The production of publications is a key component of one's career advancement in medicine. The go... more The production of publications is a key component of one's career advancement in medicine. The goal of this piece is to discuss five tips to help health profession students get started in medical writing. First, students should take full advantage of the time-saving resources at the local academic biomedical library. Second, outlining a manuscript is one of the essential first steps for producing a successful, high-quality publication. Third, planning the manuscript and writing efficiently is critical since many young authors are either in medical school or residency and do not have ample time to devote to the writing process. Fourth, communicating complex concepts, thoughts, ideas, and observations in a simple way is important and helps limit redundancies, awkward passages, and improves reader comprehension. Lastly, a student can maximize their chances at publication if they are persistent in how they approach manuscript submission. The chances for successful publication of a project can be increased if young authors consider the tips supplied here.
Objective: To analyze variation in tonsillectomy procedure rates between health care system types... more Objective: To analyze variation in tonsillectomy procedure rates between health care system types around the world. Study design: International database analysis. Methods: The 2015 Organization for Economic Cooperation and Development (OECD) Health Statistics surgical procedures database was used to ascertain tonsillectomy procedure volumes for 31 countries. Each country's health system type and structure were classified by overall system type, and by health care regulation, financing, and provision methods. Each system type and structure variable were compared using the rate of tonsillectomy procedures per 100,000 citizens. Results: 10.5 million tonsillectomy procedures completed between 1993 and 2014 were analyzed. Overall, social health insurance system types had higher total tonsillectomy rates versus other health care system types (p < 0.05 for each comparison). Health systems with private care provision had a higher procedure rate versus state provided care (159.1 vs. 131.1 per 100,000 citizens; p ¼ 0.002). Health care systems with societal regulation and financing had a higher procedure count versus state regulated or financed care (regulation 193.3 vs. 139.7 per 100,000 citizens, p < 0.0001; financing 168.2 vs. 135.0 per 100,000 citizens, p ¼ 0.0004). Conclusions: The volume of tonsillectomy procedures is associated with a health care system's overall structure, regulation, financing, and provision methods. International health care systems with state mediated provision, regulation, and financing had lower tonsillectomy rates versus systems with private provision, and societal regulation or financing. Further study is needed to determine differences in indications for tonsillectomy between countries, but these results underscore potential variation in health care delivery in different systems.
The objective of this study was to investigate the utility of electronic tablets and their capaci... more The objective of this study was to investigate the utility of electronic tablets and their capacity to increase hospital floor productivity, efficiency, improve patient care information safety, and to enhance resident education and resource utilization on a busy Otolaryngology – Head & Neck Surgery inpatient service. This was a prospective cohort study with a 2-week pre-implementation period with standard paper census lists without mobile tablet use, and a 2-week post-implementation period followed with electronic tablets used to place orders, look up pertinent clinical data, educate patients as appropriate, and to record daily to-dos that would previously be recorded on paper. The setting for the study was Duke University Medical Center in Durham, North Carolina, with 13 Otolaryngology residents comprising the study population. The time for inpa-tient rounding was shorter with the use tablets (p=0.037). There was a non-significant trend in the number of times a resident had to leave rounds to look up a clinical query on a computer, with less instances occurring in the post-implementation study period. The residents felt that having a tablet facilitated more detailed and faster transfer of information, and improved ease of documentation in the medical record. Seventy percent felt tablets helped them spend more time with patients, 70 % could spend more time directly involved in rounds because they could use the tablet to query information at point-of-care, and 80 % felt tablets improved morale. The utility of a mobile tablet device coupled with the electronic health record appeared to have both quantitative and qualitative improvements in efficiency , increased time with patients and attendance at academic conferences. Tablets should be encouraged but not mandated for clinical and educational use.
Objective: Identification of a causative pathogen in otologic infections assists in maximizing th... more Objective: Identification of a causative pathogen in otologic infections assists in maximizing therapy efficacy particularly in refractory and chronic cases. Current standards for treatment of otologic infections focus on targeted species (spp.) that are assumed to be the most common pathogens. Corynebacterium spp. may play a pathogenic role but are not routinely speciated or included in antibiotic susceptibility analysis. Our objective is to investigate the prevalence and pathogenicity of nondiphtheroid Corynebacterium spp. in commonly encountered purulent and mucopurulent otologic infections. Study Design: Retrospective case review. Setting: Academic tertiary referral center. Patients: Review of 140 microbiology cultures from adults and children presenting with purulent and mucopurulent otologic infections from 2010 to 2012. Intervention(s): Clinical history, demographics, and microbiology cultures with speciation and antibiotic susceptibility analyses. Main Outcome Measure(s): Microbiologic speciation and census, species association with clinical characteristics, antibiotic susceptibility to oral and systemic agents, therapy frequency and agent selection.
