid overprescribing has played in the current overdose crisis, reducing the supply of prescription opioids available for misuse has gained widespread support. Prescription monitoring programs (PMPs) have been identified as a tool for achieving this goal, but little is known about how to promote PMP use to prescribers. This paper describes the process of developing a health communication campaign to support the adoption of the Texas PMP. After formative research, message development and concept testing, a range of campaign concepts and messages were tested and final recommendations determined. The messages and lessons learned have utility beyond Texas.

Use of Stakeholder Focus Groups to Define the Mission and Scope of a new Department of Population Health.

BACKGROUND: The focus and funding of US healthcare is evolving from volume to value-based, and healthcare leaders, managers, payers, and researchers are increasingly focusing on managing populations of patients. Simultaneously, there is increasing interest in getting "upstream" from disease management to promote health and prevent disease. Hence, the term "population health" has both clinical and community-based connotations relevant to the tripartite mission of US medical schools. OBJECTIVE: To seek broad input for the strategic development of the Department of Population Health in a new medical school at a tier 1 research university. DESIGN: Focus groups with facilitated consensus development. PARTICIPANTS: Eighty-one persons representing the Dell Medical School and other schools at the University of Texas at Austin, city/county government, community nonprofit organizations, and faculty from other local university schools along with selected national academic leaders. APPROACH: Focus groups with subsequent consensus development of emphases identified premeeting by participants by e-mail exchanges. KEY RESULTS: The resulting departmental strategic plan included scope of work, desired characteristics of leaders, and early impact activities in seven areas of interest: community engagement and health equity, primary care and value-based health, occupational and environment medicine, medical education, health services and community-based research, health informatics and data analysis, and global health. CONCLUSIONS: Medical schools should have a primary focus in population, most effectively at the departmental level. Engaging relevant academic and community stakeholders is an effective model for developing this emerging discipline in US medical schools.

Use of diphenhydramine as an adjunctive sedative for colonoscopy in patients on chronic opioid therapy: a randomized controlled trial.

BACKGROUND AND AIMS: Chronic opioid use increases tolerance to sedatives. Diphenhydramine is recommended for difficult-to-sedate patients during endoscopic procedures. We hypothesized that the addition of diphenhydramine to midazolam and fentanyl would improve objective and subjective measures of procedural sedation. METHODS: This randomized, double-blind, placebo-controlled trial included patients on chronic opioids undergoing colonoscopy. Patients were randomized to receive 50 mg of diphenhydramine intravenously (n = 61) or placebo (n = 58), in addition to fentanyl and midazolam. Baseline characteristics, amount of fentanyl and midazolam, procedure times, and adverse events were recorded. Quality of sedation was assessed by the physician and nurse. Patients rated pain and amnesia on a 10-point scale. RESULTS: There was no difference in amounts of fentanyl (125.4 ± 56.2 µg vs 126.9 ± 53.5 µg, P = .88) and midazolam (4.9 ± 2.1 mg vs 5 ± 1.9 mg, P = .79) used. The mean sedation scores from the physician (6.2 ± 1.1 vs 5.3 ± 1.2, P =.0002) and nurses (5.6 ± 1.5 vs 5.1 ± 1.4, P =.04) were statistically significant in favor of the diphenhydramine arm. Patient scores for pain (2.05 ± 2.17 vs 3.09 ± 3.95, P =.047) and amnesia (7.8 ± 3.4 vs 6.5 ± 3.8, P =.047) favored the group that received diphenhydramine. Qualitative assessment showed no significant difference between the groups. There was no difference in induction time (P = .86), procedure duration (P = .98), or recovery time (P = .16). Hypotensive episodes were more common in the placebo group (P = .027). CONCLUSIONS: In patients on chronic opioid therapy, administration of diphenhydramine does not allow for lower doses of procedural sedatives but improves quality of sedation without increasing the number of adverse events. (Clinical trial registration number: NCT T01967433.).

Impact of fellowship training level on colonoscopy quality and efficiency metrics.

BACKGROUND AND AIMS: Previous studies have described variable effects of fellow involvement on the adenoma detection rate (ADR), but few have stratified this effect by level of training. We aimed to evaluate the "fellow effect" on multiple procedural metrics including a newly defined adenoma management efficiency index, which may have a role in documenting colonoscopy proficiency for trainees. We also describe the impact of level of training on moderate sedation use. METHODS: We performed a retrospective review of 2024 patients (mean age, 60.9 ± 10 years; 94% men) who underwent outpatient colonoscopy between June 2012 and December 2014 at our Veterans Affairs Medical Center. Colonoscopies were divided into 5 groups. The first 2 groups were first-year fellows in the first 6 months and last 6 months of the training year. Second- and third-year fellows and attending-only procedures accounted for 1 group each. We collected data on doses of sedatives used, frequency of adjunctive agent use, procedural times, and location, size, and histology of polyps. We defined the adenoma management efficiency index as average time required per adenoma resected during withdrawal. RESULTS: Of the colonoscopies performed, 1675 involved a fellow and 349 were performed by the attending alone. There was no difference in ADR between fellows according to level of training (P = .8) or between fellows compared with attending-only procedures (P = .67). Procedural times decreased consistently during training and declined further for attending-only procedures. This translated into improvement in the adenoma management efficiency index (fellow groups by ascending level of training: 23.5 minutes vs 18.3 minutes vs 13.7 minutes vs 13.4 minutes vs attending group 11.7 minutes; P < .001). There was no difference in the average doses of midazolam and fentanyl used among fellow groups (P = .16 and P = .1, respectively). Compared with attending-only procedures, fellow involvement was associated with higher doses of fentanyl and midazolam and more frequent use of diphenhydramine and glucagon (P < .0001, P = .0002, P < .0001, and P = .01, respectively). CONCLUSIONS: ADR was similar at different stages of fellowship training and comparable with the attending group. Efficiency of detecting and resecting polyps improved throughout training without reaching the attending level. Fellow involvement led to a greater use of moderate sedation, which may relate to a longer procedure duration and an evolving experience in endoscopic technique.

