Importance Cochlear implants can restore sound and enable speech and language development for children with severe to profound sensorineural hearing loss. Long-term outcomes of pediatric cochlear implant recipients are variable. Although the association between social determinants of health (SDH) and pediatric cochlear implant outcomes has been explored, the strength of this association has not been quantitatively synthesized in the literature. Objective To determine the association of SDH with language and academic outcomes in pediatric cochlear implant recipients. Data Sources In August 2023, the following databases were searched: Embase.com, Ovid MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, Cumulated Index to Nursing and Allied Health Literature Plus, APA PsycINFO, and ClinicalTrials.gov. Following duplicate exclusion of 8687 results, 5326 records were finalized. Study Selection Abstract screening, full-text review, and risk of bias assessment was performed by 1 to 2 reviewers. Articles were included if an effect size for an SDH variable that was associated with measures of language, communication, reading, academics, and quality of life was reported. Main Outcomes and Measures A random-effects meta-analysis was performed, with standardized regression coefficients measuring the relative direction and magnitude of a variable association with the outcome of interest. Results Of 5326 articles, 40 articles that included a total of 3809 children were included in the systematic review; 20 articles that included a total of 1905 children were included in the meta-analysis. Parental involvement, education level, and low socioeconomic status were moderately to strongly associated with language outcomes (beta = 0.30; 95% CI, 0.13-0.48; beta = 0.45; 95% CI, 0.29-0.62; beta = -0.47; 95% CI, -0.83 to -0.10, respectively). Known determinants of language outcomes, such as the age of cochlear implantation and duration of cochlear implant use, demonstrated moderate to no associations with language outcomes (beta = -0.30; 95% CI, -0.43 to -0.17; beta = 0.19; 95% CI, -0.26 to 0.63, respectively). Conclusions and Relevance The results of this systematic review and meta-analysis suggest that SDH are associated with childhood language development and academic achievement. In addition to efforts to expedite cochlear implant placement in eligible children, optimal outcomes may be achieved with interventions centered on the child's home, primary medical care, and school environment.

ImportanceCochlear implants can restore sound and enable speech and language development for children with severe to profound sensorineural hearing loss. Long-term outcomes of pediatric cochlear implant recipients are variable. Although the association between social determinants of health (SDH) and pediatric cochlear implant outcomes has been explored, the strength of this association has not been quantitatively synthesized in the literature.ObjectiveTo determine the association of SDH with language and academic outcomes in pediatric cochlear implant recipients.Data SourcesIn August 2023, the following databases were searched: Embase.com, Ovid MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, Cumulated Index to Nursing and Allied Health Literature Plus, APA PsycINFO, and ClinicalTrials.gov. Following duplicate exclusion of 8687 results, 5326 records were finalized.Study SelectionAbstract screening, full-text review, and risk of bias assessment was performed by 1 to 2 reviewers. Articles were included if an effect size for an SDH variable that was associated with measures of language, communication, reading, academics, and quality of life was reported.Main Outcomes and MeasuresA random-effects meta-analysis was performed, with standardized regression coefficients measuring the relative direction and magnitude of a variable association with the outcome of interest.ResultsOf 5326 articles, 40 articles that included a total of 3809 children were included in the systematic review; 20 articles that included a total of 1905 children were included in the meta-analysis. Parental involvement, education level, and low socioeconomic status were moderately to strongly associated with language outcomes (β = 0.30; 95% CI, 0.13-0.48; β = 0.45; 95% CI, 0.29-0.62; β = −0.47; 95% CI, −0.83 to −0.10, respectively). Known determinants of language outcomes, such as the age of cochlear implantation and duration of cochlear implant use, demonstrated moderate to no associations with language outcomes (β = −0.30; 95% CI, −0.43 to −0.17; β = 0.19; 95% CI, −0.26 to 0.63, respectively).Conclusions and RelevanceThe results of this systematic review and meta-analysis suggest that SDH are associated with childhood language development and academic achievement. In addition to efforts to expedite cochlear implant placement in eligible children, optimal outcomes may be achieved with interventions centered on the child’s home, primary medical care, and school environment.