Primary tumors of the parapharyngeal space are extremely rare, and lipomas are among the least co... more Primary tumors of the parapharyngeal space are extremely rare, and lipomas are among the least common primary parapharyngeal space masses. Parapharyngeal lipomas typically present as a painless neck mass, and some may present with neurologic deficits or vascular compromise attributed to the lipomas' mass effect on nearby neurovascular structures. We report long term follow-up of two large parapharyngeal lipomas. One lesion was managed expectantly, and the other was managed with a partial transcervical excision. We demonstrate that conservative management and long term patient follow-up may be reasonable if the patient is asymptomatic and liposarcoma is ruled out. Considering the uncertainty in the need for removal, the management strategy for the individual patient is best to be tailored to their clinical presentation.
Objectives. To investigate provincial cochlear implantation (CI) annual volume and cost trends. S... more Objectives. To investigate provincial cochlear implantation (CI) annual volume and cost trends. Study Design. Database analysis. Setting. National surgical volume and cost database. Subjects and Methods. Aggregate-level provincial CI volumes and cost data for adult and pediatric CI surgery from 2005 to 2014 were obtained from the Canadian Institute for Health Information. Population-level aging forecast estimates were obtained from the Ontario Ministry of Finance and Statistics Canada. Linear fit, analysis of variance, and Tukey's analyses were utilized to compare variances and means. Results. The national volume of annual CI procedures is forecasted to increase by \30 per year (R 2 = 0.88). Ontario has the highest mean annual CI volume (282; 95% confidence interval , 258-308), followed by Alberta (92.0; 95% confidence interval , 66.3-118), which are significantly higher than all other provinces (P \ .05 for each). Ontario's annual CI procedure volume is forecasted to increase by \11 per year (R 2 = 0.62). Newfoundland and Nova Scotia have the highest CI procedures per 100,000 residents as compared with all other provinces (P \.05). Alberta, Newfoundland, and Manitoba have the highest estimated implantation cost of all provinces (P \.05). Conclusions. Historical trends of CI forecast modest national volume growth. Potential bottlenecks include provincial funding and access to surgical expertise. The proportion of older adult patients who may benefit from a CI will rise, and there may be insufficient capacity to meet this need. Delayed access to CI for pediatric patients is also a concern, given recent reports of long wait times for CI surgery.
We report a case of a 55-year-old man who presented with a history of new audiovestibular symptom... more We report a case of a 55-year-old man who presented with a history of new audiovestibular symptoms in context of chronic right ear and mastoid pain. Imaging demonstrated severe bony erosion of the temporal bone, and urgent mastoidectomy revealed a mass suspicious for spindle cell variant squamous cell carcinoma. An extensive en-bloc resection was completed, and final pathology indicated high grade angiosarcoma. We detail the imaging and pathological techniques employed that led to this diagnosis. This is the eighth case of primary angiosarcoma of the temporal bone reported in literature, and possibly the first ever recorded in an adult male.
Objective: To determine if preoperative lumbar drain (LD) use reduces the incidence of postoperat... more Objective: To determine if preoperative lumbar drain (LD) use reduces the incidence of postoperative cerebrospinal fluid (CSF) leak in patients undergoing acoustic neuroma resection. Methods: Retrospective review of 282 patients presenting for acoustic neuroma resection between 2005 and 2014.