Healthcare usage after uvulopalatopharyngoplasty - Impact of analgesic regimen.

OUTCOME OBJECTIVES: 1) Analyze differences in healthcare usage between subjects receiving different perioperative analgesic medications after uvulopalatopharyngoplasty (UPPP) surgery. 2) Comment on the impact of perioperative analgesic medication on length of hospital stay and complications after UPPP. METHODS: A retrospective cohort study of 120 UPPPs conducted by a single surgeon in the past 5years was conducted. Subjects were grouped based on perioperative pain medication regimen into three groups; narcotics alone (n=83), narcotics with gabapentin (n=27), or narcotics with ketorolac tromethamine (n=10). The primary outcome variable was total number of clinic/emergency room and/or telephone encounters related to post-UPPP pain. Secondary outcomes included length of post-operative hospital stay, number of telephone and/or clinical encounters in which the patient complained specifically of pain or requested a refill for analgesics, and post-operative complications. RESULTS: No significant difference was found between the three analgesic regimens in post-operative hospital stay length (p=0.28, median stay 23.5h), number of clinic or telephone encounters related to pain (p=0.26, mean value 0.71 encounters), or post-operative complication rate (p=0.82, 5.9% complication rate). CONCLUSION: This study shows no significant difference in post-operative healthcare usage between patients with peri-operative analgesic regimens including narcotics alone, gabapentin with narcotics, or ketorolac with narcotics. Post-operative complication rate and length of stay did not differ between groups. These data suggest that these three medication regimens have similar impact on post-operative course for UPPP patients. Therefore, the most affordable or simplest options have equivalent effects on post-operative healthcare usage.

Treatment of laryngopharyngeal reflux using a sleep positioning device: A prospective cohort study.

OBJECTIVE: Laryngopharyngeal reflux (LPR) symptoms are often resistant to management and cause significant quality of life impairment to patients with this disease. This study assesses the utility of a sleep-positioning device (SPD) in treating LPR. DESIGN: Single center prospective cohort study. SETTING: Tertiary medical center PARTICIPANTS: 27 adult patients with diagnosed laryngopharyngeal reflux. INTERVENTION: An SPD consisting of a two-component wedge-shaped base pillow and a lateral positioning body pillow (Medcline, Amenity Health Inc.) was given to patients with a diagnosis of LPR. Subjects slept using the device for at least 6h per night for 28 consecutive nights. MAIN OUTCOMES: Primary outcomes were Nocturnal Gastroesophageal Reflux Symptom Severity and Impact Questionnaire (N-GSSIQ) and the Reflux Symptoms Index (RSI) survey instrument. Each was collected at baseline, after 14, and after 28days of SPD use. RESULTS: 27 patients (19 female and 8 male; age 57.1±12.8, BMI 29.0±8.1) were recruited. At baseline mean N-GSSIQ was 50.1±22.4 and mean RSI of 29.6±7.7. Repeated measure analysis showed that subjects' total N-GSSIQ scores decreased by an average of 19.1 (p=0.0004) points by two weeks and 26.5 points by 4weeks (p<0.0001). RSI decreased an average of 5.3 points by 2weeks (p=0.0425) and an average of 14.0 points by 4weeks (p<0.0001). CONCLUSIONS: In patients with LPR, SPD treatment significantly improves self-reported symptoms of nocturnal reflux as well as symptoms specific to LPR. These results support the therapeutic efficacy of a SPD for patients with LPR.

The Impact on Endoscopic Resource Utilization After a Targeted Intervention for Cost-Minimization of EGD and Colonoscopy.

OBJECTIVES: The need to define the cost of endoscopic procedures becomes increasingly important in an era of providing low-cost, high-quality care. We examined the impact of informing endoscopists of the cost of accessories and pathology specimens as a cost-minimization strategy. METHODS: We conducted a prospective observational cohort study of therapeutic outpatient esophagogastroduodenoscopy (EGD) and colonoscopy. During the pre-intervention phase (phase 1), the endoscopists were not briefed on the cost of accessories or pathology specimens obtained during the procedure. During a 3-week intervention phase and the post-intervention phase (phase 2) endoscopists were informed of the dollar value of accessories and pathology specimens after the completion of all procedures. In all cases the institutional costs (not charges) were used. The endoscopists were blinded to their observation. RESULTS: A total of 969 EGD, colonoscopy, and EGD+colonoscopy performed by 6 endoscopists were reviewed, 456 procedures in phase 1 and 513 procedures in phase 2. There was no significant difference between phases 1 and 2 in total device and pathology cost in dollars (188.8±151.4 vs. 188.9±151.8, P=0.99), total device cost (36.2±107.9 vs. 39.0±95.96, P=0.67) and total pathology cost (152.6±101.3 vs. 149.9±112.5, P=0.70). There was not a significant difference in total device and pathology cost when examined by specific procedures performed, or for any of the endoscopists between phases 1 and 2. CONCLUSIONS: Making endoscopists more cost conscious by informing them of the costs of each procedure during EGD and colonoscopy does not result in lower procedural costs. Analysis of cost-minimization strategies involving procedures in other health-care settings and procedures using high-cost accessories are warranted.