Importance Clinical guidelines recommend cognitive behavioral therapy (CBT) as a treatment for tinnitus. However, patient response to CBT is variable, and currently, there are no known predictors of response to CBT treatment for tinnitus. Objective To identify the clinical predictors of patient response to CBT for treatment of tinnitus. Design, Setting, and Participants This was a secondary cohort analysis of a single-arm clinical study including adults with chronic bothersome tinnitus recruited from Washington University School of Medicine in St Louis (Missouri) from September 2019 to February 2023. Participants completed an 8-week group CBT program with a licensed clinical psychologist. Each week consisted of 2.5 hours of CBT, amounting to 20 hours of total CBT participation, primarily delivered through a virtual platform. Conjunctive consolidation was used to create a predictive classification system for response to CBT based on tinnitus bother and anxiety levels. Main Outcome and Measure Response to CBT was predefined as a 13-point or greater decrease in the Tinnitus Functional Index (TFI) survey score. Results The study sample included 88 adult patients (median [IQR] age, 59 [49-66] years; 47 [53%] females and 41 [47%] males) with chronic bothersome tinnitus, of whom 53 (60%) had at least 13-point decrease in TFI and were considered to be responders. In univariable and multivariable logistic regression analyses, high to moderate anxiety level and severe tinnitus bother were associated with treatment response (adjusted odds ratio: anxiety, 3.33; 95% CI, 0.90-12.30; tinnitus bother, 12.08; 95% CI, 1.48-98.35). The clinical stratification system showed good predictive and discriminative ability (χ 2 for linear trend = 20.0; C statistic = 0.75; 95% CI, 0.65-0.85). Conclusions and Relevance The findings of this study show that assessment of bother and anxiety levels in patients with tinnitus may be useful for identifying those who are more likely to respond to CBT. Before incorporation into clinical practice, future research should externally validate this finding in a separate population.

BACKGROUND: Palpation of anatomic landmarks is difficult in patients with obesity, which could increase difficulty of achieving femoral access and resuscitative endovascular balloon occlusion of the aorta (REBOA) placement. The primary aim of this study was to examine the association between obesity and successful REBOA placement. We hypothesized that higher body mass index (BMI) would decrease first-attempt success and increase time to successful aortic occlusion (AO). METHODS: A review of the Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry was performed on patients who underwent REBOA placement with initiation systolic blood pressure >0 mm Hg from years 2013-2022. Patients were excluded if they received cardiopulmonary resuscitation on arrival, underwent open AO, or missing data entries for variables of interest. Body mass index categorization was as follows: non-obese (<30), class I (30-34.9), class II (35-39.9), and class III (40+) obesity. Patients were also stratified by access technique, including use of palpation or ultrasound guidance. RESULTS: Inclusion criteria were met by 410 patients. On binary analysis, no primary outcomes of interest, including rate of success, time to placement, or mortality, were significantly impacted by BMI. Among BMI subgroups, there was no statistical difference in injury severity, admission systolic blood pressure (SBP), or augmented SBP. At initiation of aortic occlusion, patients with class II and class III obesity had higher median SBP compared with non- and class I obese patients (p = 0.03). Body mass index subgroup did not impact likelihood of first-attempt success or conversion to open procedure. When stratified by access technique, there was no difference in success rates, time to success or mortality between groups. CONCLUSION: Body habitus did not impact success of REBOA placement, time to successful AO, or mortality. Further, ultrasound guidance was not superior to landmark palpation for arterial access. Following traumatic injury without hemodynamic collapse, obesity should not deter providers from considering REBOA placement. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Introduction: The retrosigmoid approach is often utilized for removal of tumors such as acoustic neuroma/vestibular schwannoma from the internal auditory canal. One risk of the surgery is leak of cerebrospinal fluid (CSF) into the temporal bone, often through small tracts of air cells around the IAC. While one option is to re-open the craniotomy site and the dura and dissect the IAC again, another option is to attempt plugging the leak on the mastoid side. This abstract showcases methods of repairing the leak via a transmastoid approach.