Objective: To estimate the prevalence of and symptoms associated with posterior semicircular cana... more Objective: To estimate the prevalence of and symptoms associated with posterior semicircular canal dehiscence (PSCD) compared to superior semicircular canal dehiscence (SSCD) and nondehiscent semicircular canals (NDSC). Study Design: Retrospective review. Setting: Academic tertiary referral center. Patients: Review of 412 temporal bone CT scans and associated patient records, excluding patients with prior mastoid or skull base surgery. Intervention(s): CT images (0.625 mm thick) were reviewed in the planes of the semicircular canals. Patient demographics and symptoms were tabulated and analyzed. Main Outcome Measure(s): Prevalence of PSCD and SSCD; degree of hearing loss; presence or absence of aural fullness, autophony, tinnitus, pulsatile tinnitus, disequilibrium, vertigo, and Tullio phenomenon. Results: Review of the 412 CT scans revealed 5 cases of PSCD (1.2%) and 20 cases of SSCD (4.9%). All patients with PSCD
Objective: To determine if providers prescribe more affordable topical antibacterial therapy for ... more Objective: To determine if providers prescribe more affordable topical antibacterial therapy for patients who are economically disadvantaged or come from economically disadvantaged communities. Study design: Prescription drug database review. Setting: Large academic hospital network. Subjects and methods: Ototopical prescription records of 2416 adults and children presenting with acute and chronic otologic infections from 2009 to 2013 were reviewed. Prescription, patient, provider, and institution variables including diagnosis, prescription type, demographics, health insurance status, healthcare provider type and setting were analyzed. Results: Otitis externa and acute otitis media were the most common diagnoses. Non-OHNS (Otolaryngology-Head and Neck Surgery) providers served 82% of all patients. OHNS providers prescribed proportionally less fluoroquinolone, and more brand-name antibiotics compared to non-OHNS providers. Adults were more likely to receive a non-fluoroquinolone antibiotic and a generic prescription versus pediatric patients. Patients who self-identified as 'white' ethnicity received proportionally more fluoroquinolone prescriptions than patients who identified as 'non-white,' but there was no difference in provider type. The proportion of fluoroquinolone prescriptions was significantly higher in patients from low-poverty counties, however poverty level was not associated with patients seeing a particular provider type. The majority of our patients had commercial insurance, followed by Medicaid. Medicare patients had the lowest proportion of fluoroquinolone antibiotic prescriptions, and were less likely to receive fluoroquinolone prescriptions versus commercial insurance. Non-insured patients received proportionally more generic versus brand prescriptions than insured patients. Conclusion: Our results indicate potential provider, patient demographic, and financial factors producing considerable variability in the prescribing patterns for topical antibiotics for common otologic infections.
The production of publications is a key component of one's career advancement in medicine. The go... more The production of publications is a key component of one's career advancement in medicine. The goal of this piece is to discuss five tips to help health profession students get started in medical writing. First, students should take full advantage of the time-saving resources at the local academic biomedical library. Second, outlining a manuscript is one of the essential first steps for producing a successful, high-quality publication. Third, planning the manuscript and writing efficiently is critical since many young authors are either in medical school or residency and do not have ample time to devote to the writing process. Fourth, communicating complex concepts, thoughts, ideas, and observations in a simple way is important and helps limit redundancies, awkward passages, and improves reader comprehension. Lastly, a student can maximize their chances at publication if they are persistent in how they approach manuscript submission. The chances for successful publication of a project can be increased if young authors consider the tips supplied here.
We sought to identify an essential component of the TEAD4/VGLL4 transcription factor complex that... more We sought to identify an essential component of the TEAD4/VGLL4 transcription factor complex that controls vascular endothelial growth factor A (VEGFA) expression in muscle. A yeast 2-hybrid screen was used to clone a novel component of the TEAD4 complex from a human heart cDNA library. We identified interferon response factor 2 binding protein 2 (IRF2BP2) and confirmed its presence in the TEAD4/VGLL4 complex in vivo by coimmunoprecipitation and mammalian 2-hybrid assays. Coexpression of IRF2BP2 with TEAD4/VGLL4 or TEAD1 alone potently activated, whereas knock-down of IRF2BP2 reduced, VEGFA expression in C 2 C 12 muscle cells. Thus, IRF2BP2 is required to activate VEGFA expression. In mouse embryos, IRF2BP2 was ubiquitously expressed but became progressively enriched in the fetal heart, skeletal muscles, and lung. Northern blot analysis revealed high levels of IRF2BP2 mRNA in adult human heart and skeletal muscles, but immunoblot analysis showed low levels of IRF2BP2 protein in skeletal muscle, indicating post-transcriptional regulation of IRF2BP2 expression. IRF2BP2 protein levels are markedly increased by isch-emia in skeletal and cardiac muscle compared to nor-moxic controls. IRF2BP2 is a novel ischemia-induced coactivator of VEGFA expression that may contribute to revascularization of ischemic cardiac and skeletal muscles .—Teng,. IRF2BP2 is a skeletal and cardiac muscle-enriched ischemia-inducible activator of VEGFA expression. FASEB J. 24, 4825– 4834 (2010). www.fasebj.org Key Words: vascular endothelial growth factor transcription factors VGLL4 TEAD4
Rationale, aims and objectives The push for electronic medical record (EMR) implementation is gro... more Rationale, aims and objectives The push for electronic medical record (EMR) implementation is grounded on increasing efficiency and cost savings. Our objective was to investigate the effect of EMR implementation on provider attrition. Methods We completed a retrospective study investigating whether medical provider attrition, clinical MD or equivalent, coincided with EMR implementation. We analysed monthly provider attrition rates and mean age at attrition 24 months preceding the EMR 'go-live' date at our institution and 12 months after. Results 208 provider departures occurred between July 2011 and June 2014. The attrition categories were classified as 'departure' (n = 137, 65.9%), 'emeritus' (n = 30; 14.4%), 'no specified reason' (n = 26; 12.5%) and 'not reappointed' (n = 15; 7.2). The most common degree held by departing providers was 'MD' (n = 170; 81.7%). Most departures occurred in June 2013 (n = 24). The mean provider age at departure was 46.4 years ± 2.9 years for June 2012, 48.1 years ± 2.5 years for June 2013 and 45.0 years ± 4.1 years for June 2014. Our data indicate a trend for both an increase in number of departing providers, as well as an increased mean age in the month immediately prior to EMR implementation. Conclusion To date, no other investigation of the effect of EMR implementation of provider retirements have been published. We demonstrate a peak in provider attrition in the month prior to EMR implementation that may not be explained by normal attrition patterns with an academic calendar. Level of evidence Level 5 – qualitative or descriptive study.
