1
|
Ponduri A, Azmy MC, Axler E, Lin J, Schwartz R, Chirilă M, Dikkers FG, Yang CJ, Mehta V, Gangar M. The Efficacy of Human Papillomavirus Vaccination as an Adjuvant Therapy in Recurrent Respiratory Papillomatosis. Laryngoscope 2023; 133:2046-2054. [PMID: 36651338 PMCID: PMC10859188 DOI: 10.1002/lary.30560] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 12/05/2022] [Accepted: 12/13/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To characterize the efficacy of human papillomavirus (HPV) vaccination as an adjuvant therapy in recurrent respiratory papillomatosis (RRP). DATA SOURCES PubMed, Embase, Cochrane, Google Scholar, ClinicalTrials.gov, and Web of Science databases were queried for articles published before April 2021. REVIEW METHODS All retrieved studies (n = 870) were independently analyzed by two reviewers according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement using predefined inclusion and exclusion criteria. 13 studies met inclusion criteria. A random-effects meta-analysis was performed to study intersurgical interval (ISI) and number of surgical procedures per year before and after vaccination. RESULTS The systematic review included 13 studies, comprising 243 patients. All studies utilized the Gardasil® quadrivalent vaccine, and one study (Yiu et al. 2019) utilized both the quadrivalent and Gardasil® 9-valent vaccines. Our meta-analysis included 62 patients with ISI data across 4 studies, and 111 patients with data on the number of surgical procedures per month across 7 studies. The mean number of surgical procedures decreased by 4.43 per year after vaccination (95% CI, -7.48 to -1.37). Mean ISI increased after vaccination, with a mean difference of 15.73 months (95% CI, 1.46-29.99). Two studies reported on HPV sero-conversion, with HPV seropositivity of 100% prior to vaccination and 25.93% after vaccination. CONCLUSION The addition of HPV vaccination was associated with an increase in time between surgeries and reduction in the number of surgical procedures required. HPV vaccination may be a beneficial adjuvant treatment for RRP. LEVEL OF EVIDENCE NA Laryngoscope, 133:2046-2054, 2023.
Collapse
Affiliation(s)
- Anusha Ponduri
- Albert Einstein College of Medicine, Bronx, New York, USA
- Department of Otorhinolaryngology - Head and Neck Surgery, Montefiore Medical Center, Bronx, New York, United States
| | - Monica C Azmy
- Albert Einstein College of Medicine, Bronx, New York, USA
- Department of Otorhinolaryngology - Head and Neck Surgery, Montefiore Medical Center, Bronx, New York, United States
| | - Eden Axler
- Albert Einstein College of Medicine, Bronx, New York, USA
| | - Juan Lin
- Albert Einstein College of Medicine, Bronx, New York, USA
| | | | - Magdalena Chirilă
- Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Frederik G Dikkers
- Department of Otorhinolaryngology/Head and Neck Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
| | - Christina J Yang
- Albert Einstein College of Medicine, Bronx, New York, USA
- Department of Otorhinolaryngology - Head and Neck Surgery, Montefiore Medical Center, Bronx, New York, United States
| | - Vikas Mehta
- Albert Einstein College of Medicine, Bronx, New York, USA
- Department of Otorhinolaryngology - Head and Neck Surgery, Montefiore Medical Center, Bronx, New York, United States
| | - Mona Gangar
- Albert Einstein College of Medicine, Bronx, New York, USA
- Department of Otorhinolaryngology - Head and Neck Surgery, Montefiore Medical Center, Bronx, New York, United States
| |
Collapse
|
2
|
Thal AG, Ahmed S, Kim S, Yang CJ, Gao Q, Gangar M, Mehta V. Assessing Impact: Implementing an Opioid Prescription Protocol in Otolaryngology. J Patient Saf 2022; 18:e992-e998. [PMID: 35093975 DOI: 10.1097/pts.0000000000000970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE A lack of guidance for pain control after otolaryngology surgery can lead to overprescription of opioids. We implemented a postoperative site-specific opioid prescription protocol and analyzed the impact on opioid prescriptions. METHODS This is a retrospective cohort study. A postoperative opioid prescription protocol was implemented within our otolaryngology department at a tertiary academic medical center on January 1, 2020. Retrospective chart review was completed for all patients undergoing otolaryngology surgery from November 1, 2019, to February 29, 2020 (2 months before and