Despite the widespread adoption of early warning systems (EWSs), it is uncertain if their implementation improves patient outcomes. The authors report a pre-post quasi-experimental evaluation of a commercially available EWS on patient outcomes at a 700-bed academic medical center. The EWS risk scores were visible in the electronic medical record by bedside clinicians. The EWS risk scores were also monitored remotely 24/7 by critical care trained nurses who actively contacted bedside nurses when a patient’s risk levels increased. The primary outcome was inpatient mortality. Secondary outcomes were rapid response team calls and activation of cardiopulmonary arrest (code-4) response teams. The study team conducted a regression discontinuity analysis adjusting for age, gender, insurance, severity of illness, risk of mortality, and hospital occupancy at admission. The analysis included 53,229 hospitalizations. Adjusted analysis showed no significant change in inpatient mortality, rapid response team call, or code-4 activations after implementing the EWS. This study confirms the continued uncertainty in the effectiveness of EWSs and the need for further rigorous examinations of EWSs.

BackgroundUnrecognised changes in a hospitalised patient’s clinical course may lead to a preventable adverse event. Early warning systems (EWS) use patient data, such as vital signs, nursing assessments and laboratory values, to aid in the detection of early clinical deterioration. In 2018, an EWS programme was deployed at an academic hospital that consisted of a commercially available EWS algorithm and a centralised virtual nurse team to monitor alerts. Our objective was to understand the nursing perspective on the use of an EWS programme with centralised monitoring.MethodsWe conducted and audio-recorded semistructured focus groups during nurse staff meetings on six inpatient units, stratified by alert frequency (high: >100 alerts/month; medium: 50–100 alerts/month; low: <50 alerts/month). Discussion topics included EWS programme experiences, perception of EWS programme utility and EWS programme implementation. Investigators analysed the focus group transcripts using a grounded theory approach.ResultsWe conducted 28 focus groups with 227 bedside nurses across all shifts. We identified six principal themes: (1) Alert timeliness, nurses reported being aware of the patient’s deterioration before the EWS alert, (2) Lack of accuracy, nurses perceived most alerts as false positives, (3) Workflow interruptions caused by EWS alerts, (4) Questions of actionability of alerts, nurses were often uncertain about next steps, (5) Concerns around an underappreciation of core nursing skills via reliance on the EWS programme and (6) The opportunity cost of deploying the EWS programme.ConclusionThis qualitative study of nurses demonstrates the importance of earning user trust, ensuring timeliness and outlining actionable next steps when implementing an EWS. Careful attention to user workflow is required to maximise EWS impact on improving hospital quality and patient safety.

Stensen’s duct carcinoma (StDC) is an extremely rare neoplasm, with fewer than 40 cases reported in the literature. We report a unique case of primary StDC with papillary features and intestinal differentiation of a 74-year-old male. We discuss the radiologic and pathologic correlation along with the differential diagnosis of this rare entity.

Objective:To determine the feasibility of audiometric screening with tablet-based applications in typical clinic locations: examination room and clinic waiting area.Study Design:A randomized prospective study.Setting:Tertiary referral center.Patients:Participants included 107 adult patients referred for audiometric testing to assess hearing loss.Intervention:Each patient completed standard audiometry testing and one of three tablet-based audiometric applications that included pure-tone air conduction testing. The tablet-based audiometric testing was completed in a quiet examination room and a clinic waiting area using noise-cancellation headphones. A 5-question patient satisfaction survey was completed at the end of the testing.Main Outcome Measure:Thresholds at each frequency were compared with those obtained from tablet-based audiometric applications in a quiet examination room and clinic waiting area. Sensitivity and specificity of each tablet-based audiogram in detecting a hearing loss at each frequency was determined.Results:All three tablet-based audiometric applications were user-friendly for hearing screening. However, one application was shown to be feasible and the most accurate of the three tested with 92% of thresholds within 10dB of conventional audiometry across all test conditions. This application had a sensitivity of 96 to 100% and specificity of 72 to 85% for identifying a hearing loss in each frequency tested. Variability was noted among applications between testing in a quiet clinic room and testing in the clinic waiting area. Patients showed no preference for either conventional audiometry or the tablet-based device.Conclusion:Tablet-based audiometric applications can be used to screen for hearing loss in typical clinic locations. This tool does not replace standard audiometry testing but allows for screening for hearing disorders when appropriate and in settings without access to audiometric equipment.

