Severe trauma induces a widespread response of the immune system. This "genomic storm" can lead to poor outcomes, including Multiple Organ Dysfunction Syndrome (MODS). MODS carries a high mortality ...and morbidity rate and adversely affects long-term health outcomes. Contemporary management of MODS is entirely supportive, and no specific therapeutics have been shown to be effective in reducing incidence or severity. The pathogenesis of MODS remains unclear, and several models are proposed, such as excessive inflammation, a second-hit insult, or an imbalance between pro- and anti-inflammatory pathways. We postulated that the hyperacute window after trauma may hold the key to understanding how the genomic storm is initiated and may lead to a new understanding of the pathogenesis of MODS.
We performed whole blood transcriptome and flow cytometry analyses on a total of 70 critically injured patients (Injury Severity Score ISS ≥ 25) at The Royal London Hospital in the hyperacute time period within 2 hours of injury. We compared transcriptome findings in 36 critically injured patients with those of 6 patients with minor injuries (ISS ≤ 4). We then performed flow cytometry analyses in 34 critically injured patients and compared findings with those of 9 healthy volunteers. Immediately after injury, only 1,239 gene transcripts (4%) were differentially expressed in critically injured patients. By 24 hours after injury, 6,294 transcripts (21%) were differentially expressed compared to the hyperacute window. Only 202 (16%) genes differentially expressed in the hyperacute window were still expressed in the same direction at 24 hours postinjury. Pathway analysis showed principally up-regulation of pattern recognition and innate inflammatory pathways, with down-regulation of adaptive responses. Immune deconvolution, flow cytometry, and modular analysis suggested a central role for neutrophils and Natural Killer (NK) cells, with underexpression of T- and B cell responses. In the transcriptome cohort, 20 critically injured patients later developed MODS. Compared with the 16 patients who did not develop MODS (NoMODS), maximal differential expression was seen within the hyperacute window. In MODS versus NoMODS, 363 genes were differentially expressed on admission, compared to only 33 at 24 hours postinjury. MODS transcripts differentially expressed in the hyperacute window showed enrichment among diseases and biological functions associated with cell survival and organismal death rather than inflammatory pathways. There was differential up-regulation of NK cell signalling pathways and markers in patients who would later develop MODS, with down-regulation of neutrophil deconvolution markers. This study is limited by its sample size, precluding more detailed analyses of drivers of the hyperacute response and different MODS phenotypes, and requires validation in other critically injured cohorts.
In this study, we showed how the hyperacute postinjury time window contained a focused, specific signature of the response to critical injury that led to widespread genomic activation. A transcriptomic signature for later development of MODS was present in this hyperacute window; it showed a strong signal for cell death and survival pathways and implicated NK cells and neutrophil populations in this differential response.
Objectives:
Telemedicine allows for the remote delivery of patient care and has been found to have a wide range of uses in otolaryngology. In order to achieve best practices in telemedicine, a ...platform must be effective and both patients and providers must be satisfied with the use of technology. As telemedicine becomes more widely used in otolaryngology clinics, particularly in the face of the current COVID-19 pandemic, it is important to assess its applicability in this field. The goal of this study was to evaluate existing literature on telemedicine and assess overall image quality, diagnostic concordance, and patient and provider satisfaction with telemedicine technologies.
Methods:
A systematic review was conducted on PubMed and MEDLINE according to the PRISMA 2009 guidelines for articles from 1982 to 2019 relating to telemedicine in otolaryngology. English language studies with primary or secondary endpoints pertaining to image quality, diagnostic concordance, or patient or provider satisfaction were included. Descriptive studies, editorials, and literature reviews were excluded.
Results:
A total of 32 studies were included in our review. Studies assessing imaging quality and diagnostic concordance reported adequate results but with some heterogeneity. Patient and provider satisfaction were consistently high.
Conclusions:
The literature supports telemedicine delivery of otorhinolaryngologic care as having achieved high rates of patient and provider satisfaction with adequate image quality and heterogeneity in diagnostic concordance. Variability in diagnostic accuracy was reported, but appears improved given proper clinical context. More standardized studies are needed specific to telemedicine in the field of otolaryngology.
The COVID-19 pandemic has forced the rapid integration of telemedicine services across several specialties, especially in Otolaryngology where risk of transmission is very high. Studies before and ...during the COVID-19 pandemic have shown that Otolaryngology is generally amenable to telemedicine. However, few studies have assessed patient satisfaction with telemedicine during the COVID-19 pandemic, and fewer have focused on patient satisfaction with telehealth in Rhinology.
To determine if patients believe the benefits of virtual live synchronous telemedicine visits out-weigh the drawbacks when compared to in-person clinical visits.
