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To clarify whether the reported lack of racial and ethnic diversity among Menière's disease (MD) patients is representative of selection bias or disease susceptibility.Retrospective medical record review and population-level analyses.Tertiary referral center.Cohort of 1091 patients diagnosed with MD by the tertiary otology service.Demographic and population-level characteristics (age, sex, race, insurance status, ZIP code, median income, education level) compared with local, regional, health system, and otolaryngology clinic demographics.Patients seen for MD were significantly older than those seen throughout the otolaryngology clinic (median, 65.0 versus 58.8 yr) or health system (65.0 versus 50.8 yr). A majority of patients with MD were of White race (92%), compared with 2.7% Black race and 0.5% Asian. Using population-level data, median income and having medical insurance were significantly correlated with care for MD. A disproportionate rate of care for MD was seen in ZIP codes outside urban areas as compared with other otologic and otolaryngologic conditions seen in the same clinic.Patients with MD are of older age, more likely to be of White race, and disproportionately from rural locales. The demographic profile of patients diagnosed with MD by tertiary otology is better explained by differential susceptibility to MD than by selection bias.

To identify variability in reported hearing outcomes for intratympanic (IT) steroid treatment of idiopathic sudden sensorineural hearing loss (ISSNHL) by comparing outcomes using the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guideline with other published criteria.Retrospective chart review.Tertiary otology practice.Patients with ISSNHL treated with IT steroid between April 2003 and December 2020.IT steroid injection and audiometric evaluation.1) Rates of full, partial, or no recovery using the AAO-HNS guideline versus other reported criteria, and 2) correlation analyses of demographic and clinical variables with response to IT steroid.Using AAO-HNS reporting criteria, full recovery of the pure-tone average was noted in 25.68% of patients. Applying eight other published outcomes criteria to this patient cohort classified full recovery in 14.87 to 40.54% of patients. Similarly, AAO-HNS criteria classified "no recovery" in 51.35% of our patients, whereas applying the other reported criteria showed an average rate of 62.16% no recovery and as high as 82.43% of patients without recovery. Younger age ( p = 0.003; effect size, 0.924) and IT injection within a week of onset ( p0.001; effect size, 1.099) positively correlated with full recovery. There was no impact of prior or concurrent oral steroids, or number of steroid injections on outcome.Great variability exists in the literature for assessment of IT steroid outcomes in ISSNHL. Standard reporting of outcomes as per the AAO-HNS SSNHL guideline is recommended to consistently characterize IT steroid efficacy and allow comparison across studies.

OBJECTIVE To determine postcochlear implantation performance for patients qualifying on preimplant testing in noise. STUDY DESIGN Retrospective chart review of cochlear implant recipients. MAIN OUTCOME MEASURE Performance on word and sentence testing in the implanted ear and bimodal condition were compared between pre- and postimplantation time points. RESULTS At 2-years postimplantation, CNC testing in quiet in the implanted ear improved from an average percent correct score of 14.0 ± 12.1% to 54.9 ± 14.8% (n = 20, p

OBJECTIVE: To identify demographic and clinical features impacting initial treatment pathway for vestibular schwannoma. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary care academic medical center. PATIENTS: Patients diagnosed with vestibular schwannoma between 2009 and 2019. INTERVENTIONS: Observation, stereotactic radiosurgery, or microsurgical resection. MAIN OUTCOME MEASURES: χ(2) Test, one-way analysis of variance, and multivariate logistic regression were used to correlate demographic and clinical factors with initial treatment pathway for 197 newly diagnosed vestibular schwannoma patients. RESULTS: Among 197 patients, 93 (47%) were initially treated with observation, 60 (30%) with stereotactic radiation (Gamma Knife) and 44 (22%) with surgical resection. Age univariately had no statistically significant impact on initial pathway, but those undergoing surgery trended toward a younger demographic (49.1 yr [surgery] versus 57.2 yr [observation] versus 59.0 yr [Gamma Knife]). Men were more likely to be initially observed than women (p = 0.04). Patients initially observed were more likely to have a lower Koos classification (p < 0.001) and have better tumor-ear hearing (p = 0.03). Only 34.4% of patients living outside the local geographic region were initially observed compared with 53.0% living locally (p = 0.055). Surgeon correlated with initial treatment (p = 0.04) but did not maintain significance when adjusting for hearing level or tumor size. A multiple linear regression model found age, maximum tumor diameter, and Koos class to correlate with initial treatment pathway (p < 0.0001, r(2) = 0.42). CONCLUSION: Initial treatment pathway for newly diagnosed vestibular schwannoma is impacted by demographic factors such as age, sex, and geographic proximity to the medical center. Clinical features including hearing level and tumor size also correlated with initial treatment modality.