ObjectiveThere is a need to develop and validate a brief questionnaire to measure tinnitus severity that can meet the needs of clinicians and researchers. The objective of this study is to demonstrate the validity and reliability of the 9-item Tinnitus Severity Short Form (TS-SF).Study DesignA cohort study of online survey respondents recruited in October 2020 from the American Tinnitus Association electronic mailing list with a 2-week follow-up time interval.SettingOnline.MethodsFace and content validity, factor analysis, internal consistency, convergent validity, reliability, and minimal clinically important difference (MCID) were analyzed.ResultsOf 1121 participants that started the survey, 325 (29%) completed the baseline TS-SF. Through confirmatory factor analysis, the 9-item survey demonstrated a bifactor model with a substantive distress factor and a method factor. The instrument had high internal consistency with Cronbach's alpha of .96. Convergent validity determined the TS-SF score to be a predictor of tinnitus severity. Of 261 follow-up respondents, the test-retest reliability of r = 0.69 (95% confidence interval, 0.62-0.75) was determined. The MCID was determined using a distribution approach to be a 12-point change.ConclusionThe TS-SF demonstrates good internal consistency, validity, and reliability. This patient-reported outcome measure for tinnitus can be used in tinnitus treatment trials and clinical practice. The 9-item survey is less likely to result in respondent survey fatigue than longer surveys, and the 2-week reference interval allows for monitoring of tinnitus severity change in an appropriate timeframe.

Introduction: Mastoiditis, inflammation of mastoid air cells of the temporal bone, remains a significant medical concern due to its potential to give rise to severe and even life-threatening intracranial complications. We present the clinical encounters and diagnostic outcomes of mastoiditis complications by describing a modern-era surgeon’s experiences in both adult and pediatric patients.

Background: Radiofrequency ablation (RFA) utilizes minimally invasive high-energy current to precisely ablate tumor cells. It has been utilized in many cancer types including thyroid, lung, and liver cancer. It has been shown to provide adequate ablative margins with minimal complications; however, incomplete RFA may lead to recurrence of tumor. The underlying cellular mechanism and behavior of ablated cancer tissue is poorly understood. Methods: A systematic review was performed, searching EMBASE, Web of Science, PubMed, and Scopus for studies published up to March 2022 and reported following PRISMA guidelines. Collection was performed by two groups of investigators to avoid risk of bias. The Cochrane Collaboration's tool was used for assessing risk of bias. We identified human, in vivo, and in vitro research studies utilizing RFA for tumor tissues. We required that the studies included at least one of the following: complications, recurrence, or survival, and took interest to studies identifying cellular signaling pathway patterns after RFA. Descriptive statistical analysis was performed in 'R' software including mean and confidence interval. Results: The most frequent cancers studied were liver and lung cancers accounting for 57.4% (N=995) and 15.4% (N=267), followed by esophageal (N=190) and breast cancer (N=134). The most common reported complications were bleeding (19%) and post-operative pain (14%). In our literature search, four independent studies showed upregulation and activation of the VEGF pathway following RFA, four showed upregulation and activation of the AKT pathway following RFA, three studies demonstrated involvement of matrix metalloproteinases, and four showed upregulation of c-Met protein following RFA. Conclusions: In our review and meta-analysis, we identify several proteins and pathways of interest of which are important in wound healing, angiogenesis, and cellular growth and survival. These proteins and pathways of interest may implicate areas of research towards RFA resistance and cancer recurrence.

Background:Despite extensive research on sex differences in primary thyroid cancer, there is a lack of data on the role of sex in the risk of developing second primary thyroid cancer (SPTC). We aimed to investigate the risk of SPTC development according to patient sex, with an emphasis concerning previous malignancy location as well as age. Methods:Cancer survivors diagnosed with SPTC were identified from the Surveillance, Epidemiology, and End Results (SEER) database. The SEER*Stat software package obtained standardized incidence ratios (SIR) and absolute excess risks of subsequent thyroid cancer development. Results:Data for 9,730 (62.3%) females and 5,890 (37.7%) males were extracted for a total of 15,620 SPTC individuals. Asian/Pacific Islanders had the highest incidence of SPTC [SIR =2.67, 95% confidence interval (CI): 2.49-2.86]. The risk of SPTC was higher in males (SIR =2.01, 95% CI: 1.94-2.08) than when compared to females (SIR =1.83, 95% CI: 1.79-1.88; P<0.001). Head and neck tumors had significantly higher SIRs for SPTC development in males when compared to females. Conclusions:Survivors of primary malignancies have an increased risk SPTC, especially males. Our work suggests that oncologists and endocrinologists may consider the need for increased surveillance of both male and female patients given their increased risk of SPTC.