Single center retrospective case series and survey study of patients presenting to a tertiary care Rhinology practice between 3/15/2020 and 6/1/2020. All patients had previous in-person encounters with Rhinology (n = 45).
Twenty-nine participants (64.4%) had audio-video visits while 16 (35.6%) had audio visits. 36 (80%) patients stated that their needs were met during their telemedicine visit while 32 (71.1%) patients felt that nothing was missed or not addressed during the virtual visit. The most commonly cited advantage to telemedicine visits was convenience (22.2%) and provider availability (20.0%). While most participants did not disclose a disadvantage to a virtual visit besides the lack of a physical exam (68.9%), the most commonly cited disadvantage to a virtual visit was technological difficulties (17.8%).
Virtual telemedicine visits were shown to effectively meet the needs of established patients and address concerns in a convenient time efficient manner. However, patients indicated that limited technology and a less personalized feel hindered the telemedicine experience in Rhinology.
Objectives/Hypothesis
The aim of this study is to establish a correlation between persistent cough (PC) and asthma diagnosis and its severity. We hypothesize that patients with past or current ...diagnosis of PC may have more severe asthma diagnosis and thus poor responsiveness to treatment.
Study Design
Retrospective chart review.
Methods
A retrospective review was performed on 699 charts that had a positive immunoglobulin E (IgE) allergy blood test between 2014 and 2018, and a positive asthma diagnosis. Patient demographics and asthma severity parameters such as number of clinic and emergency department (ED) visits, asthma treatment, and number of medications were recorded, as well as PC diagnosis. Logistic regressions were used to analyze the likelihood of severe asthma diagnosis in patients with PC.
Results
A total of 55% of patients were treated with oral corticosteroids in the PC group, compared to 41% in those without (P < .001). The mean number of hospitalizations from the ED was higher for patients with PC 0.65 (2.47) versus 0.38 (1.18) P < .05. Patients with asthma and PC, positive to lamb's quarter 2.92 (95% confidence interval CI 1.63, 5.22; P < .001), showed a higher likelihood of ED visits. Positivity to cat dander 2.09 (95% CI 1.03, 4.59; P < .05), lamb's quarter 2.96 (95% CI 1.50, 5.79; P < .002), dog dander 3.37 (95% CI 1.54, 8.45; P < .004) showed a higher likelihood of hospitalizations due to asthma.
Conclusion
Patients with PC, especially those with a positive IgE allergy class test to cat dander, dog dander, house dust, Alternaria tenuis, or lamb's quarter can have a more severe asthmatic presentation.
Level of Evidence
3 Laryngoscope, 132:1719–1722, 2022
Dermoid cysts are benign cutaneous neoplasms that contain germ cells from the ectoderm and mesoderm. Approximately 70% are diagnosed during childhood before the age of 5. Although they can present ...throughout the body, the prevalence is 7% for those arising from the head and neck. These lesions present primarily as midline masses and are classified as sublingual, submental, or overlapping depending on their relationship with the muscles of the floor of mouth. A 10-year-old female presented with a 2-week history of right submental swelling. She denied pain, dysphagia, odynophagia, or respiratory distress. Physical examination showed nontender fullness of the submental region without erythema or induration and no palpable cervical lymphadenopathy. Ultrasound showed an oval-shaped cystic mass measuring 4.8 × 4.0 × 2.6 cm. After a course of clindamycin, a computed tomography was obtained which showed a right 4.5 × 4.0 × 2.6 cm fluid filled lesion, within the right lateral floor of mouth. Intraoral resection was performed and the mass was freed from the geniohyoid and mylohyoid. Histopathology was consistent with a dermoid cyst. Submental masses have a broad differential, but rarely are they dermoid cysts if they arise lateral to the midline. With appropriate diagnosis and total surgical excision, patients and their families can be reassured in similar cases.
Objective/Hypothesis
The COVID‐19 pandemic has resulted in telehealth becoming commonplace in many health care fields. Telehealth benefits include improving access, decreasing costs, and elevating ...patient's experience. A review of cost minimization (CM) analyses was performed in order to explore scientific studies associated with integrating tele‐otolaryngology in clinical practice. Our primary objective was to evaluate published literature for cost related to the implementation of telemedicine across otolaryngology, and to determine CM when compared to in‐person visits.
Study Design
Systematic Literature Review.
Methods
We performed a systematic review using PubMed, EMBASE, and Cochrane in May 2020, to identify studies with a cost analysis of tele‐otolaryngology care. Inclusion criteria focused on articles citing CM data from telehealth services. Literature quality was assessed using the MINORS scoring system.
Results
From 380 original articles screened only nine evaluated cost in otolaryngology. CM in the US ranged from $68 to $900 per visit. Cost was evaluated in general otolaryngology, sleep medicine, otology, and head and neck cancer surgery, the latter had the most benefit. The most common types of telehealth visits were routine follow‐up and screening. Data were insufficient for meta‐analysis.