Objectives: Pediatric patient caregivers may prefer to avoid a surgical intervention and request ... more Objectives: Pediatric patient caregivers may prefer to avoid a surgical intervention and request a medical management option for eustachian tube dysfunction (ETD). However, there are limited published data evaluating the efficacy of intranasal fluticasone in the medical management of ETD as an alternative to tympanostomy tube placement. The objectives of this study were to: 1) determine if intranasal fluti-casone (INF) prevented tympanostomy tube placement in children with ETD, and 2) describe differences in patient response to INF related to cleft lip and/or palate (CLP) and Down syndrome. Methods: Case series with planned chart review at a Tertiary academic hospital. We reviewed pediatric patients treated with INF for ETD. Inclusion criteria included ETD, no prior intranasal or oral steroid therapy, and no prior tympanostomy tube placement. Outcomes included time-to-tympanostomy tube placement with or without INF and therapy compliance. Kaplan-Meier survival analyses with log-rank tests and Fisher's exact tests were used to examine outcome variables. Results: 676 fulfilled inclusion criteria. 393 (58.7%) were male, and 355 (52.5%) Caucasian with mean age of 27.1 months old. 92 (13.6%) had CLP and 46 (6.8%) had Down Syndrome. 266 (39.4%) received INF, and 202 (88.2%) were compliant at their next visit. 474 (70.1%) had tympanostomy tubes placed. Children treated with INF were less likely to have tympanostomy tubes placed than children not treated (52.6% vs. 81.5%; p < 0.0001). Using survival analyses, INF use was associated with significantly longer mean time-to-tympanostomy tube than no INF use (199.4 vs. 133.7 days; p < 0.0001). INF did not reduce time-to-tympanostomy tube in patients with CLP (p ¼ 0.05) or Down Syndrome (p ¼ 0.27). Conclusion: INF significantly reduces the number of children requiring tympanostomy tube placement for ETD. The CLP and Down Syndrome anatomical variants may attenuate INF efficacy. Further in vivo characterization of INF action on eustachian tube tissues will help further substantiate these observations.
Objectives/Hypothesis: To analyze cost and compare cholesteatoma recidivism and hearing outcomes ... more Objectives/Hypothesis: To analyze cost and compare cholesteatoma recidivism and hearing outcomes with single-stage and second-look operative strategies. Study Design: Retrospective review and cost analysis. Methods: Adult and pediatric patients who underwent a tympanoplasty with mastoidectomy for cholesteatoma with a single-stage or second-look operative strategy were identified. Variables included procedure approach, residual or recurrent cholesteatoma, ossicular chain reconstruction frequency, and operative complications. Audiologic outcomes included pre-/ postoperative air bone gap (ABG) and word recognition score (WRS). Cost analysis included charges for consultation and follow-up visits, surgical procedures, computed tomography temporal bone scans, and audiology visits. Results: One hundred and six patients had a tympanoplasty with mastoidectomy for cholesteatoma, with 80 canal wall-up procedures (CWU) as initial approach. Of these, 46 (57.5%) CWU patients had a planned second look. Two (4.3%) CWU patients had recurrent cholesteatoma and 20 (43.4%) had residual identified at second look. Four (11.7%) single-stage CWU strategy patients developed recurrent cholesteatoma. There was no significant difference in pre-/postoperative ABG and WRS between second look and single stage (P > 0.05). Compared to second-look patients, single-stage patients had significantly fewer postoperative visits (6.32 vs. 10.4; P 5 0.007), and significantly lower overall charges for care ($23,529. vs. $41.411; P < 0.0001). Conclusion: The goal of cholesteatoma surgery is to produce a safe ear, and a second-look strategy after CWU has historically been used to evaluate for recurrent or residual disease. The cholesteatoma recurrence rate at a second look after a CWU tympanoplasty-mastoidectomy is low. Costs of operative procedures are a significant proportion of healthcare resource expenditures. Considering the low rate of cholesteatoma recurrence and relatively high cost of care, implementation of a second-look strategy should be individually tailored and not universally performed.