after initiation of intervention; n = 1070). The primary outcome was change in the amount of opioid prescribed for the preintervention and postintervention cohorts. Unplanned contact related to pain and opioid refills were tracked to assess pain control. RESULTS A total of 940 cases were included; adult and pediatric data were analyzed separately. There were 489 pediatric cases, 250 preintervention and 239 postintervention. There was a significant decrease in the amount of opioid prescribed per pediatric patient in the postintervention cohort (2.7 versus 0.32 morphine milligram equivalents, P = 0.02), and 99% of patients were not prescribed opioids at all. There was no significant change in unplanned contact, and no refills were required. There were 451 adult cases, 200 preintervention and 251 postintervention. There was no statistically significant decrease in the amount of opioid prescribed per adult patient (56.8 versus 51.7 morphine milligram equivalents, P = 0.23). There was no significant increase in unplanned contact or refills. CONCLUSIONS A postoperative opioid prescribing protocol can reduce the amount of opioid prescribed without increasing unplanned contact or opioid refills.
Collapse
Affiliation(s)
- Arielle G Thal
- From the Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center
| | - Sadia Ahmed
- Albert Einstein College of Medicine, The Bronx, New York
| | - Stanley Kim
- Albert Einstein College of Medicine, The Bronx, New York
| | - Christina J Yang
- From the Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center
| | - Qi Gao
- Albert Einstein College of Medicine, The Bronx, New York
| | - Mona Gangar
- From the Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center
| | - Vikas Mehta
- From the Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center
| |
Collapse
|
3
|
Wajsberg B, Li D, Kohanzadeh A, Bitners AC, Gorthey S, Gibber MJ, Rong E, Bent JP, Gangar M, Yang CJ. Impact of a postgraduate year one (PGY-1) otolaryngology bootcamp on procedural skill development. MedEdPublish 2022; 12:47. [PMID: 36168536 PMCID: PMC9427082 DOI: 10.12688/mep.19187.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2022] [Indexed: 11/20/2022] Open
Abstract
Background:
To measure the impact of an intensive eight-week postgraduate year one (PGY-1) otolaryngology bootcamp on the acquisition and retention of otolaryngology residents’ procedural skills compared to the traditional method of skill acquisition through clinical exposure. Methods: Residents at our institution were evaluated on their performance of flexible laryngoscopy, suture ligature, and rigid bronchoscopy setup at three time points: pre-bootcamp, one-week post-bootcamp, and one-year post-bootcamp. Video recordings were scored by two blinded faculty reviewers using a multipoint rating system. A control group of rising postgraduate year two (PGY-2) residents who did not participate in bootcamp were recorded performing these same skills. Scores in the three skills were compared between groups via
t-tests. The eight-week bootcamp curriculum for PGY-1s was held at the Montefiore Einstein Center for Innovation in Simulation at Albert Einstein College of Medicine/Montefiore Medical Center. The participants were two classes of PGY-1 residents (n=8) at our institution who participated in a bootcamp at the beginning of residency, and one class of rising PGY-2 residents (n=3) who did not participate in a bootcamp (control group). Results: A comparison of pre-bootcamp scores to one-week post-bootcamp scores showed significant improvement in suture ligature (
P<0.05) and rigid bronchoscopy (
P<0.05), but no difference in flexible laryngoscopy (
P=0.54). Suture ligature (
P=0.09) and rigid bronchoscopy (
P=0.25) skills were not significantly different from one-week post-bootcamp to one-year post-bootcamp; however, a significant skill improvement was observed in flexible laryngoscopy (
P<0.05). By June of PGY1 year, the two bootcamp cohorts were similar to controls in all three skills: flexible laryngoscopy (
P=0.05), rigid bronchoscopy (
P=0.26), and suture ligature (
P=0.10). Conclusions: Participation in PGY-1 bootcamp was associated with improved acquisition and short-term retention of basic procedural skills, suggesting that bootcamps can be an effective arena to teach basic skills in otolaryngology. PGY-1 bootcamp is a promising arena for multi-institutional development.