Introduction The gender and minority gap in general surgery residency is narrowing; however, literature lacks comprehensive data regarding the demographics of fellowship programs following general surgery training. Methods Data from 2017 to 2021 for gender, ethnicity, and surgical subspecialty are publicly available from the ERAS database and ACGME yearly data reports. Cochran-Armitage trend tests were used to determine statistical significance in trends for female and minority applicants and trainees. Results The overall trend of female applicants to surgical specialties remained stagnant. However, female applicants to vascular surgery increased significantly from 25% to 35% (P = .045). There was no significant increase in female trainees in any surgical specialties evaluated. Furthermore, the overall trend of minority applicants to surgical specialties also remained stagnant, except for pediatric surgery, which showed significantly fewer minority applicants. Despite pediatric surgery having fewer applicants, minority trainees in this specialty increased significantly from 8% to 19% (P = .008). Conclusion Several current initiatives, such as intentional mentorship, are being reported to promote diverse and equal representation among female and minority applicants and trainees. However, the current overall margin of increase in diversity among surgical specialty applicants and trainees is minimal, indicating that continued efforts are needed to diversify surgical specialty training programs.

Background:Examining risk factors of readmission in adrenalectomy patients and estimated the cost burden of unplanned readmission on the United States' healthcare system.Methods:According to the Nationwide Readmission Database, 20,494 patients underwent adrenalectomy between 2010-2014. Demographics, comorbidities, clinical data, length of stay (LOS), annual case volume, and discharge disposition of 30- and 90-day readmission cohorts were compared to the non-readmitted cohort.Results:A total of 1,463 (7.9%) and 1,959 (12.7%) adrenalectomy patients were readmitted at 30 and 90 days after discharge, respectively. Prolonged initial hospital stays [odds ratio (OR) =1.93; 95% confidence interval (CI): 1.63-2.27] and postoperative complications (OR =4.91; 95% CI: 1.98-12.16) were associated with a higher risk of readmission. Complications were significantly more frequent in patients with a primary or secondary malignancy (OR =1.42; 95% CI: 1.23-1.64) and in patients undergoing a procedure at a low adrenalectomy volume hospital [hazard ratio (HR) =0.75; 95% CI: 0.62-0.91; P=0.003]. Readmission extended overall LOS by an average of 2.06 days, costing an additional $18,529.49 per admission.Conclusions:Readmission adds significantly to the burden of disease after adrenalectomy. Understanding contributing factors may identify strategies to reduce readmissions and improve healthcare for patients.

Objectives: Perceptions of difficulty in obtaining arterial access in obese patients may impact the rate of resuscitative endovascular balloon occlusion of the aorta (REBOA) use in clinical practice. Excess adipose tissue can obstruct palpation of anatomic landmarks, limit sonographic visualization, and potentially increase difficulty of REBOA placement. We aimed to examine the association between obesity and REBOA placement, hypothesizing that increased body habitus would decrease success and increase time to successful aortic occlusion (AO). Methods: A retrospective analysis of the Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry was performed on REBOA patients (2013-2022). Patients with systolic blood pressure > 0mmHg admission were included. Patients requiring CPR on arrival to the ED were excluded. Body mass index (BMI) categorized obesity subgroups as follows: non-obese (<30), mildly obese (30-34.9), moderately obese (35-39.9), and severely obese (40+). Results: Inclusion criteria was met by 410 patients. There was no statistical difference in injury severity or admission systolic blood pressure (SBP) among the subgroups. At initiation of AO, moderately and severely obese patients had higher median SBP compared to non- and mildly obese patients (p=0.03). On multivariate analysis, BMI did not significantly impact the success of REBOA placement or time to successful AO. When stratified by arterial access technique, there was no difference in success rates, time to successful AO, or mortality between groups. Overall time to successful AO, response SBP, and mortality did not differ across subgroups. Conclusion: Following traumatic injury in obese patients, REBOA placement is a feasible intervention. Despite differences in patient body habitus, ultrasound guidance was not superior to landmark palpation for acquiring arterial access. Placement of REBOA is equally effective in obese patients and severe obesity should not impede REBOA use.

