The role of trauma services in intentional self-harm at a regional level 1 trauma center

INTRODUCTION

Suicide claims many lives globally, each year. For every person that dies by suicide, multitudes more attempt it. A national shortage of psychiatrists may prevent many individuals from receiving timely mental health care. For many individuals, the primary entry point into the healthcare system is through the emergency department. The trauma service frequently treats patients with severe self-inflicted injuries and for many this is not the first time. This represents an opportunity for intervention to disrupt the cycle and prevent future death.

METHODS

We conducted a retrospective chart review of all patients with self-inflicted injuries, admitted to the trauma surgery service between 2012 and 2021. All patients above 10 years old were included.

RESULTS

Four hundred forty-one patients were admitted due to self-injurious behavior in the period under study. The majority of patients (71.9%) had a pre-existing mental health disorder. Fifty six patients suffered fatal injuries; the majority were White (78.6%), males (80.3%), and were inflicted by gunshot (71.4%). Nearly one third of patients with self-inflicted injuries had a history of self-injurious behavior with the average number of attempts being 2.7 (SD: ±3.8).

CONCLUSIONS

We need interdisciplinary and innovative solutions for this public health crisis. Perhaps telemedicine can be used to buttress the access to adequate mental health care. More research needs to be done to better identify the barriers individuals encounter in accessing mental health care, both pre- and post-crisis. The goal is that, by identifying the gaps, we can collaboratively bridge them to prevent a preventable death.

Pediatric COVID-19 Involving Complicated Sinusitis With Intracranial Extension and Lemierre Syndrome: A Case Report

Pediatric coronavirus disease 2019 (COVID-19) has been associated with various complications including chronic respiratory disease and multisystem inflammatory syndrome. There are a few reported cases of complicated sinusitis following pediatric COVID-19 infection. We present a patient with recent COVID-19 who developed complicated sinusitis with intracranial extension and Lemierre syndrome. A 16-year-old female with a history of COVID-19 diagnosis 17 days prior presented with worsening head and neck symptoms. Physical examination demonstrated left proptosis, cranial nerve (CN) VI palsy, and limited neck range of motion. Imaging demonstrated bilateral sinus disease, a 3.3 × 2 × 3-centimeter sellar/clival abscess, bilateral cavernous sinus thrombosis, and thrombosis of bilateral internal jugular veins. Urgent endoscopic sinus surgery was performed, and long-term intravenous antibiotics and anticoagulation were initiated with improvement in symptoms over three weeks. Providers caring for patients with COVID-19 should keep complicated sinusitis and Lemierre syndrome in their differential. Further study of COVID-19 pathophysiology in the sinonasal mucosa is needed.

Pilot randomized, controlled, preoperative intervention for nutrition trial in head and neck cancer

BACKGROUND

Several prospective studies report improved outcomes with pretreatment nutrition interventions prior to radiation therapy for head and neck cancer (HNC), but none have assessed similar interventions before surgery for HNC.

METHODS

POINT, a pilot randomized controlled trial, was conducted to evaluate a multimodal nutrition intervention. Patients undergoing primary surgery with free flap reconstruction for HNC were randomly assigned to the control arm or a preoperative multimodal nutrition intervention.

RESULTS

POINT included 49 patients. Nutrition risk scores did not change significantly for either the intervention or control group. Control patients had a significant decrease in body weight in the preoperative period (p < 0.001). Conversely, weight among intervention patients did not significantly decrease (p = 0.680). The intervention mitigated weight loss in patients with dysphagia (p = 0.001).

CONCLUSIONS

Preoperative nutrition optimization shows potential to reduce weight loss normally experienced by patients with head and neck cancer prior to surgical extirpation, especially among those with subjective dysphagia.

Evaluation of Portable Tablet-Based Audiometry in a South Indian Population

While a comprehensive booth audiogram is the gold standard for diagnosis of hearing loss, access to this may not be available in remote and low resource settings. The aims of this study were to validate a tablet-based audiometer in a tertiary medical center in India and explore its capacity in improving access to hearing healthcare. Subjects presenting to Ear-Nose-Throat clinics for conventional booth audiometry testing were recruited for subsequent tablet-based audiometric testing. Testing with the tablet was conducted in a non-sound-treated hospital clinic room. Bilateral air and bone conduction hearing threshold data from 250 through 4000 Hz were validated against conventional booth audiometry. In addition, a small feasibility study was conducted in rural clinics. 70 participants (37 adults and 33 children between the ages 5-18) were assessed. 69% were male, with a mean age of 29.7 years. Sensitivity and specificity for the tablet were 89% (95% CI 80-94%) and 70% (95% CI 56-82%), respectively. While median differences in air conduction thresholds between conventional and tablet audiograms showed statistical significance at 250, 500, and 1000 Hz (p < 0.001), the threshold results of the tablet audiometer were within 5 dB of the conventional audiogram and not clinically significant. Ten patients were successfully screened in rural clinics with tablet audiometry. Tablet portable audiometry is a valid tool for air and bone conduction threshold assessment outside of conventional sound booths. It can accurately identify hearing impairment and offers a screening tool for hearing loss in low resource settings.