The production of publications is a key component of one's career advancement in medicine. The go... more The production of publications is a key component of one's career advancement in medicine. The goal of this piece is to discuss five tips to help health profession students get started in medical writing. First, students should take full advantage of the time-saving resources at the local academic biomedical library. Second, outlining a manuscript is one of the essential first steps for producing a successful, high-quality publication. Third, planning the manuscript and writing efficiently is critical since many young authors are either in medical school or residency and do not have ample time to devote to the writing process. Fourth, communicating complex concepts, thoughts, ideas, and observations in a simple way is important and helps limit redundancies, awkward passages, and improves reader comprehension. Lastly, a student can maximize their chances at publication if they are persistent in how they approach manuscript submission. The chances for successful publication of a project can be increased if young authors consider the tips supplied here.
Objective: To analyze variation in tonsillectomy procedure rates between health care system types... more Objective: To analyze variation in tonsillectomy procedure rates between health care system types around the world. Study design: International database analysis. Methods: The 2015 Organization for Economic Cooperation and Development (OECD) Health Statistics surgical procedures database was used to ascertain tonsillectomy procedure volumes for 31 countries. Each country's health system type and structure were classified by overall system type, and by health care regulation, financing, and provision methods. Each system type and structure variable were compared using the rate of tonsillectomy procedures per 100,000 citizens. Results: 10.5 million tonsillectomy procedures completed between 1993 and 2014 were analyzed. Overall, social health insurance system types had higher total tonsillectomy rates versus other health care system types (p < 0.05 for each comparison). Health systems with private care provision had a higher procedure rate versus state provided care (159.1 vs. 131.1 per 100,000 citizens; p ¼ 0.002). Health care systems with societal regulation and financing had a higher procedure count versus state regulated or financed care (regulation 193.3 vs. 139.7 per 100,000 citizens, p < 0.0001; financing 168.2 vs. 135.0 per 100,000 citizens, p ¼ 0.0004). Conclusions: The volume of tonsillectomy procedures is associated with a health care system's overall structure, regulation, financing, and provision methods. International health care systems with state mediated provision, regulation, and financing had lower tonsillectomy rates versus systems with private provision, and societal regulation or financing. Further study is needed to determine differences in indications for tonsillectomy between countries, but these results underscore potential variation in health care delivery in different systems.
The objective of this study was to investigate the utility of electronic tablets and their capaci... more The objective of this study was to investigate the utility of electronic tablets and their capacity to increase hospital floor productivity, efficiency, improve patient care information safety, and to enhance resident education and resource utilization on a busy Otolaryngology – Head & Neck Surgery inpatient service. This was a prospective cohort study with a 2-week pre-implementation period with standard paper census lists without mobile tablet use, and a 2-week post-implementation period followed with electronic tablets used to place orders, look up pertinent clinical data, educate patients as appropriate, and to record daily to-dos that would previously be recorded on paper. The setting for the study was Duke University Medical Center in Durham, North Carolina, with 13 Otolaryngology residents comprising the study population. The time for inpa-tient rounding was shorter with the use tablets (p=0.037). There was a non-significant trend in the number of times a resident had to leave rounds to look up a clinical query on a computer, with less instances occurring in the post-implementation study period. The residents felt that having a tablet facilitated more detailed and faster transfer of information, and improved ease of documentation in the medical record. Seventy percent felt tablets helped them spend more time with patients, 70 % could spend more time directly involved in rounds because they could use the tablet to query information at point-of-care, and 80 % felt tablets improved morale. The utility of a mobile tablet device coupled with the electronic health record appeared to have both quantitative and qualitative improvements in efficiency , increased time with patients and attendance at academic conferences. Tablets should be encouraged but not mandated for clinical and educational use.
Objective: Identification of a causative pathogen in otologic infections assists in maximizing th... more Objective: Identification of a causative pathogen in otologic infections assists in maximizing therapy efficacy particularly in refractory and chronic cases. Current standards for treatment of otologic infections focus on targeted species (spp.) that are assumed to be the most common pathogens. Corynebacterium spp. may play a pathogenic role but are not routinely speciated or included in antibiotic susceptibility analysis. Our objective is to investigate the prevalence and pathogenicity of nondiphtheroid Corynebacterium spp. in commonly encountered purulent and mucopurulent otologic infections. Study Design: Retrospective case review. Setting: Academic tertiary referral center. Patients: Review of 140 microbiology cultures from adults and children presenting with purulent and mucopurulent otologic infections from 2010 to 2012. Intervention(s): Clinical history, demographics, and microbiology cultures with speciation and antibiotic susceptibility analyses. Main Outcome Measure(s): Microbiologic speciation and census, species association with clinical characteristics, antibiotic susceptibility to oral and systemic agents, therapy frequency and agent selection.