To evaluate the utility of intracochlear electrocochleography (ECochG) monitoring during cochlear implant (CI) surgery on postoperative hearing preservation.Prospective, randomized clinical trial.Ten high-volume, tertiary care CI centers.Adult patients with sensorineural hearing loss meeting the CI criteria who selected an Advanced Bionics CI.Patients were randomized to CI surgery either with audible ECochG monitoring available to the surgeon during electrode insertion or without ECochG monitoring. Hearing preservation was determined by comparing preoperative unaided low-frequency (125-, 250-, and 500-Hz) pure-tone average (LF-PTA) to postoperative LF-PTA at CI activation. Pre- and post-CI computed tomography was used to determine electrode scalar location and electrode translocation.Eighty-five adult CI candidates were enrolled. The mean (standard deviation [SD]) unaided preoperative LF-PTA across the sample was 54 (17) dB HL. For the whole sample, hearing preservation was "good" (i.e., LF-PTA change 0-15 dB) in 34.5%, "fair" (i.e., LF-PTA change15-29 dB) in 22.5%, and "poor" (i.e., LF-PTA change ≥30 dB) in 43%. For patients randomized to ECochG "on," mean (SD) LF-PTA change was 27 (20) dB compared with 27 (23) dB for patients randomized to ECochG "off" ( p = 0.89). Seven percent of patients, all of whom were randomized to ECochG off, showed electrode translocation from the scala tympani into the scala vestibuli.Although intracochlear ECochG during CI surgery has important prognostic utility, our data did not show significantly better hearing preservation in patients randomized to ECochG "on" compared with ECochG "off."

Identify the impact of demographics and social determinants of health on surgical follow-up and complications after medial orbital wall decompression (MOWD) secondary to thyroid associated orbitopathy (TAO).Demographics and social determinants of health (age, sex, race, insurance status) for 46 patients undergoing MOWD secondary to TAO were correlated with post-operative compliance and surgical complications by chi-square analyses.Among 46 patients, 23 were compliant with follow-up. There was no statistically significant difference between compliance and non-compliance based on age (60.25 vs 56.4, p = .41), sex (71.9 % female vs 85.7 % female, p = .31), race (65.6 % white vs 71.4 % white, p = .70) or insurance status (59.4 % private vs 42.9 % private, p = .30). Complications were noted in 50 % of patients of which sinus infection was most common (47.8 % of complications) and epistaxis rare (4.3 % of complications). No correlation was noted between development of complications and compliance (p = .20). Likewise, age, race and insurance status did not correlate with complications.For patients undergoing MOWD, no correlations with compliance or complication rate were noted with age, sex, race, or insurance status. A larger cohort may be indicated to identify such patterns. The overall complication rate was 50 % and the increased number of visits may have economic impact.This study provides a unique chance to assess demographic correlates of compliance and complication while controlling for surgeon preference. There was no association between sociodemographics and compliance or complications.

Objective To determine the impact of illustrated postoperative instructions on patient-caregiver knowledge and retention. Design Prospective study with all participants receiving an educational intervention. Setting Pediatric plastic surgical missions in Guatemala City, Guatemala, between 2019 and 2020. Participants A total of 63 majority-indigenous Guatemalan caregivers of patients receiving cleft lip and/or palate surgery. Intervention Illustrated culturally appropriate postoperative care instructions were iteratively developed and given to caregivers who were surveyed on illustration-based and text-based information at preoperative, postoperative, and four-week follow-up time points. Main Outcome Measure Postoperative care knowledge of illustration-based versus text-based information as determined by the ability to answer 11 illustration- and 8 text-based all-or-nothing questions, as well as retention of knowledge as determined by the same survey given at four weeks follow-up. Results Scores for illustration-based and text-based information both significantly increased after caregivers received the postoperative instructions (+13.30 ± 3.78 % SE, + 11.26 ± 4.81 % SE; P .05), but significantly lower for text-based information (−28.46 ± 6.09 % SE, P Conclusions In the setting of language and cultural barriers on a surgical mission, understanding of illustration-based and text-based information both increased after verbal explanation of illustrated postoperative instructions. Illustration-based information was more likely to be retained by patient caregivers after four weeks than text-based information, the latter of which correlated with increased education and literacy.