Factors affecting adherence to intranasal treatment for allergic rhinitis: A qualitative study

Objective

To determine the facilitators of and barriers to adherence to use of intranasal pharmacotherapy (daily intranasal corticosteroids and/or antihistamine, and nasal saline irrigation [NSI]), for allergic rhinitis (AR).

Methods

Patients were recruited from an academic tertiary care rhinology and allergy clinic. Semi-structured interviews were conducted after the initial visit and/or 4-6 weeks following treatment. Transcribed interviews were analyzed using a grounded theory, inductive approach to elucidate themes regarding patient adherence to AR treatment.

Results

A total of 32 patients (12 male, 20 female; age 22-78) participated (seven at initial visit, seven at follow-up visit, and 18 at both). Memory triggers, such as linking nasal routine to existing daily activities or medications, were identified by patients as the most helpful strategy for adherence at initial and follow-up visits. Logistical obstacles related to NSI (messy, takes time, etc.) was the most common concept discussed at follow-up. Patients modified the regimen based on side effects experienced or perceived efficacy.

Conclusions

Memory triggers help patients adhere to nasal routines. Logistical obstacles related to NSI can deter from use. Health care providers should address both concepts during patient counseling. Nudge-based interventions that incorporate these concepts may help improve adherence to AR treatment.

Level of Evidence

2.

A Systematic Review of Head and Neck Cancer Health Disparities: A Call for Innovative Research

OBJECTIVE

(1) Describe the existing head and neck cancer health disparities literature. (2) Contextualize these studies by using the NIMHD research framework (National Institute on Minority Health and Health Disparities). (3) Explore innovative ideas for further study and intervention.

DATA SOURCES

Ovid MEDLINE, Embase, Web of Science, and Google Scholar.

REVIEW METHODS

Databases were systematically searched from inception to April 20, 2020. The PRISMA checklist was followed (Preferred Reporting Items for Systematic Reviews and Meta-analyses). Two authors reviewed all articles for inclusion. Extracted data included health disparity population and outcomes, study details, and main findings and recommendations. Articles were also classified per the NIMHD research framework.

RESULTS

There were 148 articles included for final review. The majority (n = 104) focused on health disparities related to at least race/ethnicity. Greater than two-thirds of studies (n = 105) identified health disparities specific to health behaviors or clinical outcomes. Interaction between the individual domain of influence and the health system level of influence was most discussed (n = 99, 66.9%). Less than half of studies (n = 61) offered specific recommendations or interventions.

CONCLUSIONS

There has been extensive study of health disparities for head and neck cancer, largely focusing on individual patient factors or health care access and quality. This review identifies gaps in this research, with large numbers of retrospective database studies and little discussion of potential contributors and explanations for these disparities. We recommend shifting research on disparities upstream toward a focus on community and societal factors, rather than individual, and an evaluation of interventions to promote health equity.

Rates of bone reabsorption and union in mandibular reconstruction using the osteocutaneous radial forearm free flap

BACKGROUND

Historical concerns over bone resorption and malunion of the osteocutaneous radial forearm free flap (OCRFFF) limited its widespread adoption for head and neck reconstruction, despite lack of outcomes data evaluating this notion.

METHODS

A retrospective cohort study was performed including patients 18 years or older who underwent reconstruction of the mandible using an OCRFFF. Linear modeling and logistic regression were used to evaluate the change in bone volume and union over time.

RESULTS

One hundred and twenty-one patients were included in the study. A mixed effects linear model incorporating age, sex, treatment type, and number of bone segments did not demonstrate a significant loss of bone volume over time. A logistic regression model identified lack of adjuvant treatment and time to be significantly associated with complete union.

CONCLUSION

This study supports that the OCRFFF is a stable form of osseus reconstruction for defects of the head and neck.

Educational Informed Consent Video Equivalent to Standard Verbal Consent for Rhinologic Surgery: A Randomized Controlled Trial

BACKGROUND

Informed consent is an integral part of pre-operative counseling. However, information discussed can be variable. Recent studies have explored the use of multimedia in providing informed consent for rhinologic surgery.

