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OBJECTIVES Prior studies have associated morbidity following anatomic lung resection with prolonged postoperative length of stay; however, each complication's individual impact on length of stay as a continuous variable has not been studied. The purpose of this study was to determine the risk-adjusted increase in length of stay associated with each individual postoperative complications following anatomic lung resection. METHODS Patients who underwent anatomic lung resection cataloged in the prospectively collected American College of Surgeons National Surgical Quality Improvement Program participant use file, 2005–2018, were targeted. The association between preoperative characteristics, postoperative complications and length of stay in days was tested. A negative binomial model adjusting for the effect of preoperative characteristics and 18 concurrent postoperative complications was used to generate incidence rate ratios. This model was fit to generate risk-adjusted increases in length of stay by complication. RESULTS Of 32 133 patients, 5065 patients (15.8%) experienced at least one post-operative complication. The most frequent complications were pneumonia (n  = 1829, 5.7%), the need for transfusion (n  = 1794, 5.6%) and unplanned reintubation (n  = 1064, 3.3%). The occurrence of each of the 18 individual complications was associated with significantly increased length of stay. This finding persisted after risk-adjustment, with the greatest risk-adjusted increases being associated with prolonged ventilation (+17.4 days), followed by septic shock (+17.2 days), acute renal failure (+16.5 days) and deep surgical site infection (+13.2 days). CONCLUSIONS All 18 postoperative complications studied following anatomic lung resection were associated with significant risk-adjusted increases in length of stay, ranging from an increase of 17.4 days with prolonged ventilation to 2.6 days following the need for transfusion. [ABSTRACT FROM AUTHOR]

Background: In 2012, the American Society of Anesthesiologists (ASA) published guidelines recommending against routine preoperative laboratory testing for low‐risk patients to reduce unnecessary medical expenditures. The aim of this study was to assess the change in routine preoperative laboratory testing in low‐risk versus higher‐risk patients before and after release of these guidelines. Methods: The ACS‐NSQIP database, 2005–2018, was separated into low‐risk versus higher‐risk patients based upon a previously published stratification. The guideline implementation date was defined as January 2013. Changes in preoperative laboratory testing over time were compared between low‐ and higher‐risk patients. A difference‐in‐differences model was applied. The primary outcome included any laboratory test obtained ≤90 days prior to surgery. Results: Of 7,507,991 patients, 972,431 (13.0%) were defined as low‐risk and 6,535,560 (87.0%) higher‐risk. Use of any preoperative laboratory test declined in low‐risk patients from 66.5% before to 59.6% after guidelines, a 6.9 percentage point reduction, versus 93.0%–91.9% in higher‐risk patients, a 1.1 percentage point reduction (p < 0.0001, comparing percentage point reductions). After risk‐adjustment, the adjusted odds ratio for having any preoperative laboratory test after versus before the guidelines was 0.77 (95% CI 0.76–0.78) in low‐risk versus 0.93 (0.92–0.94) in higher‐risk patients. In low‐risk patients, lack of any preoperative testing was not associated with worse outcomes. Conclusions: While a majority of low‐risk patients continue to receive preoperative laboratory testing not recommended by the ASA, there has been a decline after implementation of guidelines. Continued effort should be directed at the deimplementation of routine preoperative laboratory testing for low‐risk patients. [ABSTRACT FROM AUTHOR]

Objectives Carcinomas involving the cavernous sinus are challenging to resect without compromising important neurovascular structures. Given the morbidity and mortality of these operations, radiotherapy, chemotherapy, and immunotherapy are more often utilized. Although limited to case reports and small series, radical resection of the cavernous sinus has been proposed. We aimed to study surgeons' willingness to perform cavernous sinus exenteration (CSE) under different clinical scenarios. Design, Setting, Participants, Main Outcome Measures We conducted an online survey from April to July 2021 among members of the Skull Base Congress and the North American Skull Base Society. Descriptive statistics were used to analyze the main outcome measure of willingness to perform CSE. Results The analytic sample (n = 112) included 54% otolaryngologists and 43% neurosurgeons. Eighty-six percent practiced in an academic setting. Surgeons' willingness to perform CSE was low (6–16% under different clinical scenarios), citing a belief that they could not obtain oncologic margins and the procedure's morbidity. Forty-five percent had at least one patient undergo CSE with 72% of patients surviving no more than 2 years. Complications included chronic intractable pain, cerebrospinal fluid leak, cerebrovascular accident, and/or intraoperative/postoperative death within 30 days. Sixty percent agreed that the availability of immunotherapy and genomic sequencing has affected their willingness to offer CSE. Conclusion Overall, most of the surgeons surveyed were unwilling to offer CSE for carcinomatous cavernous sinus invasion, whether for primary disease or recurrence. Given the rarity of these tumors and the limited data on CSE, these results may provide more information for clinicians and patients for these treatment decisions. [ABSTRACT FROM AUTHOR]

