Analysis of the Clinical Course of Children With Initial Negative Polysomnography

OBJECTIVES

To determine the clinical course of children with initial negative polysomnography (PSG) tests.

METHODS

A retrospective chart review was performed on pediatric patients seen by an otolaryngologist who underwent a PSG between October 2012 and March 2019 for obstructive sleep apnea at a single, academic, tertiary-care center. Data including demographics, follow-up PSG tests, and surgeries were collected.

RESULTS

A total of 2018 pediatric patients underwent PSG during the timeframe. About 535/2018 (26.5%) patients were negative for obstructive sleep apnea by PSG and had no prior adenotonsillectomy. About 408/535 (76.3%) did not obtain follow-up testing or surgeries; 69/535 (12.9%) underwent subsequent adenotonsillectomy for worsening symptoms without repeat PSG; and 58/535 (10.8%) obtained 1 or multiple follow-up PSG tests. Of the 58 who obtained repeat PSG, 25 (43.1%) were subsequently positive, with 17 of those 25 (29.3% of 58) undergoing adenotonsillectomy. Taken together, 94/535 (17.6%) of patients with initial negative PSG had worsening sleep disordered breathing.

CONCLUSION

A significant minority of children who initially tested negative for pediatric obstructive sleep apnea met criteria for diagnosis on follow up PSG. Additionally, other children with initial negative PSG underwent adenotonsillectomy for worsening symptoms in lieu of repeat testing. Patients should be educated that snoring in children could persist or worsen over time, even in the setting of a initial negative PSG.

Where are we now? Evaluating the one year impact of an anti-racism curriculum review

PURPOSE

Undergraduate medical education has had a call to action to acknowledge racist practices that are impacting learners throughout their training. In 2020, our school performed a detailed curricular review and provided recommendations to address racism in the curriculum. Many schools have now undergone a similar curricular review process, but little is known about whether suggested antiracist curricular changes impact faculty teaching behavior or the overall curriculum.

MATERIAL AND METHODS

In 2021, as part of the medical school's annual educational quality improvement process, course directors were required to answer a question about the changes they made to address racism in their courses based on recommendations provided the year prior from an antiracism curricular review. The documented changes were analyzed for themes and then organized by course and curricular year. These changes were compared with the suggested recommendations to analyze the number and types of changes implemented after one year. To evaluate student perceptions of change the general comments from academic years 2019-2021 were reviewed.

RESULTS

After 1 year, approximately, 74% of our school's 328 anti-racism curricular review recommendations were implemented in courses. Over 80% were implemented in curricular year 1. The greatest number of recommendations implemented were related to the theme of critiquing the strength of evidence in race-based medical practices. The least amount change was made around the theme of challenging the biologic notion of race.

CONCLUSIONS

An antiracism curricular review followed by an embedded continuous quality improvement process can be an effective approach to address racism in medical school curricula. Addressing racism in medical education requires medical schools to regularly identify curricular gaps, faculty needs and monitor their progress.

Assessing the Accuracy of Otomatch.com Data for Individuals Applying to Otolaryngology Residency

OBJECTIVES

Otomatch.com is an online forum for residency applicants to discuss the otolaryngology match process including academic metrics. The purpose of this study is to assess the accuracy of self-reported match data on Otomatch relative to official data reported by the National Residency Match Program (NRMP) and the Association of American Medical Colleges (AAMC).

METHODS

Data was collected from publicly editable Otomatch forums (2017-2018, 2018-2019, 2019-2020) and curated Otomatch survey responses (2018-2019, 2019-2020) whose results are released after Match Day. Aggregated data was collected from the NRMP 2018 and 2020 Charting Outcomes in the Match and AAMC Report on Residents (2017-2018, 2018-2019). Measures of interest included Step 1 scores, Step 2 CK scores, publications, number of interview invitations, number of interviews attended, and AOA status. ANOVA and 2 tailed T tests were performed to compare variables within each match year.