A compounding feature of greater than 50% of all cancers is the high incidence of the cachexia syndrome, a complex metabolic disorder characterized by extreme weight loss due mainly to the gross depletion of skeletal muscle tissue. Although studies into the cause of cancer cachexia has spanned over multiple decades, little is known about the effects of various cancer treatments themselves on cachexia. For example, chemotherapy agents induce side effects such as nausea and anorexia, but these symptoms do not fully account for the changes seen with cancer cachexia. In this study we examine the effects of chemotherapeutic compounds, specifically, cisplatin in the colon-26 adenocarcinoma model of cancer cachexia. We find that although cisplatin is able to reduce tumor burden as expected, muscle wasting in mice nevertheless persists. Strikingly, cisplatin alone was seen to regulate muscle atrophy, which was independent of the commonly implicated ubiquitin proteasome system. Finally, we show that cisplatin is able to induce NF-κB activity in both mouse muscles and myotube cultures, suggesting that an additional side effect of cancer treatment is the regulation of muscle wasting that may be mediated through activation of the NF-κB signaling pathway.

Objective: Shoulder pain or weakness, lymphedema, and xerostomia are known treatment-related impairments of head and neck cancer, often leading to significant disability. The purpose of this study is to determine the referral patterns to rehabilitation for these impairments in patients who underwent primary surgery that included neck dissection and to identify potential predictors of need for rehabilitation. Design: Retrospective chart review. Setting: Tertiary hospital. Patients: Patients who had ten or more lymph nodes removed via neck dissection. Methods and Outcome Measurements: Demographics, cancer history, symptoms and referrals to rehabilitation for shoulder pain or weakness, lymphedema, and xerostomia were recorded. Results: 155 patients with a mean age of 61.4 were identified. 29 patients (20.1%) had shoulder pain or weakness, 39 patients (27.9%) had lymphedema, and 72 subjects (50.7%) had xerostomia. No rehabilitation referrals were made for 24.1% of patients with shoulder pain or weakness, 51.3% with lymphedema, and 61.1% with xerostomia. Adjuvant radiation was associated with shoulder pain or weakness (p=0.0004), lymphedema (p=0.001), and xerostomia (p 4 days post-operatively (p=0.002) were associated with lymphedema. Conclusion: The majority of patients with shoulder pain or weakness were referred to rehabilitation, but less than half of patients with lymphedema or xerostomia were referred for appropriate rehabilitation treatment. In addition to radiation, which is a known association for these common impairments after HNC treatment, greater number of lymph nodes removed and prolonged drain placement may identify patients at risk of lymphedema.