Background: Total thyroidectomy (TT) and hemithyroidectomy (HT) are acceptable surgical options for the treatment of low-risk differentiated thyroid cancer (DTC). While previous data suggest similar disease-free and disease-specific survival regardless of initial surgical treatment, the effect of the extent of surgery on health-related quality of life (HRQOL) is less clear. This systematic review aimed to examine HRQOL in low-risk DTC survivors after TT compared with HT. Methods: A search of PubMed, CINAHL, Cochrane, PsycINFO, and Scopus databases was conducted to identify studies published between January 1, 2011, and December 31, 2022, that assessed HRQOL predominantly in patients with low-risk DTC who underwent open thyroid surgery. Covidence™ software was used to apply the inclusion criteria, and a validated instrument was used to assess study quality. Results: Sixteen of the 1402 identified studies were included: 5 prospective and 11 retrospective cohort studies. The majority of included studies were of good quality (n = 14) and were from Asia and the Middle East (n = 11). Overall, six studies concluded that HT led to a better HRQOL than TT, two concluded that HT only resulted in better HRQOL compared with TT with central neck dissection (CND), and two concluded HT resulted in better short-term HRQOL that dissipated by 6 months postoperatively. The HRQOL domains found across all studies to be most consistently improved after HT included physical health, psychological/emotional, and social function. Factors found to be associated with HRQOL in more than one study included age, stage, and marital status. Conclusion: Differences in HRQOL after HT and TT tended to favor HT particularly when measured <6 months after surgery or when compared with TT with CND. Additional prospective and ideally randomized data are needed to fully determine the impact of the extent of surgery on HRQOL in patients with low-risk thyroid cancer. [ABSTRACT FROM AUTHOR]

Purpose: Although early identification of pediatric hearing loss is crucial, a formal online training course has not been freely accessible to a global audience. In response, we created a novel course for health professionals worldwide. Method: Course development occurred from February 2019 to May 2020. Seventeen multidisciplinary experts provided video lectures and demonstrations, including a tour of ear anatomy, operating footage of cochlear implant insertion, and demonstrations of children undergoing hearing testing. Content also included steps for interpreting audiograms, an overview of early screening programs, interviews with deaf/hard of hearing children, and an introduction to public health/educational infrastructure. The course was hosted on Coursera and launched on May 4, 2020. Results: The course was approved for 11.5 Continuing Medical Education and American Board of Pediatrics Maintenance of Certification-Part 2 credits and spanned five modules composed of 50 video learning segments: (a) Ear Anatomy, (b) Hearing Loss and Assessments, (c) Hearing Loss Diagnosis and Impact on Speech and Language Development, (d) Interventions for Hearing Loss, and (e) Pediatric Vestibular System and Balance. Since its launch, 6,556 learners have enrolled and 1,540 have fully completed the course: 50% were 25-34 years old, 62% were women, and 43% were from Asia. Average rating was 4.9/5 (n = 180 reviews). Conclusions: We created a freely accessible course for a global audience that provides a broad overview of pediatric hearing loss. Our multidisciplinary approach addresses an educational gap and can serve as a model for developing other online courses. [ABSTRACT FROM AUTHOR]