Primary tumors of the parapharyngeal space are extremely rare, and lipomas are among the least co... more Primary tumors of the parapharyngeal space are extremely rare, and lipomas are among the least common primary parapharyngeal space masses. Parapharyngeal lipomas typically present as a painless neck mass, and some may present with neurologic deficits or vascular compromise attributed to the lipomas' mass effect on nearby neurovascular structures. We report long term follow-up of two large parapharyngeal lipomas. One lesion was managed expectantly, and the other was managed with a partial transcervical excision. We demonstrate that conservative management and long term patient follow-up may be reasonable if the patient is asymptomatic and liposarcoma is ruled out. Considering the uncertainty in the need for removal, the management strategy for the individual patient is best to be tailored to their clinical presentation.
Objectives. To investigate provincial cochlear implantation (CI) annual volume and cost trends. S... more Objectives. To investigate provincial cochlear implantation (CI) annual volume and cost trends. Study Design. Database analysis. Setting. National surgical volume and cost database. Subjects and Methods. Aggregate-level provincial CI volumes and cost data for adult and pediatric CI surgery from 2005 to 2014 were obtained from the Canadian Institute for Health Information. Population-level aging forecast estimates were obtained from the Ontario Ministry of Finance and Statistics Canada. Linear fit, analysis of variance, and Tukey's analyses were utilized to compare variances and means. Results. The national volume of annual CI procedures is forecasted to increase by \30 per year (R 2 = 0.88). Ontario has the highest mean annual CI volume (282; 95% confidence interval , 258-308), followed by Alberta (92.0; 95% confidence interval , 66.3-118), which are significantly higher than all other provinces (P \ .05 for each). Ontario's annual CI procedure volume is forecasted to increase by \11 per year (R 2 = 0.62). Newfoundland and Nova Scotia have the highest CI procedures per 100,000 residents as compared with all other provinces (P \.05). Alberta, Newfoundland, and Manitoba have the highest estimated implantation cost of all provinces (P \.05). Conclusions. Historical trends of CI forecast modest national volume growth. Potential bottlenecks include provincial funding and access to surgical expertise. The proportion of older adult patients who may benefit from a CI will rise, and there may be insufficient capacity to meet this need. Delayed access to CI for pediatric patients is also a concern, given recent reports of long wait times for CI surgery.
We report a case of a 55-year-old man who presented with a history of new audiovestibular symptom... more We report a case of a 55-year-old man who presented with a history of new audiovestibular symptoms in context of chronic right ear and mastoid pain. Imaging demonstrated severe bony erosion of the temporal bone, and urgent mastoidectomy revealed a mass suspicious for spindle cell variant squamous cell carcinoma. An extensive en-bloc resection was completed, and final pathology indicated high grade angiosarcoma. We detail the imaging and pathological techniques employed that led to this diagnosis. This is the eighth case of primary angiosarcoma of the temporal bone reported in literature, and possibly the first ever recorded in an adult male.
Objective: To determine if preoperative lumbar drain (LD) use reduces the incidence of postoperat... more Objective: To determine if preoperative lumbar drain (LD) use reduces the incidence of postoperative cerebrospinal fluid (CSF) leak in patients undergoing acoustic neuroma resection. Methods: Retrospective review of 282 patients presenting for acoustic neuroma resection between 2005 and 2014.
Objective: To estimate the prevalence of and symptoms associated with posterior semicircular cana... more Objective: To estimate the prevalence of and symptoms associated with posterior semicircular canal dehiscence (PSCD) compared to superior semicircular canal dehiscence (SSCD) and nondehiscent semicircular canals (NDSC). Study Design: Retrospective review. Setting: Academic tertiary referral center. Patients: Review of 412 temporal bone CT scans and associated patient records, excluding patients with prior mastoid or skull base surgery. Intervention(s): CT images (0.625 mm thick) were reviewed in the planes of the semicircular canals. Patient demographics and symptoms were tabulated and analyzed. Main Outcome Measure(s): Prevalence of PSCD and SSCD; degree of hearing loss; presence or absence of aural fullness, autophony, tinnitus, pulsatile tinnitus, disequilibrium, vertigo, and Tullio phenomenon. Results: Review of the 412 CT scans revealed 5 cases of PSCD (1.2%) and 20 cases of SSCD (4.9%). All patients with PSCD
Objective: To determine if providers prescribe more affordable topical antibacterial therapy for ... more Objective: To determine if providers prescribe more affordable topical antibacterial therapy for patients who are economically disadvantaged or come from economically disadvantaged communities. Study design: Prescription drug database review. Setting: Large academic hospital network. Subjects and methods: Ototopical prescription records of 2416 adults and children presenting with acute and chronic otologic infections from 2009 to 2013 were reviewed. Prescription, patient, provider, and institution variables including diagnosis, prescription type, demographics, health insurance status, healthcare provider type and setting were analyzed. Results: Otitis externa and acute otitis media were the most common diagnoses. Non-OHNS (Otolaryngology-Head and Neck Surgery) providers served 82% of all patients. OHNS providers prescribed proportionally less fluoroquinolone, and more brand-name antibiotics compared to non-OHNS providers. Adults were more likely to receive a non-fluoroquinolone antibiotic and a generic prescription versus pediatric patients. Patients who self-identified as 'white' ethnicity received proportionally more fluoroquinolone prescriptions than patients who identified as 'non-white,' but there was no difference in provider type. The proportion of fluoroquinolone prescriptions was significantly higher in patients from low-poverty counties, however poverty level was not associated with patients seeing a particular provider type. The majority of our patients had commercial insurance, followed by Medicaid. Medicare patients had the lowest proportion of fluoroquinolone antibiotic prescriptions, and were less likely to receive fluoroquinolone prescriptions versus commercial insurance. Non-insured patients received proportionally more generic versus brand prescriptions than insured patients. Conclusion: Our results indicate potential provider, patient demographic, and financial factors producing considerable variability in the prescribing patterns for topical antibiotics for common otologic infections.