Primary cancer survivors have a higher risk of developing second primary thyroid cancer (SPTC). Patients with SPTC who survived primary malignancies, diagnosed from 1975 to 2016, were identified from the Surveillance, Epidemiology, and End Results (SEER) database (SEER 18 Registry). A total of 33,551 cancer cases were enrolled in the final analysis. Individuals with a primary malignancy were at a significant 90% increased risk of developing SPTC (SIR = 1.90, 95%CI = 1.86–1.93, p < 0.05) compared to the general population. More than half (54.7%) of SPTC diagnoses were made in the first three years after primary cancer diagnosis, and the most aggressive presentations of SPTC occurred within the first year following malignancy. A latency trend analysis identified persistent high risk for development of SPTC after diagnosis of lymphoma, leukemia, soft tissue tumors, kidney, breast, and uterine cancer; elevated 10-year risk for most cancers such as salivary gland, melanoma, stomach, lung, colon, ovarian, pancreas, prostate, and bladder; and high 5-year risk after cancers such as larynx, oral, orbit, bone, small intestine, and liver. Our latency period model identifying risk according to each type of primary cancer may aid clinicians in identifying at-risk patients to be screened for thyroid cancer and guide them in developing a surveillance plan according to the latency period attributed to a patient’s primary cancer.

Triple-negative breast cancer (TNBC) is a highly aggressive form of breast cancer. Due to its heterogeneity and lack of hormone receptor expression, this subtype is more likely to metastasize and resist treatment attempts than are other forms of breast cancer. Due to the absence of targetable receptors, chemotherapy and breast conserving surgery have been the predominant treatment options for patients. However, resistance to chemotherapy and local recurrence of the tumors is frequent. Emerging immunotherapies have begun to change treatment plans for patients diagnosed with TNBC. In this review, we discuss the various immune pathways identified in TNBC and the role they play as targets for new potential treatment choices. Various therapeutic options that inhibit key pathways in cellular growth cycles, DNA repair mechanisms, epithelial mesenchymal transition, and immunosuppression have been shown to improve survival in patients with this disease. With promising results thus far, continued studies of immunotherapy and neoadjuvant therapy options for TNBC are likely to alter the treatment course for these diagnoses in the future.

Papillary thyroid carcinoma (PTC) is the most common thyroid cancer worldwide and is known to spread to adjacent neck lymphatics. Lymph node metastasis (LNM) is a known predictor of disease recurrence and is an indicator for aggressive resection. Our study aims to determine if ultrasound sonographers’ degree of training influences overall LNM detection. PubMed, Embase, and Scopus articles were searched and screened for relevant articles. Two investigators independently screened and extracted the data. Diagnostic test parameters were determined for all studies, studies reported by radiologists, and studies reported by non-radiologists. The total sample size amounted to 5768 patients and 10,030 lymph nodes. Radiologists performed ultrasounds in 18 studies, while non-radiologists performed ultrasounds in seven studies, corresponding to 4442 and 1326 patients, respectively. The overall sensitivity of LNM detection by US was 59% (95%CI = 58–60%), and the overall specificity was 85% (95%CI = 84–86%). The sensitivity and specificity of US performed by radiologists were 58% and 86%, respectively. The sensitivity and specificity of US performed by non-radiologists were 62% and 78%, respectively. Summary receiver operating curve (sROC) found radiologists and non-radiologists to detect LNM on US with similar accuracy (p = 0.517). Our work suggests that both radiologists and non-radiologists alike detect overall LNM with high accuracy on US.

The endothelial glycocalyx (EGX) contributes to the permeability barrier of vessels and regulates the coagulation cascade. EGX damage, which occurs in numerous disease states, including sepsis and trauma, results in endotheliopathy. While influenza and other viral infections are known to cause endothelial dysfunction, their effect on the EGX has not been described. We hypothesized that the H1N1 influenza virus would cause EGX degradation. Human umbilical vein endothelial cells (HUVECs) were exposed to varying multiplicities of infection (MOI) of the H1N1 strain of influenza virus for 24 hours. A dose-dependent effect was examined by using an MOI of 5 (n = 541), 15 (n = 714), 30 (n = 596), and 60 (n = 653) and compared to a control (n = 607). Cells were fixed and stained with FITC-labelled wheat germ agglutinin to quantify EGX. There was no difference in EGX intensity after exposure to H1N1 at an MOI of 5 compared to control (6.20 vs. 6.56 Arbitrary Units (AU), p = 0.50). EGX intensity was decreased at an MOI of 15 compared to control (5.36 vs. 6.56 AU, p<0.001). The degree of EGX degradation was worse at higher doses of the H1N1 virus; however, the decrease in EGX intensity was maximized at an MOI of 30. Injury at MOI of 60 was not worse than MOI of 30. (4.17 vs. 4.47 AU, p = 0.13). The H1N1 virus induces endothelial dysfunction by causing EGX degradation in a dose-dependent fashion. Further studies are needed to characterize the role of this EGX damage in causing clinically significant lung injury during acute viral infection.