Background: Completion axillary lymph node dissection (cALND) was standard treatment for breast cancer with positive sentinel lymph nodes (SLNs) until 2011, when data from the Z11 and AMAROS trials challenged its survival benefit in early stage breast cancer. We assessed the contribution of patient, tumor, and facility factors on cALND use in patients undergoing mastectomy and SLN biopsy. Patients and Methods: Using the National Cancer Database, patients diagnosed from 2012 to 2017 who underwent upfront mastectomy and SLN biopsy with at least one positive SLN were included. A multivariable mixed effects logistic regression model was used to determine the effect of patient, tumor, and facility variables on cALND use. Reference effect measures (REM) were used to compare the contribution of general contextual effects (GCE) to variation in cALND use. Results: From 2012 to 2017, the overall use of cALND decreased from 81.3% to 68.0%. Overall, younger patients, larger tumors, higher grade tumors, and tumors with lymphovascular invasion were more likely to undergo cALND. Facility variables, including higher surgical volume and facility location in the Midwest, were associated with increased use of cALND. However, REM results showed that the contribution of GCE to the variation in cALND use exceeded that of the measured patient, tumor, facility, and time variables. Conclusions: There was a decrease in cALND use during the study period. However, cALND was frequently performed in women after mastectomy found to have a positive SLN. There is high variability in cALND use, mainly driven by interfacility practice variation rather than specific high-risk patient and/or tumor characteristics. [ABSTRACT FROM AUTHOR]

Phenomenon: According to adult learning theories, effective cognitive integration of basic and clinical science may promote the transfer of knowledge to patient care. The placement of the U.S. Medical Licensing Examination (USMLE) Step 1 after the core clerkships is one strategy intended to facilitate cognitive integration, though learner experiences with this model are unexplored. The purpose of this study is to understand students' perspectives on basic and clinical science integration in a post-clerkship Step 1 curriculum. Approach: Focus groups were conducted between August and September 2020 with senior medical students from the University of California, San Francisco School of Medicine and University of Michigan Medical School. Data were analyzed using a constructivist approach to thematic analysis. Findings: Thirty-three students participated in six focus groups. Participants described multiple barriers to cognitive integration in the clerkship learning environment, though they also identified examples of teaching and learning that facilitated integration. Early in their clerkships, students struggled to integrate because of their tenuous basic science foundation, cognitive overload, and difficulty perceiving the relevance of basic science to patient care. They felt that educators primarily focused on clinical science, and many basic science teaching sessions during clerkships felt irrelevant to patient care. However, students also described experiences that made the connection between basic and clinical science more explicit, including modeling by educators and clerkship learning activities that more overtly encouraged the application of basic science to clinical care. In addition, the return to basic science studying during the post-clerkship dedicated Step 1 study period offered powerful integration opportunities. These facilitators of cognitive integration helped students recognize the value of integration for enduring learning. Insights: There are myriad barriers to cognitive integration of basic and clinical science during clerkships in a post-clerkship Step 1 curriculum. The relevance of basic science to patient care needs to be made more explicit to students through modeling by clinician educators to augment the potential benefits of curricular change. The post-clerkship Step 1 study period appears to offer a unique opportunity for cognitive integration later in a learner's trajectory that may be related to curricular design. When learners recognize the applicability of basic science to patient care, they may more intentionally transfer basic science knowledge to clinical practice. [ABSTRACT FROM AUTHOR]

National guidelines recommend against routine axillary staging with sentinel lymph node biopsy (SLNB) and adjuvant radiotherapy (RT) in women ≥70 y with early-stage, hormone receptor-positive, HER2-negative breast cancer and clinically negative axilla; however, these practices remain common. We conducted a prospective pilot study from August 2021 to 2022 using an intervention targeting breast surgeons and radiation oncologists in Michigan that aimed to reduce SLNB and RT in eligible patients. The intervention consisted of (1) a geriatric assessment, (2) an assessment of the patient's medical maximizing-minimizing preferences, and (3) a tailored script with counterpoints to reasons patients commonly seek SLNB or RT. At the end of the study period, participants completed a survey providing feedback with the primary outcomes being: acceptability, appropriateness, feasibility, and intention and motivation to use the materials based on validated measures. Participants (n = 23) included 15 breast surgeons and 8 radiation oncologists. Collectively, the materials were used with 115 patients. Considering all materials holistically, acceptability, appropriateness, and feasibility of the intervention were high; participants also intended and were motivated to use the intervention. Scores across all measures were highest for the geriatric assessment and lowest for the tailored script. The major barriers to using the intervention were limited time and instances of disagreement on treatment recommendations among surgeons and radiation oncologists. The omission of SLNB and adjuvant RT should be discussed in appropriately selected patients. A multifaceted provider-level deimplementation strategy may be an effective means for achieving this goal. [ABSTRACT FROM AUTHOR]