The nasopharynx is an integral component of the upper aerodigestive tract, whose morphologic features share an intimate relationship with a vast array of clinical, functional, and quality of life conditions related to contemporary humans. Its composite architecture and central location amidst the nasal cavity, pharyngotympanic tube, palate, and skull base bears implications for basic physiologic functions including breathing, vocalization, and alimentation. Over the course of evolution, morphological modifications of nasopharyngeal anatomy have occurred in genus Homo which serve to distinguish the human upper aerodigestive tract from that of other mammals. Understanding of these adaptive changes from both a comparative anatomy and clinical perspective offers insight into the unique blueprint which underpins many clinical pathologies currently encountered by anthropologists, scientists, and otorhinolaryngologists alike. This discussion intends to familiarize readers with the fundamental role that nasopharyngeal morphology plays in upper aerodigestive tract conditions, with consideration of its newfound clinical relevance in the era of the COVID-19 pandemic.

Background: In this first in human study, PLG0206, a novel engineered cationic antimicrobial peptide was evaluated for safety, tolerability and pharmacokinetics when intravenously administered as a single dose to healthy subjects. Methods: Six cohorts of 8 subjects received escalating single IV infusions of PLG0206 at 0.05, 0.125, 0.25, 0.5, or 1 mg/kg dose or placebo over 1-to-4-hours. Subjects were randomized to receive either PLG0206 (6 per cohort) or placebo (2 per cohort). Serial pharmacokinetic samples were taken prior to infusion and up to 48 hours post infusion. Safety and tolerability were assessed throughout the study. Results: The demographic characteristics of subjects were comparable between those treated with PLG0206 and placebo and between dose groups. The incidence of treatment emergent adverse events (TEAE) related to PLG0206 was low and most events were mild in severity and were similar between the PLG0206 treatment and placebo groups. The most common adverse events reported for PLG0206 were infusion related reactions, which were mitigated with increasing infusion time and volume. There were no serious adverse events (SAE), life-threatening events, or deaths throughout the study. IV PLG0206 exhibited linear pharmacokinetics over the dose range of 0.05 to 1.0 mg/kg. The median terminal half-life (t½) ranged from 7.37 to 19.97 hours. Conclusion: Following a single IV infusion to healthy subjects, PLG0206 was safe and well tolerated and exhibited linear PK at doses ranging from 0.05 to 1 mg/kg. These findings support the ongoing development of IV PLG0206 as an antimicrobial agent.

The current COVID-19 global pandemic continues to impact healthcare services beyond those directly related to the management of SARS-CoV-2 transmission and disease. We reviewed the published literature to assess the pandemic impact on existing global immunization activities and how the impact may be addressed. Widespread global disruption in routine childhood immunization has impacted a majority of regions and countries, especially in the initial pandemic phases. While data indicate subsequent recovery in immunization rates, a substantial number of vulnerable people remain unvaccinated. The downstream impact may be even greater in resource-limited settings and economically poorer populations, and consequently there are growing concerns around the resurgence of vaccine-preventable diseases, particularly measles. Guidance on how to address immunization deficits are available and continue to evolve, emphasizing the importance of maintaining and restoring routine immunization and necessary mass vaccination campaigns during and after pandemics. In this, collaboration between a broad range of stakeholders (governments, industry, healthcare decision-makers and frontline healthcare professionals) and clear communication and engagement with the public can help achieve these goals.Key messagesThe COVID-19 pandemic has a substantial impact on essential immunization activities.Disruption to mass vaccination campaigns increase risk of VPD resurgence.Catch-up campaigns are necessary to limit existing shortfalls in vaccine uptake.Guidance to mitigate these effects continues to evolve.