IMPORTANCE:Quality metrics for patients with head and neck cancer are available, but it is unknown whether compliance with these metrics is associated with improved patient survival.OBJECTIVE:To identify whether compliance with various process-related quality metrics is associated with improved survival in patients with oral cavity squamous cell carcinoma who receive definitive surgery with or without adjuvant therapy.DESIGN, SETTING, AND PARTICIPANTS:A retrospective cohort study was conducted at a tertiary academic medical center among 192 patients with previously untreated oral cavity squamous cell carcinoma who underwent definitive surgery with or without adjuvant therapy between January 1, 2003, and December 31, 2010. Data analysis was performed from January 26 to August 7, 2015.INTERVENTIONS:Surgery with or without adjuvant therapy.MAIN OUTCOMES AND MEASURES:Compliance with a collection of process-related quality metrics possessing face validity that covered pretreatment evaluation, treatment, and posttreatment surveillance was evaluated. Association between compliance with these quality metrics and overall survival, disease-specific survival, and disease-free survival was calculated using univariable and multivariable Cox proportional hazards analysis.RESULTS:Among 192 patients, compliance with the individual quality metrics ranged from 19.7% to 93.6% (median, 82.8%). No pretreatment or surveillance metrics were associated with improved survival. Compliance with the following treatment-related quality metrics was associated with improved survival: elective neck dissection with lymph node yield of 18 or more, no unplanned surgery within 14 days of the index surgery, no unplanned 30-day readmissions, and referral for adjuvant radiotherapy for pathologic stage III or IV disease. Increased compliance with a "clinical care signature" composed of these 4 metrics was associated with improved overall survival, disease-specific survival, and disease-free survival on univariable analysis (log-rank test; P < .05 for each). On multivariable analysis controlling for pT stage, pN stage, extracapsular spread, margin status, and comorbidity, increased compliance with these 4 metrics was associated with improved overall survival (100% vs ≤50% compliance: adjusted hazard ratio [aHR], 4.2; 95% CI, 2.1-8.5; 100% vs 51%-99% compliance: aHR, 1.7; 95% CI, 1.0-3.1), improved disease-specific survival (100% vs ≤50% compliance: aHR, 3.9; 95% CI, 1.7-9.0; 100% vs 51%-99%: aHR, 1.3; 95% CI, 0.6-2.9), and improved disease-free survival (100% vs ≤50% compliance: aHR, 3.0; 95% CI, 1.5-5.8; 100% vs 51%-99% compliance: aHR, 1.6; 95% CI, 0.9-2.7).CONCLUSIONS AND RELEVANCE:Compliance with a core set of process-related quality metrics was associated with improved survival for patients with surgically managed oral cavity squamous cell carcinoma. Multi-institutional validation of these metrics is warranted.

Objectives Determine if routine computed tomography (CT) imaging is necessary in the workup for children with connexin-related (DFNB1) sensorineural hearing loss (SNHL). Study Design Case-control retrospective chart and imaging review. Setting Tertiary care otolaryngology practice. Subjects and Methods High-resolution temporal bone CT scans of children (n = 21) with DFNB1 SNHL were compared to age-matched controls with either conductive hearing loss (CHL, n = 33) or a nonsyndromic, non-DFNB1 SNHL (n = 33). Sixteen measurements of cochleo-vestibular structures were recorded. Statistical analysis was performed using a repeated analysis of variance model that controlled for both age and gender. Area under the curve (AUC) and multidimensional AUC (MAUC) analyses were also performed. Results Overall, no statistically significant differences were found between the 3 experimental groups. In addition, comparisons between the DFNB1 and CHL groups, DFNB1 and non-DFNB1 SNHL groups, and CHL and non-DFNB1 SNHL groups failed to demonstrate any statistically significant differences. AUC and MAUC analyses also failed to detect any significant differences between the 3 groups. Conclusions Patients with DFNB1 SNHL do not have significant anatomic differences on temporal bone CT scans when compared to non-DFNB1 SNHL and CHL control groups. Based on the above analysis, it is reasonable to avoid routine CT imaging of the temporal bones in children with known DFNB1 SNHL unless otherwise clinically indicated.

Immunoglobulin-derived light chain amyloidosis can occasionally be associated with localized disease. We present a patient with localized lymph node light chain amyloidosis without an underlying monoclonal protein or lymphoproliferative disorder and review the literature of lymph node amyloidosis discussing work-up and risk factors for systemic progression.

Education in patient safety (PS) and quality improvement (QI) helps both medical students and residents understand the health care environment in the United States, where these concepts are now incorporated into virtually every aspect of patient care. The Accreditation Council of Graduate Medical Education has made PS/QI a mandatory component of resident education, and a number of specialties have published their experiences with incorporating PS/QI into their training programs. In otolaryngology–head and neck surgery, a strong curriculum can be built by teaching residents about the principles of PS/QI through both didactic and experiential learning, and morbidity and mortality and QI conferences can serve as the cornerstone of this curriculum. Understanding the potential challenges in PS/QI education can allow training programs to plan their strategy effectively for successful incorporation into their existing curricula.