Rapid accumulation of data in surgical and medical oncology has changed the treatment landscape for patients with stage-III melanoma, introducing options for active surveillance and adjuvant systemic therapy; however, these options have increased the complexity of decision making. We conducted an explanatory sequential mixed-methods study consisting of surveys and semistructured interviews among patients diagnosed with stage-III melanoma at a single institution from August 2019 to December 2021. The survey included the validated 30-point satisfaction with decision scale (SWD). The interview guide was developed using a shared decision-making framework. Twenty-six participants completed the survey (response rate 40%) and 17 were interviewed. In the survey, 69% of participants reported receiving a recommendation for active surveillance and 23% received a recommendation for adjuvant systemic therapy. Overall SWD for treatment of the lymph node basin and adjuvant systemic therapy was high at 27.94 and 26.21 out of 30, respectively. In the interviews, participants stressed the importance of the physician's recommendation as well as the desire to minimize intervention and avoid potential side effects in their decisions. However, they demonstrated persistent knowledge gaps in their understanding of the treatment options. Like other cancer types where the option for active surveillance exists, the physician's recommendation is influential in shaping decisions for patients with stage-III melanoma. Physicians can improve shared decision making in this complex treatment landscape through improved multidisciplinary collaboration and mechanisms for ensuring patients' understanding of the treatment options. [ABSTRACT FROM AUTHOR]

Objective: To explore challenges and opportunities for supporting midcareer women otolaryngologists in the areas of negotiation and sponsorship. Study Design: Qualitative approach using semistructured interviews. Setting: Online multi‐institutional interviews. Methods: This study was performed from June to August 2021. Women otolaryngologists representing diverse subspecialties, training, and practice environments were recruited via a purposive criterion‐based sampling approach. Semistructured interviews were transcribed, coded, and analyzed via an inductive‐deductive approach to produce a thematic content analysis. Results: Among the 12 women interviewees, who represented 7 subspecialties, the majority were Caucasian (58%) and in academic practice (50%). The median residency graduation year was 2002 (range, 1982‐2013). Participants expressed several challenges that women otolaryngologists face with respect to negotiation, including the absence of systematic formal negotiation training, gendered expectations that women experience during negotiations, and a perceived lack of power in negotiations. Obstacles to effective sponsorship included difficulty in the identification of sponsors and the influence of gender and related systemic biases that hindered sponsorship opportunities. Conclusion: Notable gender disparities exist for negotiation and sponsorship in the midcareer stage for women otolaryngologists. Women start at a disadvantage due to a lack of negotiation training and access to sponsors, which is exacerbated by systemic gender bias and power differentials as women advance in their careers. This study highlights opportunities to improve negotiation and sponsorship for women, with the goal of promoting a more diverse workforce. [ABSTRACT FROM AUTHOR]

PURPOSE Financial hardship is a growing concern for patients with cancer. Patients with head and neck cancer (HNC) are particularly vulnerable, given that a third leave the workforce following treatment. The goal of our study was to characterize financial hardship in the psychologic response (response to increased expenses) and coping behaviors (behaviors patients adopt to manage their care in the setting of increased expenses) domains in patients with HNC compared with patients with other cancers. METHODS This was a retrospective cohort study of nationally representative public survey data from 2013 to 2018 in the National Health Interviews Survey, an annual cross-sectional household survey. We included respondents age $ 18 years who reported a diagnosis of cancer and identified a subset of patients with HNC. Our main outcomes were financial hardship in the psychologic response and coping behaviors domains. RESULTS Our sample included a weighted population of 357,052 patients with HNC and 21.4 million patients with other cancers. Compared with patients with other cancers, patients with HNC reported greater levels of coping behaviors hardship (31% v 23%, P 5 .015), but similar levels of psychologic financial hardship (73% v 72%, P 5 .787). Medicaid or uninsured patients more often reported coping behaviors hardship. On multivariable analysis, HNC (odds ratio, 1.51; 95% CI, 1.01 to 2.24) was independently associated with coping behaviors hardship. CONCLUSION To our knowledge, this is the first study to evaluate financial hardship in patients with HNC compared with patients with other cancers that includes Medicaid and uninsured patients, who are more often to have financial hardship. Patients with HNC have greater levels of hardship in the coping behaviors domain compared with patients with other cancers, but similar levels in the psychologic response domain. [ABSTRACT FROM AUTHOR]