OBJECTIVE

To measure impact of an educational video (Video) compared to verbal informed consent (Verbal) on knowledge gained, alleviation of concerns, and efficiency.

METHODS

Patients undergoing endoscopic sinus surgery (ESS), septoplasty, or ESS+septoplasty were prospectively enrolled and randomized to receive Video or Verbal consent. The Video group watched an educational video; the Verbal group received standard verbal consent from an Otolaryngology resident per institutional protocol. Both groups had the opportunity to discuss questions or concerns with their attending surgeon. Prior to, and after, consent was signed, both groups completed surveys regarding knowledge of purpose, risks, and benefits of surgery as well as surgical concerns. Decision regret and patient satisfaction were also assessed post-operatively.

RESULTS

77 patients were enrolled (39 Video, 38 Verbal). Demographics were not significantly different between groups. Overall knowledge significantly improved (p < 0.005) and concerns significantly decreased (p < 0.001) following consent in both groups. Improvements in these metrics were equivalent between groups (p < 0.02). Furthermore, resident time to complete consent, patient satisfaction, and decision regret were not significantly different between groups.

CONCLUSION

Use of an educational video was equivalent to standard verbal informed consent for patients undergoing rhinologic surgery. Otolaryngologists can consider developing procedure-specific videos to allow allocation of time to other tasks, standardized education of patients, and streamlining of the informed consent process.

Decision regret 3 and 6 months after treatment for head and neck cancer: An observational study of associations with clinicodemographics, anxiety, and quality of life

BACKGROUND

While quality of life (QOL), psychosocial health, and adverse treatment outcomes have been studied in head and neck cancer (HNC) patients, decision regret is an important and understudied complication that can negatively impact future health care decision making.

METHODS

Data collected using a HNC patient registry with questionnaires administered at initial consultation visits plus 3 and 6 months after treatment completion was retrospectively analyzed. A visual analog anxiety scale and the University of Washington Quality of Life were given at clinic visits. Decision regret was determined using a validated scale. Demographic and clinical variables were collected retrospectively and at baseline.

RESULTS

Patients with higher anxiety and lower self-reported QOL had higher concurrent regret at 3-month (n = 140) and at 6-month (n = 82) post-treatment. Later disease stage at presentation, nonprimary surgical treatment, and lower health literacy were associated with greater regret.

CONCLUSIONS

Decision regret was highest in HNC patients with high anxiety, low QOL, and more advanced disease.

A Systematic Review of the Neuropathologic Findings of Post-Viral Olfactory Dysfunction: Implications and Novel Insight for the COVID-19 Pandemic

BACKGROUND

Post-viral olfactory dysfunction is a common cause of both short- and long-term smell alteration. The coronavirus pandemic further highlights the importance of post-viral olfactory dysfunction. Currently, a comprehensive review of the neural mechanism underpinning post-viral olfactory dysfunction is lacking.

OBJECTIVES

To synthesize the existing primary literature related to olfactory dysfunction secondary to viral infection, detail the underlying pathophysiological mechanisms, highlight relevance for the current COVID-19 pandemic, and identify high impact areas of future research.

METHODS

PubMed and Embase were searched to identify studies reporting primary scientific data on post-viral olfactory dysfunction. Results were supplemented by manual searches. Studies were categorized into animal and human studies for final analysis and summary.

RESULTS

A total of 38 animal studies and 7 human studies met inclusion criteria and were analyzed. There was significant variability in study design, experimental model, and outcome measured. Viral effects on the olfactory system varies significantly based on viral substrain but generally include damage or alteration in components of the olfactory epithelium and/or the olfactory bulb.

CONCLUSIONS

The mechanism of post-viral olfactory dysfunction is highly complex, virus-dependent, and involves a combination of insults at multiple levels of the olfactory pathway. This will have important implications for future diagnostic and therapeutic developments for patients infected with COVID-19.

Pain Management and Education for Ambulatory Surgery: A Qualitative Study of Perioperative Nurses

BACKGROUND

Ambulatory surgery presents unique challenges regarding adequate pain management and education. Studies have documented issues with transfer of information and patient comfort. Our objective was to explore perioperative nurses' perspectives of current practices and challenges with pain management and education.

MATERIALS AND METHODS

We used a qualitative descriptive design and conducted four focus group interviews, with 24 total participants from two perioperative areas of an academic medical center, using a standardized script. Using qualitative analysis software, two investigators reviewed the data and coded major themes and subthemes. The consolidated criteria for reporting qualitative studies guidelines were followed for reporting the data.