Collapse
Affiliation(s)
| | - Daniel Li
- Department of Surgery (Division of Otolaryngology), Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Anna C. Bitners
- Department of Pediatrics, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Scott Gorthey
- Department of Otorhinolaryngology–Head & Neck Surgery, Montefiore Medical Center, Bronx, New York, USA
| | - Marc J. Gibber
- Department of Otorhinolaryngology–Head & Neck Surgery, Montefiore Medical Center, Bronx, New York, USA
| | - Esther Rong
- Department of Radiology, Montefiore Medical Center, Bronx, New York, USA
| | - John P. Bent
- Department of Otorhinolaryngology–Head & Neck Surgery, Montefiore Medical Center, Bronx, New York, USA
| | - Mona Gangar
- Department of Otorhinolaryngology–Head & Neck Surgery, Montefiore Medical Center, Bronx, New York, USA
| | - Christina J. Yang
- Department of Otorhinolaryngology–Head & Neck Surgery, Montefiore Medical Center, Bronx, New York, USA
- Department of Pediatrics, Montefiore Medical Center/Children’s Hospital at Montefiore, Bronx, New York, USA
| |
Collapse
|
4
|
Jiang S, Yang C, Bent J, Yang CJ, Gangar M, Nassar M, Suskin B, Dar P. Ex utero intrapartum treatment (EXIT) for fetal neck masses: A tertiary center experience and literature review. Int J Pediatr Otorhinolaryngol 2019; 127:109642. [PMID: 31479918 DOI: 10.1016/j.ijporl.2019.109642] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 07/17/2019] [Accepted: 08/09/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Currently no established criteria exist to guide use of ex utero intrapartum treatment (EXIT) for fetal neck mass management. This study aims to correlate prenatal radiographic findings with incidence of ex utero intrapartum treatment and necessity of airway intervention at delivery. METHODS We reviewed our EXIT experience between 2012 and 17. Furthermore, we performed a literature review of articles reporting incidences of fetal neck masses considered for EXIT. Articles that were included (1) discussed prenatal radiographic findings such as size, features, and evidence of compression and (2) reported extractable data on delivery outcomes and airway status. RESULTS Ten cases at our institution were reviewed. Another 137 cases across 81 studies met inclusion criteria. These studies showed aerodigestive tract compression to be significantly associated with neck masses undergoing EXIT. Additionally, there was significantly higher incidence of airway intervention in cases where polyhydramnios, anatomic compression, and solid masses were seen on prenatal diagnostic imaging, while mass location and size did not correlate with airway intervention. CONCLUSION With this data, we propose that any neck mass with anatomic compression on fetal imaging in the 3rd trimester should be considered for EXIT. When radiographic findings do not show compression but do display polyhydramnios or a solid neck mass (regardless of polyhydramnios), an airway surgeon should be available for perinatal airway assistance.
Collapse
Affiliation(s)
- Sydney Jiang
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center / Children's Hospital of Montefiore, 3400 Bainbridge Avenue 3rd Floor, Bronx, NY, 10467, USA; Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, 10461, USA.