National recommendations allow for the omission of sentinel lymph node biopsy (SLNB) and post-lumpectomy radiotherapy in women ≥ 70 y/o with early-stage, hormone-receptor positive invasive breast cancer, but these therapies remain common. Previous work demonstrates an individual's maximizing-minimizing trait—an inherent preference for more or less medical care—may influence the preference for low-value care. We recruited an equal number of women ≥ 70 yrs who were maximizers, minimizers, or neutral based on a validated measure between September 2020 and November 2020. Participants were presented a hypothetical breast cancer diagnosis before randomization to one of three follow-up messages: maximizer-tailored, minimizer-tailored, or neutral. Tailored messaging aimed to redirect maximizers and minimizers toward declining SLNB and radiotherapy. The main outcome measure was predicted probability of choosing SLNB or radiotherapy. The final analytical sample (n = 1600) was 515 maximizers (32%), 535 neutral (33%) and 550 (34%) minimizers. Higher maximizing tendency positively correlated with electing both SLNB and radiotherapy on logistic regression (P < 0.01). Any tailoring (maximizer- or minimizer-tailored) reduced preference for SLNB in maximizing and neutral women but had no effect in minimizing women. Tailoring had no impact on radiotherapy decision, except for an increased probability of minimizers electing radiotherapy when presented with maximizer-tailored messaging. Maximizing-minimizing tendencies are associated with treatment preferences among women facing a hypothetical breast cancer diagnosis. Targeted messaging may facilitate avoidance of low-value breast cancer care, particularly for SLNB. [ABSTRACT FROM AUTHOR]

In February 2020, the Federation of State Medical Boards and National Board of Medical Examiners announced that Step 1 of the United States Medical Licensing Examination would transition from a three-digit numerical score to a pass/fail outcome. While several opinion pieces have been authored on the potential implications of this change, no study has formally assessed the student voice. The purpose of this study is to explore medical students' perspectives of a pass/fail Step 1, with an emphasis on how this transition will impact their well-being. Approach: We conducted virtual focus groups from May 2020–June 2020 with first- and second-year medical students from six institutions (n = 30). We analyzed focus group content following the inductive and iterative constructivist approach to produce a thematic analysis. Findings: Participants included females (50%), males (47%), and one non-binary student. The majority were Caucasian (57%), followed by Asian (27%), African American (10%), and Hispanic or Latino/a (7%). Overall, students were confused regarding the decision to transition Step 1 to a pass/fail outcome. They expressed anxiety over the uncertainty of how a pass/fail Step 1 may impact future residency applications and pressure to re-allocate time and resources to other academic pursuits that would make them competitive. Students explicitly stated skepticism or disbelief that a pass/fail Step 1 would improve their well-being. Insights: While the decision to make Step 1 pass/fail was in part intended to decrease stress associated with performance on a single high-stakes exam designed for licensing purposes, it has led to increased worries for students, and secondary, unanticipated consequences remain to be seen. In this new setting, it will be imperative to provide clarity regarding the metrics used to evaluate students and to incorporate their perspectives in future policy changes. [ABSTRACT FROM AUTHOR]