Conclusions
Telemedicine has been trialed across various otolaryngology subspecialties; its incorporation is projected to have a meaningful impact on access to specialty care. This research suggests that the delivery of virtual care reduces cost with the potential of increasing net revenue across multiple otolaryngology subspecialties. Further studies are needed to better discern the entirety of cost savings and the best settings for integration.
Level of Evidence
3 Laryngoscope, 131:1741–1748, 2021
The ideal timing for melanoma treatment, predominantly surgery, remains undetermined. Patient concern for receiving immediate treatment often exceeds surgeon or hospital availability, requiring ...establishment of a safe window for melanoma surgery.
To assess the impact of time to definitive melanoma surgery on overall survival.
Patients with stage I to III cutaneous melanoma and with available time to definitive surgery and overall survival were identified by using the National Cancer Database (N = 153,218). The t test and chi-square test were used to compare variables. Cox regression was used for multivariate analysis.
In a multivariate analysis of patients in all stages who were treated between 90 and 119 days after biopsy (hazard ratio HR, 1.09; 95% confidence interval CI, 1.01-1.18) and more than 119 days (HR, 1.12; 95% CI, 1.02-1.22) had a higher risk for mortality compared with those treated within 30 days of biopsy. In a subgroup analysis of stage I, higher mortality risk was found in patients treated within 30 to 59 days (HR, 1.05; 95% CI, 1.01-1.1), 60 to 89 days (HR, 1.16; 95% CI, 1.07-1.25), 90 to 119 days (HR, 1.29; 95% CI, 1.12-1.48), and more than 119 days after biopsy (HR, 1.41; 95% CI, 1.21-1.65). Surgical timing did not affect survival in stages II and III.
Melanoma-specific survival was not available.
Expeditious treatment of stage I melanoma is associated with improved outcomes.
Temporal bone squamous cell carcinoma (TBSCC) is rare and often confers a poor prognosis. The aim of this study was to synthesize survival and recurrence outcomes data reported in the literature for ...patients who underwent temporal bone resection (TBR) for curative management of TBSCC. We considered TBSCC listed as originating from multiple subsites, including the external ear, parotid, and external auditory canal (EAC), or nonspecifically from the temporal bone.
PubMed, Cochrane Library, Embase, and manual search of bibliographies.
A systematic literature review conducted in December 2020 according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
Survival data were collected from 51 retrospective studies, resulting in a pooled cohort of 501 patients with TBSCC. Compared to patients undergoing lateral TBR (LTBR), patients undergoing subtotal (SBTR) or total (TTBR) TBR exhibited significantly higher rates of stage IV disease (P < .001), positive surgical margins (P < .001), facial nerve involvement (P < .001), and recurrent disease (P < .001). A meta-analysis of 15 studies revealed a statistically significant 97% increase in mortality in patients who underwent STBR or TTBR. On multivariate analysis, recurrent disease was independently associated with worse overall survival (P < .001). On univariate analysis, facial nerve involvement was also associated with decreased overall survival (P < .001).
Recurrent disease was associated with risk of death in patients undergoing TBR. Larger prospective multi-institutional studies are needed to ascertain prognostic factors for a wider array of postoperative outcomes, including histology-specific survival and recurrence outcomes.
Objectives
Evaluate resident perception on implementation of a night float (NF) system to an otolaryngology residency program. We compared these perceptions to Accreditation Council for Graduate ...Medical Education (ACGME) case log data.
Methods
A retrospective anonymous survey was sent to residents and alumni graduating between 2015 and 2023. Deidentified ACGME case log information was then examined for key indicator (KI) cases from post graduate year (PGY) 2 and PGY5.
Results
Thirty (93.8%) residents and alumni responded. Residents with NF answered more positively compared to those without NF on following duty hour violations: 80‐hour work week, 1‐in‐7 days off, 1 call every 3 days, adequate time between shifts, and allotted time after a 24‐hour shift. Residents most commonly agreed that NF has improved patient care, resident education, and resident morale. Although residents with NF were neutral on PGY2 case volume effects, they disagreed that it affected overall case volume. The only KIs that differed for both PGY2 and PGY5s were airway cases (P = .004 vs P = .002) and bronchoscopy (P = .02 vs P = .006), which were significantly higher for those with NF. Thyroid surgery was the only KI higher for the residents without NF and spanned all PGY levels.
Conclusion
Residents and alumni agreed that NF implementation had a positive effect on duty hour violations. The NF system does not have significant impact on case volume.
Level of Evidence
4 Laryngoscope, 131:2211–2218, 2021
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