| | - Catherina Yang
- Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, 10461, USA
| | - John Bent
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center / Children's Hospital of Montefiore, 3400 Bainbridge Avenue 3rd Floor, Bronx, NY, 10467, USA
| | - Christina J Yang
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center / Children's Hospital of Montefiore, 3400 Bainbridge Avenue 3rd Floor, Bronx, NY, 10467, USA
| | - Mona Gangar
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center / Children's Hospital of Montefiore, 3400 Bainbridge Avenue 3rd Floor, Bronx, NY, 10467, USA
| | - Michel Nassar
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center / Children's Hospital of Montefiore, 3400 Bainbridge Avenue 3rd Floor, Bronx, NY, 10467, USA
| | - Barrie Suskin
- Department of Obstetrics and Gynecology, Stamford Hospital, One Hospital Plaza, Whittingham Pavilion, Stamford, CT, 06902, USA
| | - Peer Dar
- Division of Fetal Medicine and OB-Gyn Ultrasound, Albert Einstein College of Medicine / Montefiore Medical Center, 1695 Eastchester Road Room L4, Bronx, NY, 10461, USA
| |
Collapse
|
5
|
Affiliation(s)
- Risa E Bochner
- Department of Pediatrics, Children's Hospital at Montefiore, Bronx, NY
| | - Mona Gangar
- Department of Pediatrics, Children's Hospital at Montefiore, Bronx, NY.,Department of Otorhinolaryngology/Head and Neck Surgery, Division of Pediatric Otorhinolaryngology, Albert Einstein College of Medicine, Bronx, NY
| | | |
Collapse
|
6
|
Mukhatiyar P, Nandalike K, Cohen HW, Sin S, Gangar M, Bent JP, Arens R. Intracapsular and Extracapsular Tonsillectomy and Adenoidectomy in Pediatric Obstructive Sleep Apnea. JAMA Otolaryngol Head Neck Surg 2016; 142:25-31. [PMID: 26583828 DOI: 10.1001/jamaoto.2015.2603] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Limited information exists regarding clinical outcomes of children undergoing extracapsular tonsillectomy and adenoidectomy (ETA) or intracapsular tonsillectomy and adenoidectomy (ITA) for treatment of obstructive sleep apnea syndrome (OSAS). OBJECTIVES To quantify polysomnography (PSG) and clinical outcomes of ETA and ITA in children with OSAS and to assess the contribution of comorbid conditions of asthma and obesity. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study using medical records at a tertiary pediatrics inner-city hospital. Medical records from 89 children who underwent ETA or ITA between October 1, 2008, and December 31, 2013, were analyzed. The dates of our analysis were January 6, 2014, to April 11, 2014. Inclusion criteria required no evidence of craniofacial or neurological disorders, confirmation of OSAS by PSG within the 2 years before surgery, and a second PSG within the 2 years after surgery. INTERVENTIONS Each child underwent ETA or ITA after being evaluated by a pediatric otolaryngologist and obtaining written parental informed consent. MAIN OUTCOMES AND MEASURES Main primary outcomes were derived from PSG. Secondary outcomes included treatment failure, defined as residual OSAS with an obstructive apnea-hypopnea index of at least 5 events per hour. Comparisons were made between and within groups. Logistic regression was used to identify factors associated with treatment failure. RESULTS Fifty-two children underwent ETA, and 37 children underwent ITA. Children in the ETA group were older (7.5 vs 5.2 years, P = .001) and more obese (60% [31 of 52] vs 30% [11 of 37], P = .004). However, both groups had similar severity of OSAS, with median preoperative obstructive apnea-hypopnea indexes of 17.0 in the ETA group and 24.1 in the ITA group (P = .21), and similar prevalences of asthma (38% [20 of 52] vs 38% [14 of 37]). After surgery, significant improvement was noted on PSG in both groups, with no differences in any clinical outcomes. There was no association between procedure type, age, or body mass index z score and treatment failure. However, in a subset of patients with asthma and obesity, ITA was associated with residual OSAS (odds ratio, 16.5; 95% CI, 1.1-250.2; P = .04). CONCLUSIONS AND RELEVANCE Both ETA and ITA are effective modalities to treat OSAS, with comparable surgical outcomes on short-term follow-up. However, when comorbid diagnoses of both asthma and obesity exist, OSAS is likely to be refractory to treatment with ITA compared with ETA.