Background: Data suggest variation in utilization of completion lymph node dissection (CLND) and adjuvant systemic therapy (AT) for sentinel lymph node-positive melanoma. We aimed to explore how clinicians consider multidisciplinary treatment options., Methods: We conducted semi-structured interviews of surgical oncologists, medical oncologists, and otolaryngologists to produce a thematic analysis., Results: Participants (n = 26) described melanoma care as inherently "multidisciplinary," noting the importance of conversations facilitated by shared clinic days or space. Despite believing that their practice mirrored other clinicians, participants revealed diverging perspectives on CLND and AT. Multidisciplinary care presented challenges for surveillance as surgeons expressed desire to retain ownership of patients but did not feel comfortable overseeing AT needs. Participants questioned the fidelity of nodal ultrasounds, noted redundancy in their roles, and described a "surveillance burden" for patients., Conclusion: Opportunities exist to improve multidisciplinary melanoma care through broader consensus of how to translate emerging data into patient care and delineating surveillance roles., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objectives  Carcinomas involving the cavernous sinus are challenging to resect without compromising important neurovascular structures. Given the morbidity and mortality of these operations, radiotherapy, chemotherapy, and immunotherapy are more often utilized. Although limited to case reports and small series, radical resection of the cavernous sinus has been proposed. We aimed to study surgeons' willingness to perform cavernous sinus exenteration (CSE) under different clinical scenarios. Design, Setting, Participants, Main Outcome Measures  We conducted an online survey from April to July 2021 among members of the Skull Base Congress and the North American Skull Base Society. Descriptive statistics were used to analyze the main outcome measure of willingness to perform CSE . Results  The analytic sample ( n  = 112) included 54% otolaryngologists and 43% neurosurgeons. Eighty-six percent practiced in an academic setting. Surgeons' willingness to perform CSE was low (6-16% under different clinical scenarios), citing a belief that they could not obtain oncologic margins and the procedure's morbidity. Forty-five percent had at least one patient undergo CSE with 72% of patients surviving no more than 2 years. Complications included chronic intractable pain, cerebrospinal fluid leak, cerebrovascular accident, and/or intraoperative/postoperative death within 30 days. Sixty percent agreed that the availability of immunotherapy and genomic sequencing has affected their willingness to offer CSE. Conclusion  Overall, most of the surgeons surveyed were unwilling to offer CSE for carcinomatous cavernous sinus invasion, whether for primary disease or recurrence. Given the rarity of these tumors and the limited data on CSE, these results may provide more information for clinicians and patients for these treatment decisions., Competing Interests: Conflict of Interest N.M.M. and C.Y.R. were supported by grants from the National Institutes of Health (NIH; 5 TL1 TR002242–05) during the conduct of this study. C.H.S. has equity in SPIWay, LLC and Respair, Inc. The authors have no other disclosures or conflicts of interest related to this work., (Thieme. All rights reserved.)

Importance: Surveillance imaging and visits are costly and have not been shown to improve oncologic outcomes for patients with head and neck cancer (HNC). However, the benefit of surveillance visits may extend beyond recurrence detection. To better understand surveillance and potentially develop protocols to tailor current surveillance paradigms, it is important to elicit the perspectives of the clinicians who care for patients with HNC., Objective: To characterize current surveillance practices and explore clinician attitudes and beliefs on deintensifying surveillance for patients with HNC., Design, Setting, and Participants: This qualitative study was performed from January to March 2021. Guided by an interpretive description approach, interviews were analyzed to produce a thematic description. Data analysis was performed from March to April 2021. Otolaryngologists and radiation oncologists were recruited using purposive and snowball sampling strategies., Main Outcomes and Measures: The main outcomes were current practice, attitudes, and beliefs about deintensifying surveillance and survivorship as well as patients' values and perspectives collected from interviews of participating physicians., Results: Twenty-one physicians (17 [81%] men) were interviewed, including 13 otolaryngologists and 8 radiation oncologists with a median of 8 years (IQR, 5-20 years) in practice. Twelve participants (57%) stated their practice comprised more than 75% of patients with HNC. Participants expressed that there was substantial variation in the interpretation of the surveillance guidelines. Participants were open to the potential for deintensification of surveillance or incorporating symptom-based surveillance protocols but had concerns that deintensification may increase patient anxiety and shift some of the burden of recurrence monitoring to patients. Patient and physician peace of mind, the importance of maintaining the patient-physician relationship, and the need for adequate survivorship and management of treatment-associated toxic effects were reported to be important barriers to deintensifying surveillance., Conclusions and Relevance: In this qualitative study, clinicians revealed a willingness to consider altering cancer surveillance but expressed a need to maintain patient and clinician peace of mind, maintain the patient-clinician relationship, and ensure adequate monitoring of treatment-associated toxic effects and other survivorship concerns. These findings may be useful in future research on the management of posttreatment surveillance.