RESULTS

We identified four major themes impacting current perioperative pain management and education practices: communication among the perioperative care team, sources of nurses' frustrations in the perioperative setting, patient expectations for pain, and nurse-driven pain management and education. Nurses highlighted their work became easier with adequate information transfer and trust from physicians. Frustrations stemmed from surgeon, system, and patient factors. Nurses often use their clinical experience and judgment in managing patients throughout the perioperative period. Furthermore, nurses felt patients have limited pain education and stressed education throughout the surgical care pathway could improve overall care.

CONCLUSIONS

Perioperative pain management, assessment, and education practices are inconsistent, incomplete, and sources of frustrations according to participants. Participant experiences highlight the need for improved and standardized models. Patient pain education should use a multidisciplinary approach, beginning at the point of surgery scheduling and continuing through postoperative follow-up.

Prognostic Impact of Metastatic Site and Pattern in Patients with Metastatic Head and Neck Cancer

OBJECTIVES/HYPOTHESIS

Investigate the relationship between site and pattern of distant metastasis (DM) and overall survival (OS) in a multi-institutional cohort of patients with DM head and neck cancer (HNC).

STUDY DESIGN

Retrospective review.

METHODS

283 patients treated at 4 academic centers in the Midwest HNC Consortium between 2000 and 2015 were retrospectively reviewed. Disease patterns were divided between solitary metastatic versus polymetastatic (≥2 sites) disease. Survival functions for clinically relevant variables were estimated using Kaplan-Meier and Cox proportional hazards models.

RESULTS

Median OS for all patients was 9.0 months (95% confidence interval [CI]: 7.4-10.6). Lung (n = 220, 77.7%) was the most common site of DM, followed by bone (n = 90, 31.8%), mediastinal lymph nodes (n = 55, 19.4%), liver (n = 41, 14.5%), and brain (n = 17, 6.0%). Bone metastases were independently associated with the worst prognosis (hazard ratio [HR] = 1.6, 95% CI: 1.3-2.1). On univariate analysis, brain metastases were associated with improved prognosis (HR = 0.5, 95% CI: 0.3-0.9), although this was not statistically significant on the multivariate analysis. Polymetastatic disease was present in the majority of patients (n = 230, 81.3%) and was associated with a worse prognosis compared to solitary metastatic disease (HR = 1.4, 95% CI: 1.0-2.0).

CONCLUSION

Our large, multi-institutional review indicates that both the metastatic pattern and site of DM impact OS. Polymetastatic disease and bone metastasis are associated with worse prognosis, independent of treatment received.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E1838-E1846, 2021.

Predicting salvage laryngectomy in patients treated with primary nonsurgical therapy for laryngeal squamous cell carcinoma using machine learning

BACKGROUND

Machine learning (ML) algorithms may predict patients who will require salvage total laryngectomy (STL) after primary radiotherapy with or without chemotherapy for laryngeal squamous cell carcinoma (SCC).

METHODS

Patients treated for T1-T3a laryngeal SCC were identified from the National Cancer Database. Multiple ML algorithms were trained to predict which patients would go on to require STL after primary nonsurgical treatment.

RESULTS

A total of 16 440 cases were included. The best classification performance was achieved with a gradient boosting algorithm, which achieved accuracy of 76.0% (95% CI 74.5-77.5) and area under the curve = 0.762. The most important variables used to construct the model were distance from residence to treating facility and days from diagnosis to start of treatment.

CONCLUSION

We can identify patients likely to fail primary radiotherapy with or without chemotherapy and who will go on to require STL by applying ML techniques and argue for high-quality, multidisciplinary regionalized care.

Incidence of Odontogenic Disease in Patients With Pott's Puffy Tumor

PURPOSE

Osteomyelitis with subperiosteal abscess of the frontal bone, or Pott's puffy tumor (PPT), is a rare but life-threatening condition. The relationship of concurrent dental disease to PPT has not been well described. This study sought to delineate the incidence of odontogenic disease in PPT, especially in cases where there is no history of facial trauma or prior frontal sinus surgery.

METHODS

A retrospective chart review of patients diagnosed with PPT between 2010 and 2019 was carried out. Demographics, pertinent medical history, surgical procedures performed, and microbial cultures and antibiotics used were extracted for analysis. Maxillofacial computed tomography scans were reviewed for presence of odontogenic disease.