BACKGROUND: As the COVID-19 pandemic significantly reduced the ability of medical students to travel and interact directly with combined Internal Medicine-Pediatrics (Med-Peds) residency programs, medical students desiring appropriate guidance and information about Med-Peds residency training needed a national forum for information during an unprecedented virtual recruitment year. OBJECTIVE: To develop a nationally coordinated webinar series for medical students and student advisors to learn about the Med-Peds specialty for residency training to keep applicant numbers and applicant interest from significantly falling. METHODS: A national webinar series focusing on general Med-Peds information, career interests, and tailored advising was created amongst the three national Med-Peds organizations over a three-month period in Spring 2020. RESULTS: There was a 221% increase in medical student membership to the National Med-Peds Residents' Association (NMPRA) compared to the same months in 2017, 2018, and 2019 and no significant reduction in the Electronic Residency Application Service® applications to Med-Peds programs over that same time period. CONCLUSIONS: A national forum for medical students inquiring about the combined Med-Peds specialty can be effective in recruiting members to NMPRA and keeping interest high in Med-Peds.

Meningococcal serogroup B (MenB) has become the main cause of invasive meningococcal disease in industrialized countries in recent years. The diversity of MenB strains and poor immunogenicity of the MenB capsular polysaccharide have made vaccine development challenging. Two MenB vaccines, including factor H binding protein (fHbp) as a major antigenic component, are now licensed for use. In addition to fHbp variant 1, the multicomponent vaccine 4CMenB contains neisserial heparin binding antigen, Neisseria adhesin A, and outer membrane vesicles containing porin A. The vast majority of circulating MenB strains contain genes encoding at least one 4CMenB component and many express genes for more than one vaccine antigen. Recent studies have suggested that serum bactericidal activity is enhanced against strains that express two or more vaccine antigens. Bacterial killing may also occur when antibodies to vaccine components are collectively present at levels that would individually be sub-lethal. The evaluation of immune responses to separate vaccine components does not take cooperative activity into account and may underestimate the overall protection. Available data on 4CMenB effectiveness indicate that this multicomponent vaccine affords broad coverage and protection against MenB disease. 4CMenB also has the potential to protect against disease caused by non-MenB meningococci and Neisseria gonorrhoeae. Keywords: 4CMenB, Multicomponent vaccine, Meningococcal serogroup B, Cross-protection

To measure the impact of social determinants of health and clinical comorbidities on the incidence of post-tympanotomy tube otorrhea (PTTO).Retrospective observational cohort study. All children between the ages of 0 and 17 having tympanotomy tube placement between 2009 and 2019. Between group comparisons entailed the calculation of odds ratios (OR) with 95% confidence intervals and associated p-values.Among 12,757 patients who underwent myringotomy and tube placement, 2217 (17.4%) presented with PTTO within 1 year. Race and sex did not correlate with the development of PTTO. Non-Hispanic ethnicity had a negative association with PTTO (OR: 0.80 (0.70-0.91), p .0001). Insurance status correlated with incidence of PTTO with a higher rate noted among those with public insurance (OR: 1.12 (1.02-1.23), p = .02) and a lower rate among those with private insurance (OR: 0.84 (0.77-0.92), p .0001). Craniofacial abnormalities had the strongest positive correlation with PTTO, particularly, cleft lip and/or cleft palate (OR2.24, p .0001). Immunodeficiency had similar impact on PTTO (OR: 2.38 (1.46-3.91), p .0001). Asthma and prematurity did not significantly correlate with occurrence of PTTO.Higher rates of PTTO correlated strongest with clinical factors; particularly craniofacial abnormalities and immunodeficiency. Social determinants, including private insurance and non-Hispanic ethnicity, were associated with lower rates of PTTO. Race and sex did not show significant correlations.