The production of publications is a key component of one's career advancement in medicine. The go... more The production of publications is a key component of one's career advancement in medicine. The goal of this piece is to discuss five tips to help health profession students get started in medical writing. First, students should take full advantage of the time-saving resources at the local academic biomedical library. Second, outlining a manuscript is one of the essential first steps for producing a successful, high-quality publication. Third, planning the manuscript and writing efficiently is critical since many young authors are either in medical school or residency and do not have ample time to devote to the writing process. Fourth, communicating complex concepts, thoughts, ideas, and observations in a simple way is important and helps limit redundancies, awkward passages, and improves reader comprehension. Lastly, a student can maximize their chances at publication if they are persistent in how they approach manuscript submission. The chances for successful publication of a project can be increased if young authors consider the tips supplied here.
We sought to identify an essential component of the TEAD4/VGLL4 transcription factor complex that... more We sought to identify an essential component of the TEAD4/VGLL4 transcription factor complex that controls vascular endothelial growth factor A (VEGFA) expression in muscle. A yeast 2-hybrid screen was used to clone a novel component of the TEAD4 complex from a human heart cDNA library. We identified interferon response factor 2 binding protein 2 (IRF2BP2) and confirmed its presence in the TEAD4/VGLL4 complex in vivo by coimmunoprecipitation and mammalian 2-hybrid assays. Coexpression of IRF2BP2 with TEAD4/VGLL4 or TEAD1 alone potently activated, whereas knock-down of IRF2BP2 reduced, VEGFA expression in C 2 C 12 muscle cells. Thus, IRF2BP2 is required to activate VEGFA expression. In mouse embryos, IRF2BP2 was ubiquitously expressed but became progressively enriched in the fetal heart, skeletal muscles, and lung. Northern blot analysis revealed high levels of IRF2BP2 mRNA in adult human heart and skeletal muscles, but immunoblot analysis showed low levels of IRF2BP2 protein in skeletal muscle, indicating post-transcriptional regulation of IRF2BP2 expression. IRF2BP2 protein levels are markedly increased by isch-emia in skeletal and cardiac muscle compared to nor-moxic controls. IRF2BP2 is a novel ischemia-induced coactivator of VEGFA expression that may contribute to revascularization of ischemic cardiac and skeletal muscles .—Teng,. IRF2BP2 is a skeletal and cardiac muscle-enriched ischemia-inducible activator of VEGFA expression. FASEB J. 24, 4825– 4834 (2010). www.fasebj.org Key Words: vascular endothelial growth factor transcription factors VGLL4 TEAD4
Rationale, aims and objectives The push for electronic medical record (EMR) implementation is gro... more Rationale, aims and objectives The push for electronic medical record (EMR) implementation is grounded on increasing efficiency and cost savings. Our objective was to investigate the effect of EMR implementation on provider attrition. Methods We completed a retrospective study investigating whether medical provider attrition, clinical MD or equivalent, coincided with EMR implementation. We analysed monthly provider attrition rates and mean age at attrition 24 months preceding the EMR 'go-live' date at our institution and 12 months after. Results 208 provider departures occurred between July 2011 and June 2014. The attrition categories were classified as 'departure' (n = 137, 65.9%), 'emeritus' (n = 30; 14.4%), 'no specified reason' (n = 26; 12.5%) and 'not reappointed' (n = 15; 7.2). The most common degree held by departing providers was 'MD' (n = 170; 81.7%). Most departures occurred in June 2013 (n = 24). The mean provider age at departure was 46.4 years ± 2.9 years for June 2012, 48.1 years ± 2.5 years for June 2013 and 45.0 years ± 4.1 years for June 2014. Our data indicate a trend for both an increase in number of departing providers, as well as an increased mean age in the month immediately prior to EMR implementation. Conclusion To date, no other investigation of the effect of EMR implementation of provider retirements have been published. We demonstrate a peak in provider attrition in the month prior to EMR implementation that may not be explained by normal attrition patterns with an academic calendar. Level of evidence Level 5 – qualitative or descriptive study.