Objectives/HypothesisReview contemporary definitions of professionalism and apply them to resident evaluation and education. Data SourcesReview of PubMed, Medline, and Google Scholar. Review MethodsReview of articles and bibliographies from 1980 to 2012 for professionalism definitions, evaluation, and education in resident training was performed. ResultsOur initial search returned 291 articles. Sixty-seven articles were included in the final review. Definitions of professionalism often focused on attitudes and traits such as honesty, altruism, self-reflection, reliability, and respect for others. The operationalization of such abstract definitions is challenging as they are subject to variable interpretations when translated into measurable behaviors. Despite the challenges, specific behavioral benchmarks can be developed and utilized for evaluation with available methods including patient/nurse surveys, faculty observation, objective structured clinical exams (OSCE), ethical reasoning tests, and completion of administrative tasks. Curriculums have often been lecture-based, limiting the ability to transmit professional values and behaviors. Professionalism is taught most effectively through multiple modalities including mentorship, faculty role modeling, self-reflection, and resident professionalism portfolios. For professionalism evaluation and education to be effective, the curriculum should be developed as a collaborative effort between residents and faculty. ConclusionsProfessionalism training requires practical, behavior-based definitions of professional conduct. Once professional expectations are defined, multiple methods should be used to comprehensively evaluate the learner. Professionalism curriculums must be interactive and promote development through a variety of methods with the goal to improve resident performance in this critical core competency.

Objectives/HypothesisTo propose a clinically applicable anatomic classification system describing three progressive endoscopic endonasal approaches (EEAs) to the infratemporal fossa (ITF) and their potential sequelae. Overall feasibility and outcomes of these approaches are presented through a consecutive case series.Study DesignDescription of classification system for EEAs to the ITF and case series.MethodsA classification system of EEAs to ITF tumors was created based on the senior author's clinical experience and cadaveric dissection. A retrospective chart review of 21 child and adult patients with primary ITF tumors treated by these approaches from 2008 to 2012 at a tertiary‐care academic medical center was conducted.ResultsThree progressive EEAs to ITF tumors were defined: 1) a transpterygopalatine fossa approach, 2) a transmedial pterygoid plate approach, and 3) a translateral pterygoid plate approach. Twenty‐one patients treated with these approaches were identified consecutively, with a mean age of 44.2 years (range, 11–79 years). Tumors primarily involving the pterygopalatine fossa and not the ITF were excluded. Pathology included three advanced juvenile nasopharyngeal angiofibromas, three adenoid cystic carcinomas, two recurrent inverted papillomas, two trigeminal schwannomas, and 11 other diverse skull base pathologies. No intraoperative or postoperative complications occurred, with a mean follow‐up of 21.5 months (range, 1–55 months). Expected potential sequelae such as V2/palatal numbness, Eustachian tube dysfunction, and trismus occurred in 10/21 patients.ConclusionsEEAs to ITF tumors are technically feasible with low risk of complications for well‐selected patients. The proposed classification system is useful for anticipating potential sequelae for each approach.Level of Evidence4 Laryngoscope, 124:2443–2450, 2014

Resident professionalism development is important for physician training and patient care. Meaningful professionalism curriculum requires collaboration between learners and educators. We aimed to better understand attitudes of Otolaryngology–Head and Neck Surgery (OHNS) program directors (PDs) and residents toward professionalism education.