Introduction: Prior data suggest associations between hearing loss, cardiovascular (CV) risk factors, and CV disease. Whether specific hearing loss patterns, including a strial pattern associated with inner ear vascular disease, are associated with systemic endothelial dysfunction and carotid intima–media thickness (IMT) remains unclear. Methods: We evaluated participants without prevalent CVD in the Framingham Offspring Study who underwent formal audiogram testing and brachial and carotid artery ultrasounds. Audiograms were categorized as normal or as belonging to one of four abnormal patterns: cochlear-conductive, low-sloping, sensorineural, or strial. Endothelial function as measured by brachial artery flow-mediated dilation (FMDmm and FMD%). Internal and common intima–media thicknesses (icIMT and ccIMT, respectively) were compared between audiogram patterns. Results: We studied 1672 participants (mean age 59 years, 57.6% women). The prevalence of each hearing pattern was as follows: 43.7% normal; 20.3% cochlear-conductive; 20.3% sensorineural; 7.7% low-sloping; and 8.0% strial. Strial pattern hearing loss was nearly twice as prevalent ( p = 0.001) in those in the highest quartile of ccIMT and nearly 50% higher in those in the highest icIMT quartile ( p = 0.04). There were no statistically significant differences between the prevalence of the strial pattern comparing the lowest quartiles of FMDmm and FMD% with the upper three quartiles. Age- and sex-adjusted linear regression models did not show significant associations between the vascular measures and hearing patterns. Conclusion: Abnormal hearing patterns were not significantly associated with impaired brachial FMD and increased carotid IMT after adjusting for age and sex effects, which may reflect age and sex-related distributional differences based on hearing loss pattern.

Stereotactic radiosurgery (SRS) for treatment of vestibular schwannoma (VS) is usually planned with magnetic resonance imaging (MRI) with and without contrast. This report describes a case of a patient with vestibular schwannoma with contraindications to MRI and intravascular contrast who underwent successful SRS using computed tomography (CT) cisternography for planning. The patient is a 76-year-old female with a complicated medical history including an MRI-incompatible cardiac pacemaker, prior severe anaphylactic reaction to intravascular iodinated contrast, and an enlarging left-sided cerebellopontine angle (CPA) neoplasm, presumed to be a VS. Due to her imaging limitations, CT cisternography was used in the planning of her Gamma Knife® SRS. She ultimately underwent successful Gamma Knife® treatment of her VS. CT cisternography for planning of SRS is a novel strategy for VS treatment that may be considered in patients with contraindications to MRI and intravascular iodinated contrast.

Background: Although graduated autonomy is an essential component of residency training, we have an incomplete understanding of resident and attending faculty perceptions of autonomy. Objective: In this study, we assessed differences in perceived autonomy among residents and faculty in pediatrics, internal medicine, and combined internal medicine-pediatrics. Methods: We surveyed senior-level (PGY-2-5) residents and faculty in pediatrics, internal medicine, and combined internal medicine-pediatrics in three large, urban training centers in November 2014. The survey included domain items such as general perceptions of autonomy, case management, rounding structure, and individual resident and faculty factors that may interplay with the granting or receiving of autonomy. Results: Of 489 eligible respondents, 215 (44%) responded. Internal medicine-pediatrics residents were more likely than categorical pediatrics residents and pediatrics faculty to disagree that they received an appropriate level of autonomy while on inpatient pediatrics general wards (mean = 2.7 relative to 4.0 and 4.3, categorical residents and faculty; 5-point Likert scale; P < .001). On a 5-point Likert scale, the internal medicine-pediatrics residents were more likely to agree that they received too much oversight on pediatrics general ward rotations (mean, 3.9) compared to internal medicine general ward rotations (mean, 1.9) with a P-value between rotations of