RESULTS

Average Step 2 CK score was significantly higher on publicly editable Otomatch forums than AAMC in 2017-2018 (257vs 253, P < .05) and 2018-2019 (258vs 252, P < .05). Interviews attended were significantly higher on Otomatch survey responses than the publicly editable forum in 2019-2020 (13vs 9, P-value < .05). Step 1 scores, interview invitations, and AOA status were not statistically significantly different when data was available.

CONCLUSION

Applicant statistics from online forums, online surveys, NRMP, and AAMC are consistent, except for Step 2 CK scores. Self-reported data on the Otomatch forum is an accurate estimate of academic metrics of otolaryngology residency applicants.

The Home Program Advantage in the Otolaryngology Residency Match

OBJECTIVE

To evaluate the effect of home residency programs on outcomes in the otolaryngology residency match DESIGN: A retrospective online survey study during the 2015, 2018, 2019, 2020, and 2021 match cycles was conducted. All available otolaryngology residency positions listed by the National Resident Matching Program were compared with publicly available spreadsheets containing the following information: matriculated applicant name, medical school, whether the final match institution was the matriculated applicant's home program (HP), whether the matriculated applicant had completed an away rotation at their final matched institution (designated away institution, AI), or neither (designated Other Institution, OI).

SETTING

Nonclinical survey study using publicly available spreadsheets containing The Match data from 2015 to 2021 located online at Otomatch.com.

PARTICIPANTS

Newly matched United States otolaryngology-head and neck surgery residents completing the Otomatch.com survey RESULTS: A total of 1771 matched OHNS applicants were identified. Fifty-one percent of students were affiliated with their matched institution, with 25% of students matching at HPs, and 26% matching at AIs. Students with home programs had an increased likelihood of remaining in the same geographic region compared to students without home programs (OR 1.742 95% CI [1.21-2.506], p = 0.003). Applicants with HPs matched at significantly larger residency programs (p < 0.001).

CONCLUSIONS

This study found that a majority of residents match at an institution with which they were affiliated, either their home program or away institution. Applicants with HPs are more likely to remain in the same geographic region as their medical school, and to match into larger residency programs compared to applicants without HPs.

Management of children with co-occurring sleep disordered breathing and hearing loss

OBJECTIVES

To examine hearing loss incidence in a pediatric otolaryngology patients with sleep disordered breathing, and secondarily, identify possible disparities in management.

METHODS

A retrospective case-control study of pediatric patients with sleep-disordered breathing or obstructive sleep apnea from 2012 to 2019 was conducted at a private, not-for-profit, academic, tertiary care center. Study parameters were extracted from the electronic medical record and compared in study groups of patients with sleep-disordered breathing generated based on presence of hearing loss (cases) versus absence (controls). Study parameters were also compared in study groups based on timing of hearing loss onset.

RESULTS

14.8% of patients with sleep disordered breathing had hearing loss. Hearing loss was associated with an increased risk of undergoing adenotonsillectomy (OR 1.632 [1.294-2.058], p < 0.001, adjusted for age). In patients who underwent polysomnographic testing, 9.8% patients had pre-existing hearing loss and 12% patients developed hearing loss over the study period. Patients with pre-existing hearing loss and those who developed hearing loss had significantly more visits with otolaryngology compared to controls (p < 0.001). Hearing loss did not significantly delay adenotonsillectomy. More patients who developed hearing loss had adenotonsillectomies (OR 2.475 [1.672-3.663], p < 0.001, adjusted for age) versus controls. This difference was not identified in patients with pre-existing hearing loss.

CONCLUSION

Patients with evidence of hearing loss in addition to sleep disordered breathing had more adenotonsillectomies performed and more clinic visits. Further work must be done to understand the associations and implications of hearing loss in this population.