Objective To investigate ERCC1 protein expression and its relationship to clinical factors and treatment outcomes in patients with head and neck squamous cell carcinoma (HNSCC). Design Case series. Setting Tertiary care academic center. Subjects One hundred and seventy-six patients diagnosed with HNSCC and treated with intent to cure between 2002 and 2008 were analyzed with respect to clinical data and tumor pathology. Main Outcome Measures Tissue microarrays were constructed from tumor blocks and immunohistochemical staining for ERCC1 performed. ERCC1 expression status was dichotomized into high and low using the Allred score. Clinical characteristics of patients with high versus low ERCC1 expression were compared. Distributions of overall survival (OS) and progression-free survival (PFS) were analyzed using the Kaplan-Meier method. Results Of 176 patients, ERCC1 showed baseline nuclear staining in 148 patients (84.1%). Lower staining intensity ERCC1 expression was prominent in parabasal cells in the lower half of the epithelium, while at high staining intensity, ERCC1 expression was present throughout the epithelium. The median H-score was 50. No significant differences in age, gender, smoking status, tumor site, or stage were seen between the high and low ERCC1 expression groups. Expression of ERCC1 stratified by tumor site correlates with OS. Patients with oropharyngeal HNSCC and high ERCC1 expression (H-score > 120) were more likely to survive (P < .01) and remain disease free when compared to non-oropharyngeal squamous cell carcinoma (SCCa) patients with high ERCC1 expression despite treatment modality and human papillomavirus virus (HPV) status. Conclusion Patients with oropharyngeal SCCa and high ERCC1 expression may have better outcomes despite HPV status.

Objectives:1) Review the importance of quality and patient safety initiatives in surgical care, identifying the specific role that these play in transoral surgical (TOS) procedures. 2) Describe the usefulness of a surgical safety checklist designed for TOS procedures.Methods:Expert opinion, clinical consensus, and a comprehensive literature search were conducted in this project. A systematic review of the literature between 1946 and January 2013 was performed using Pubmed and Medline. Search terms included: quality, patient safety, otolaryngology, head and neck surgery, Surgical checklist, clinical care pathway, transoral laser microsurgery, transoral robotic surgery. Altogether, 200 abstracts were initially reviewed, and 51 studies were selected based on their relevance to the objectives listed above.Results:A comprehensive review of quality and patient safety initiatives in surgical care revealed that clinical care pathways and surgical safety checklists are effective tools in reducing perioperative morbidity, mortality, and cost of care. In otolaryngology‐head and neck surgery, checklists have only been described for endoscopic sinus surgery. A comprehensive, yet usable, surgical quality and safety checklist for TOS procedures was then developed by the authors based on previously successful models from the literature, as well as from expert opinion.Conclusions:Transoral surgery (TOS), including the use of lasers and/or robotics, is an increasingly used and important treatment option for the management of neoplastic diseases of the head and neck. We propose a comprehensive surgical safety checklist that addresses the unique risks and technical requirements of TOS procedures.

Necrotizing fasciitis is a severe, rapidly progressive infection of the subcutaneous tissue that causes significant destruction. It is rarely encountered in the pediatric population. We describe the case of a 14-year-old boy who was diagnosed with Chromobacterium violaceum necrotizing fasciitis and subsequently found to have autosomal recessive chronic granulomatous disease.

Stadler, Michael E.*; Huang, Benjamin Y.†; Campbell, Adam*; Buchman, Craig A.*; Adunka, Oliver F.* Author Information

Objective: 1) Describe a novel operative technique using a posteriorly pedicled nasoseptal flap (NSF) for reconstruction of secondary palatal defects. 2) Report initial outcomes of patients with secondary palatal defects who underwent NSF palatal reconstruction. Method: Case series of 5 patients who underwent NSF for repair of secondary palatal defects at a tertiary referral center from October 2008 to October 2010. A NSF pedicled on the posterior nasoseptal artery was used for coverage of palatal defects. Clinical outcomes and images will be presented. Results: Two patients had secondary palatal defects from prior tumor resection, 1 patient had a traumatic injury, 1 patient had granulomatous disease, and 1 patient had a palatal defect after Le Fort I advancement. Area of defects ranged from 0.5 to 7cm2. Initial outcomes reveal that all defects less than 1cm in width (n = 3) closed successfully and defects larger than 2cm in width (n = 2) did not completely close. There were no intraoperative complications. All patients had complete intranasal healing by 6 weeks postoperatively. There were no postoperative bleeding, infectious, or wound complications, as well as no cerebrospinal fluid leaks. Conclusion: Secondary palatal defects are challenging and reconstruction with vascularized tissue is desirable. A posteriorly pedicled nasoseptal flap offers a novel option to repair palatal defects. The success rate for small defects is promising with minimal donor site morbidity.