Background: For medical students seeking additional specialty experience in Med-Peds, in-person electives have often been a source of mentorship and guidance. The COVID-19 pandemic has impacted the ability for the completion of in-person clerkships for medical students across the nation. Virtual opportunities to increase exposure to Med-Peds programs and didactics are lacking at this time. Objective: To develop a virtual Med-Peds student elective that serves to increase awareness of the Med-Peds specialty, exposure to Med-Peds topics and relevant didactics, and exposure to Med-Peds specific mentorship when on-site clerkships are not available due to the COVID-19 pandemic. Methods: Fifteen medical students participated in a virtual Med-Peds student elective utilizing Zoom (Zoom Inc, San Jose, CA). Three separate cohorts of five students each completed two-week elective experiences. The virtual elective curriculum was created using asynchronous and synchronous learning modalities. Sessions were composed of self-directed learning topics, peer-to-peer interactive case discussions, resident-led didactics, and attending physician-led didactics and mentorship sessions. A pre-survey was administered at the beginning of the elective and a post-survey was administered at the end of the elective to assess the effectiveness of the elective, student experiences with Med-Peds mentors, and students’ general perceptions of Med-Peds as a residency application choice. Results: All students (100%), rated the Med-Peds elective to have exceeded their expectations. All students indicated this elective had been extremely (100%) valuable to increase their understanding and interest in Med-Peds (top rating on a five-point Likert scale). Compared to prior to the elective, most were very likely (87%) or likely (7%) to apply to Med-Peds as their top (preferred) specialty. Similar to pre-survey data, one-third (33%) of the students were still likely to apply to an alternate specialty in addition to Med-Peds. Hundred percent of students indicated that the mentorship component of the elective exceeded their original expectations. While most students indicated that they are much more strongly considering applying to Med-Peds as a top (preferred) specialty, the number of students who continue to consider dual-application to include either categorical Internal Medicine, categorical Pediatrics, or Family Medicine did not differ before and after completion of the virtual elective. Conclusions: Implementation of a virtual medical student elective focusing on exposure to Med-Peds can strengthen medical students’ interest in the combined specialty despite a paucity of previous experiences or an affiliated Med-Peds program. This new type of rotation can positively impact a student’s view of a hospital system and a residency program when in-person clinical rotations are not available.

PURPOSE GK-SRS is an accepted definitive treatment option for appropriately selected patients with VS. To assess long-term outcomes in VS patients treated with GK-SRS, we retrospectively evaluated all patients treated at our institution from 2007-2019. METHODS For VS patients treated with GK-SRS from 2007-2019, clinical data (symptoms, physical exams, audiograms, and imaging) was collected via retrospective chart review at pre-treatment and standard follow-up intervals (6 weeks, 6 months, 12 months, then annually). Descriptive analyses, including the proportions of patients in different grades of clinical parameters, are reported. For each clinical parameter, only patients with both pre- and post-treatment data were included in the evaluation set used for analysis. RESULTS Of 177 patients identified, 46 were excluded from the evaluable set (age < 18 years, prior resection, NF-2, or no follow-up). Among the remaining 131, median follow-up was 42 months (6 weeks to 11 years), and 36.6% completed 5+ years of follow-up. At time of treatment, median age was 61 years, and median Karnofsky Performance Score was 90. 58.0% of lesions were left-sided, and 42.0% were right-sided. The majority were Koos grade II (37.4%) or III (38.2%); the remainder were grade I (13.0%) or IV (11.5%). Pre-treatment central necrosis and ventriculomegaly were present in 39.7% and 4.6%, respectively. Following treatment, audiogram analysis with Gardner-Robertson Hearing Score demonstrated no change in 48.9%, some level of decline in 47.8%, and improvement in 3.3% at last follow-up. 97.7% had House-Brackmann scores of I at diagnosis; the remainder were House-Brackmann II. House-Brackmann scores remained unchanged at last follow-up for 96.9%, improved for 1.6%, and worsened for 1.6%. Salvage therapy in the form of surgery (n=5) or repeat GK-SRS (n=2) was necessary in 5.3% (n=6 for progression; n=1 for trigeminal symptoms). CONCLUSION Long-term follow-up demonstrates that GK-SRS remains a well-tolerated, primary definitive treatment for VS.

Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disease leading to recurrent epistaxis, telangiectasias, and/or visceral arteriovenous malformations. Multiple treatment methods, including both pharmacologic and surgical, are described to be effective in managing symptomatic HHT. Few report the duration of symptom improvement for each of these treatment methods. This study aims to analyze the duration of effectiveness of coblation treatment for recurrent epistaxis in those with HHT.Retrospective single-center chart review was completed for patients diagnosed with HHT who underwent coblation treatment by the same otolaryngologist from December 2009 to November 2021. Demographic information was collected along with whether local Bevacizumab was used during each treatment. Months between treatment coblation sessions was used as a surrogate for duration of treatment effectiveness. Descriptive statistics were used for analysis alongside quantitative statistical analysis.Over the course of 12 years, 57 patients (24 female, 42.11%) with HHT underwent a total number of 150 coblation treatments. The average age at initial coblation was 59 years (29-88) with an average follow-up time of 5 years (1-12 years). Of the 150 coblations, 30 treatments (20%) included bevacizumab injections into the nasal cavity. The average duration of treatment effectiveness across all 150 treatment sessions was 24.5 months (1-87 months). Of the 26 patients (46%) that underwent multiple coblation treatments, the overall average duration of coblation effectiveness was 16.4 months (1-72 mos). When Bevacizumab was utilized, the average duration of effectiveness was 18.3 months (3-62 mos), while the average duration of effectiveness for treatments without Bevacizumab was 15.7 months (1-87 mos, p 0.251). Further, there was no correlation between duration of treatment effectiveness and age, sex, and race; yet,there was a significant negative correlation between the use of tobacco and duration of coblation effectiveness (p = 0.0202).Coblation is an effective treatment option for the management of epistaxis in patients with HHT with duration of benefit lasting approximately 2 years. The use of Bevacizumab did not add to the duration of treatment benefit. Further, the duration of benefit was negatively impacted by smoking history.

Objective To identify novel language usage by expert providers predictive of specific vestibular conditions. Study design Retrospective chart review and natural language processing. Level IV. Setting Tertiary referral center. Patients Patients seen for vestibular complaint. Intervention(s) Natural language processing and machine learning analyses of semantic and syntactic patterns in clinical documentation from vestibular patients. Main outcome measure Accuracy of Naive Bayes predictive models correlating language usage with clinical diagnoses. Results Natural language analyses on 866 physician-generated histories from vestibular patients found 3,286 unique examples of language usage of which 614 were used 10 or greater times. The top 15 semantic types represented only 11% of all Unified Medical Language System semantic types but covered 86% of language used in vestibular patient histories. Naive Bayes machine learning algorithms on a subset of 255 notes representing benign paroxysmal positional vertigo, vestibular migraine, anxiety-related dizziness and central dizziness generated strong predictive models showing an average sensitivity rate of 93.4% and a specificity rate of 98.2%. A binary model for assessing whether a subject had a specific diagnosis or not had an average AUC for the receiver operating characteristic curves of .995 across all conditions. Conclusions These results indicate that expert providers utilize unique language patterns in vestibular notes that are highly conserved. These patterns have strong predictive power toward specific vestibular diagnoses. Such language elements can provide a simple vocabulary to aid nonexpert providers in formulating a differential diagnosis. They can also be incorporated into clinical decision support systems to facilitate accurate vestibular diagnosis in ambulatory settings.

Objective: To demonstrate the safety and effectiveness of the MED-EL Electric-Acoustic Stimulation (EAS) System, for adults with residual low-frequency hearing and severe-to-profound hearing loss in the mid to high frequencies. Study Design: Prospective, repeated measures. Setting: Multicenter, hospital. Patients: Seventy-three subjects implanted with PULSAR or SONATA cochlear implants with FLEX24 electrode arrays. Intervention: Subjects were fit postoperatively with an audio processor, combining electric stimulation and acoustic amplification. Main Outcome Measures: Unaided thresholds were measured preoperatively and at 3, 6, and 12 months postactivation. Speech perception was assessed at these intervals using City University of New York sentences in noise and consonant–nucleus–consonant words in quiet. Subjective benefit was assessed at these intervals via the Abbreviated Profile of Hearing Aid Benefit and Hearing Device Satisfaction Scale questionnaires. Results: Sixty-seven of 73 subjects (92%) completed outcome measures for all study intervals. Of those 67 subjects, 79% experienced less than a 30 dB HL low-frequency pure-tone average (250–1000 Hz) shift, and 97% were able to use the acoustic unit at 12 months postactivation. In the EAS condition, 94% of subjects performed similarly to or better than their preoperative performance on City University of New York sentences in noise at 12 months postactivation, with 85% demonstrating improvement. Ninety-seven percent of subjects performed similarly or better on consonant–nucleus–consonant words in quiet, with 84% demonstrating improvement. Conclusion: The MED-EL EAS System is a safe and effective treatment option for adults with normal hearing to moderate sensorineural hearing loss in the low frequencies and severe-to-profound sensorineural hearing loss in the high frequencies who do not benefit from traditional amplification.