Deconstructing Racism, Hierarchy, and Power in Medical Education: Guiding Principles on Inclusive Curriculum Design

In the context of current U.S. racial justice movements, analysis of racism in medicine within medical education is a critical task for all institutions. To educate the next generation of physicians about racism in medicine and out of concern that the curriculum required critical assessment and change, a group of students and faculty at Boston University School of Medicine (BUSM) initiated a longitudinal curricular analysis through a vertical integration group, commissioned by the Medical Education Committee, from May 2019 to June 2020. The curriculum analysis and the major outcomes and guiding principles that emerged from it are described as a path forward, toward a more inclusive curriculum. The major elements of this analysis included a comprehensive internal curricular assessment and an external assessment of peer institutions that led to the development of key curricular recommendations and overarching equity and specific racially focused equity competencies. The curricular recommendations fall into the following domains: (1) challenging the persistence of biological/genetic notions of race, (2) embedding structural practices in medical education to dismantle racism in medicine, and (3) promoting institutional climate change. Initial steps to implement these recommendations are described. The authors believe that the historic and present reality of racism in America and in medicine has impacted medical education specifically, and more broadly, the practice of medicine, trainee experience, and patient outcomes. The key findings of the BUSM analysis are transferable to other medical education institutions, and the described review process can support peer institutions as they engage in the imperative work of institutional reflection and addressing the salient ideas and practices that uphold racism in medicine.

Factors Contributing to Missed Appointments in a Pediatric Otolaryngology Clinic

OBJECTIVE

To understand why pediatric otolaryngology patients do not attend scheduled clinic appointments and identify factors correlated with no-show status.

STUDY DESIGN

Retrospective cohort study.

METHODS

This is a retrospective cohort study that uses medical record data extraction of patients that was scheduled to attend new patient appointments at a pediatric otolaryngology clinic in 2018.

RESULTS

Factors associated with no-shows included complex psychiatric history (OR (95% CI) 0.789 (0.71-0.88), P < .001), increased appointment lead time (OR (95% CI) 0.981 (0.976-0.987), P < .001), afternoon appointments (OR (95% CI) 0.783 (0.64-0.99), P = .038), and complex maternal medical history (OR (95% CI) 0.987 (0.979-0.996), P < .005). In contrast, factors associated with attendance included complex patients' medical history (OR (95% CI) 1.058 (0.98-1.02), P < .001), primary care physician at the same hospital (OR (95% CI) 2.766 (2.25-3.39), P < .001), and primary language being Spanish (OR (95% CI) 2.536 (1.75-3.67) P < .001). The factors of distance from the hospital (OR (95% CI) 1.001 (0.99-1.01), P = .868), season of appointment (P = .997), race (P = .623), and ethnicity (P = .804) were not associated with attendance or no-shows.

CONCLUSION

Patient and maternal medical problems, mental health history, primary care location, appointment lead time, hour of appointment, and primary language, all contribute to appointment attendance, while appointment timing, race, and ethnicity are not associated with attendance. Further work must be performed to overcome these barriers to minimize healthcare risks and improve patient outcomes.

QUALITY OF EVIDENCE

Level 3 Laryngoscope, 2021.

Salivary levels of total huntingtin are elevated in Huntington's disease patients

Patients with Huntington's disease (HD), an autosomal-dominant neurodegenerative disease, show substantial variability in age-of-onset, symptom severity and course of illness, warranting the need for biomarkers to anticipate and monitor these features. The HD gene encodes the disease protein huntingtin (Htt), a potentially useful biomarker for this disease. In the current study, we determined whether total Htt protein (normal plus mutant; "tHtt") could be reliably measured in human saliva, a body fluid that is much more accessible compared to cerebral spinal fluid or even blood, and whether salivary levels of tHtt were clinically meaningful. We collected 146 saliva samples from manifest HD patients, early-premanifest individuals, late-premanifest patients, gene-negative family members and normal controls. We found that tHtt protein could be reliably and stably detected in human saliva and that tHtt levels were significantly increased in saliva from HD individuals compared to normal controls. Salivary tHtt showed no gender effects, nor were levels correlated with total protein levels in saliva. Salivary tHtt was significantly positively correlated with age, but not age-of-onset or CAG-repeat length. Importantly, salivary tHtt was significantly correlated with several clinical measures, indicating relevance to disease symptom onset and/or severity. Measurements of salivary tHtt offer significant promise as a relevant, non-invasive disease biomarker for HD, and its use could be implemented into clinical applications.