Objectives: Pediatric patient caregivers may prefer to avoid a surgical intervention and request ... more Objectives: Pediatric patient caregivers may prefer to avoid a surgical intervention and request a medical management option for eustachian tube dysfunction (ETD). However, there are limited published data evaluating the efficacy of intranasal fluticasone in the medical management of ETD as an alternative to tympanostomy tube placement. The objectives of this study were to: 1) determine if intranasal fluti-casone (INF) prevented tympanostomy tube placement in children with ETD, and 2) describe differences in patient response to INF related to cleft lip and/or palate (CLP) and Down syndrome. Methods: Case series with planned chart review at a Tertiary academic hospital. We reviewed pediatric patients treated with INF for ETD. Inclusion criteria included ETD, no prior intranasal or oral steroid therapy, and no prior tympanostomy tube placement. Outcomes included time-to-tympanostomy tube placement with or without INF and therapy compliance. Kaplan-Meier survival analyses with log-rank tests and Fisher's exact tests were used to examine outcome variables. Results: 676 fulfilled inclusion criteria. 393 (58.7%) were male, and 355 (52.5%) Caucasian with mean age of 27.1 months old. 92 (13.6%) had CLP and 46 (6.8%) had Down Syndrome. 266 (39.4%) received INF, and 202 (88.2%) were compliant at their next visit. 474 (70.1%) had tympanostomy tubes placed. Children treated with INF were less likely to have tympanostomy tubes placed than children not treated (52.6% vs. 81.5%; p < 0.0001). Using survival analyses, INF use was associated with significantly longer mean time-to-tympanostomy tube than no INF use (199.4 vs. 133.7 days; p < 0.0001). INF did not reduce time-to-tympanostomy tube in patients with CLP (p ¼ 0.05) or Down Syndrome (p ¼ 0.27). Conclusion: INF significantly reduces the number of children requiring tympanostomy tube placement for ETD. The CLP and Down Syndrome anatomical variants may attenuate INF efficacy. Further in vivo characterization of INF action on eustachian tube tissues will help further substantiate these observations.
Objectives/Hypothesis: To analyze cost and compare cholesteatoma recidivism and hearing outcomes ... more Objectives/Hypothesis: To analyze cost and compare cholesteatoma recidivism and hearing outcomes with single-stage and second-look operative strategies. Study Design: Retrospective review and cost analysis. Methods: Adult and pediatric patients who underwent a tympanoplasty with mastoidectomy for cholesteatoma with a single-stage or second-look operative strategy were identified. Variables included procedure approach, residual or recurrent cholesteatoma, ossicular chain reconstruction frequency, and operative complications. Audiologic outcomes included pre-/ postoperative air bone gap (ABG) and word recognition score (WRS). Cost analysis included charges for consultation and follow-up visits, surgical procedures, computed tomography temporal bone scans, and audiology visits. Results: One hundred and six patients had a tympanoplasty with mastoidectomy for cholesteatoma, with 80 canal wall-up procedures (CWU) as initial approach. Of these, 46 (57.5%) CWU patients had a planned second look. Two (4.3%) CWU patients had recurrent cholesteatoma and 20 (43.4%) had residual identified at second look. Four (11.7%) single-stage CWU strategy patients developed recurrent cholesteatoma. There was no significant difference in pre-/postoperative ABG and WRS between second look and single stage (P > 0.05). Compared to second-look patients, single-stage patients had significantly fewer postoperative visits (6.32 vs. 10.4; P 5 0.007), and significantly lower overall charges for care ($23,529. vs. $41.411; P < 0.0001). Conclusion: The goal of cholesteatoma surgery is to produce a safe ear, and a second-look strategy after CWU has historically been used to evaluate for recurrent or residual disease. The cholesteatoma recurrence rate at a second look after a CWU tympanoplasty-mastoidectomy is low. Costs of operative procedures are a significant proportion of healthcare resource expenditures. Considering the low rate of cholesteatoma recurrence and relatively high cost of care, implementation of a second-look strategy should be individually tailored and not universally performed.
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articles by Matt Crowson