Collapse
Affiliation(s)
- Pamela Mukhatiyar
- Division of Pediatric Respiratory and Sleep Medicine, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Kiran Nandalike
- Department of Pediatric Pulmonology, UC Davis Children's Hospital, Sacramento, California
| | - Hillel W Cohen
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
| | - Sanghun Sin
- Division of Pediatric Respiratory and Sleep Medicine, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Mona Gangar
- Department of Otolaryngology-Head and Neck Surgery, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - John P Bent
- Department of Otolaryngology-Head and Neck Surgery, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Raanan Arens
- Division of Pediatric Respiratory and Sleep Medicine, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| |
Collapse
|
7
|
Gangar M, Ow TJ, Khorsandi AS, Persky MS. Diagnosis and Management of Cervical Schwannomas: Is Surgery Always Necessary? Laryngoscope 2009. [DOI: 10.1002/lary.20286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
8
|
Abstract
OBJECTIVE To determine the frequency of cutaneous reactions in a group of HIV-infected adults attending a public hospital HIV clinic who received nevirapine, delavirdine, or both, as well as the consequences of rechallenge with the same or alternative agent. DESIGN The medical records of patients who had received either or both agents between March 1997 and July 1998 were reviewed, including 69 patients who initially received nevirapine and 20 who initially received delavirdine. Gender, ethnicity, HIV status, and plasma HIV RNA concentrations were analyzed as risk factors for the development of rash. RESULTS The overall incidence of rash attributed to the initial use of one of these drugs was 37.1%. While rash due to delavirdine occurred more often, the rash due to nevirapine was more severe and resulted in hospitalization more frequently. There was a trend toward a higher frequency of rash in Latinos and possibly in women, but HIV status, CD4+ cell counts, and plasma HIV RNA were not risk factors for the development of rash. Drug therapy was temporarily or permanently discontinued because of rash in 19 of 69 (28%) and in five of 20 (25%) patients initially receiving nevirapine or delavirdine, respectively. Rash recurred in six of eight (75%) patients rechallenged with the same agent, and in seven of 10 (70%) who were crossed over to the alternative agent because of rash. Fever, in the absence of any apparent cause, was a significant predictor for the development of rash in patients receiving nevirapine. CONCLUSIONS There is probably little value in attempting to retreat patients with cutaneous reactions, even with the alternative agent, except in patients with limited treatment options.
Collapse
Affiliation(s)
- M Gangar
- Department of Medicine, Santa Clara Valley Medical Center, San Jose, CA 95128, USA
| | | | | | | |
Collapse
|
9
|
Kemper CA, Gangar M, Arias G, Kane C, Deresinski SC. The prevalence of measles antibody in human immunodeficiency virus-infected patients in northern California. J Infect Dis 1998; 178:1177-80. [PMID: 9806055 DOI: 10.1086/515679] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The seroprevalence of measles (rubeola) antibody in 619 human immunodeficiency virus (HIV)-infected adults was determined by a standard ELISA. Risk factors for a lack of antibody and presumed susceptibility to measles were examined. Whereas overall, 9.8% of patients (60) were found to lack antibody, 17.8% of those born within the United States in 1957 or later were antibody-negative. Multivariate analysis showed that absence of measles antibody was significantly associated with younger age (born in 1957 or later) (odds ratio [OR], 8.15; 95% confidence interval [CI], 3.7-21.5; P < .0001) and birth within the United States (OR, 4.72; 95% CI, 1.7-19.7; P = .0045). Neither minority status, stage of HIV infection, CD4 cell count, nor a history of opportunistic infection bore any relationship to the presence of antibody. While progression of HIV disease does not affect measles serostatus, younger HIV-infected patients, especially those born in the United States in 1957 or later, are at the greatest risk for measles.
Collapse
Affiliation(s)
- C A Kemper
- Department of Medicine, Santa Clara Valley Medical Center, San Jose, California 95128, USA
| | | | | | | | | |
Collapse
|