RESULTS

A total of 17 patients were identified. Four had documented history of frontal bone trauma; 3 had previous frontal sinus surgery. Seven (41%) had documented odontogenic disease on initial radiology reports; however, upon dentist review, 16 (94%) had various pathology visible on their computed tomography scans. Twelve of these 16 patients had no previous frontal sinus trauma or surgery. Eight patients (47%) had only ipsilateral maxillary or ethmoid inflammation respective to PPT on computed tomography. Seventy-six percent of patients underwent endoscopic sinus surgery. Of 14 patients with cultures collected at the time of surgery, 7 (50%) had polymicrobial growth and 6 (43%) had anaerobic growth.

CONCLUSIONS

The incidence of odontogenic disease in this population of PPT was 94%. In the absence of a history of frontal bone trauma or frontal sinus surgery, underlying dental origin should be suspected in cases of PPT. Initial radiology reports may not document all identifiable dental pathology. Therefore, patients presenting with PPT should undergo comprehensive evaluation, including an oral cavity and dental examination, and potential referral to dental colleagues.

National Database Research in Head and Neck Reconstructive Surgery: A Call for Increased Transparency and Reproducibility

OBJECTIVE

To reproduce a published study comparing outcomes of patients who underwent microvascular reconstruction by plastic surgeons and otolaryngologists and to examine how case selection and methodology using the National Surgical Quality Improvement Program (NSQIP) data set can affect results and conclusions.

STUDY DESIGN

Cross-sectional analysis of US national database.

SETTING

American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from 2005 to 2017.

SUBJECTS AND METHODS

A recently published study that used the NSQIP database to compare outcomes after head and neck free tissue transfer between plastic surgeons and otolaryngologists was reproduced. Different approaches to case selection and statistical analysis were evaluated and their effects on statistical significance and study conclusions were compared.

RESULTS

When all cases of free tissue transfer, captured in NSQIP between 2005 and 2017, were compared between plastic surgery and otolaryngology, plastic surgery patients appeared to have lower rates of complications and length of stay. However, a more in-depth analysis demonstrated that these results were confounded by older and sicker otolaryngology patients. A second analysis of the same NSQIP data, limited to only head and neck oncologic reconstructions, demonstrated that otolaryngology patients had fewer complications on univariate and multivariable analysis.

CONCLUSION

We demonstrated how case selection and analysis can significantly affect results. It is incumbent upon researchers who use NSQIP and other publicly available data sets to fully detail their methodology to allow other researchers to reproduce and evaluate their work and for the journal editorial process to carefully evaluate the methodology and conclusions of their contributing authors.

Giant carotid pseudoaneurysm amenable to pipeline stenting in a patient with Ehlers-Danlos type IV

Background:

Ehlers–Danlos type IV primarily affects collagen synthesis in the vasculature, increasing the risk of these patients to have dissection and pseudoaneurysm formation. Due to friable vessels, antiplatelet or anticoagulation has been the treatment of choice. However, newer intravascular surgical devices may be promising for future management.

Case Description:

A 24-year-old man with a history of Ehlers–Danlos type IV with multiple vascular and bleeding complications presented after recurrent, unprovoked presyncopal episodes. Patient was found to have dissection of bilateral internal carotid arteries (ICA) and right vertebral artery. Left ICA pseudoaneurysm was found in the proximal cervical segment. Patient was stabilized as an inpatient and discharged with outpatient follow-up with neurointerventional surgery. Follow-up imaging showed growth of the left ICA aneurysm. Patient elected to have pipeline stenting of the left ICA pseudoaneurysm. The procedure was performed without complication. Patient was discharged on dual antiplatelet therapy. At 7-month follow-up appointment, patient noted no neurological deficits. Follow-up digital subtraction angiogram at 7 months documented near-complete resolution of the pseudoaneurysm secondary to pipeline stenting.

Conclusion:

Pipeline stent implantation may be a viable corrective surgical option for patients with connective tissue disorders (specifically Ehlers–Danlos type IV) who present with pseudoaneurysm formation.

Superficial femoral artery transection following penetrating trauma

We describe a patient who sustained a penetrating injury to the posterior right lower extremity just above the popliteal region with transection of the superficial femoral artery (SFA) despite minimal evidence of active bleeding. An on-table angiogram identified flow in the SFA followed by the popliteal artery and into the trifurcation of the right lower extremity. Eventually, a second operation revealed transection followed by end-to-end anastomosis of SFA and stabilization of the patient. The findings of this case highlight the need for a high index of suspicion and persistent clinical investigation to identify vascular injuries in the absence of hard signs of vascular trauma.