Vaccines are considered to be one of the greatest public health achievements of the last century. Depending on the biology of the infection, the disease to be prevented, and the targeted population, a vaccine may require the induction of different adaptive immune mechanisms to be effective. Understanding the basic concepts of different vaccines is therefore crucial to understand their mode of action, benefits, risks, and their potential real-life impact on protection. This review aims to provide healthcare professionals with background information about the main vaccine designs and concepts of protection in a simplified way to improve their knowledge and understanding, and increase their confidence in the science of vaccination (Supplementary Material).KEY MESSAGEDifferent vaccine designs, each with different advantages and limitations, can be applied for protection against a particular disease.Vaccines may contain live-attenuated pathogens, inactivated pathogens, or only parts of pathogens and may also contain adjuvants to stimulate the immune responses.This review explains the mode of action, benefits, risks and real-life impact of vaccines by highlighting key vaccine concepts.An improved knowledge and understanding of the main vaccine designs and concepts of protection will help support the appropriate use and expectations of vaccines, increase confidence in the science of vaccination, and help reduce vaccine hesitancy. Different vaccine designs, each with different advantages and limitations, can be applied for protection against a particular disease. Vaccines may contain live-attenuated pathogens, inactivated pathogens, or only parts of pathogens and may also contain adjuvants to stimulate the immune responses. This review explains the mode of action, benefits, risks and real-life impact of vaccines by highlighting key vaccine concepts. An improved knowledge and understanding of the main vaccine designs and concepts of protection will help support the appropriate use and expectations of vaccines, increase confidence in the science of vaccination, and help reduce vaccine hesitancy.

Bottom trawling disturbance and hypoxia are affecting marine benthic habitats worldwide. We present an approach to predict their effects on benthic communities, and use the approach to estimate the state, the biomass relative to carrying capacity, of the Baltic Sea at the local, habitat, and regional scale. Responses to both pressures are expected to depend on the longevity of fauna, which is predicted from benthic data from 1558 locations. We find that communities in low-salinity regions mostly consist of short-lived species, which are, in our model, more resilient than those of the saline areas. The model predicts that in 14% of the Baltic Sea region benthic biomass is reduced by at least 50%, whereas an additional 8% of the region has reductions of 10–50%. The effects of hypoxia occur over larger spatial scales and lead to a low state of especially deep habitats. The approach is based on a simple characterization of the benthic community, which comes with high uncertainty, but allows for the identification of benthic habitats that are at greatest risk and prioritization of management actions at the regional scale. This information supports the development of sustainable approaches to manage impact of human activities on benthic ecosystems.

OBJECTIVES/HYPOTHESIS Cell culture models are valuable tools for investigation of the molecular pathogenesis of diseases including otitis media (OM). Previous study indicates that age-, sex-, and race-associated differences in molecular signaling may impact disease pathophysiology. Currently, a singular immortalized middle ear epithelial (MEE) cell line exists, HMEEC-1, derived from an adult without known middle ear disease. In this study, HMEEC-1 and primary MEE cultures from pediatric patients with and without OM were stimulated with inflammatory cytokines or OM-pathogenic bacterial lysates to examine differences in the response of molecules associated with OM pathogenesis. STUDY DESIGN Case-control series. METHODS MEE cultures were established from patients aged

Physician burnout impacts care (self and patients), productivity, longevity of career, and overall cost. While burnout rates for pediatricians are lower than average (41%), rates have not improved significantly over time. Although strategies at the system level have been more successful than the individual level, both aspects are vital. This QI study explores individual physician wellness and burnout trends of a sample population of pediatricians at the 2018 and 2019 AAP National Conference and Exhibition (NCE) utilizing the Physician Health and Wellness Booth (PHWB). The aim was to improve burnout by 20% over a …

Objective: To investigate the contributions of envelope and fine-structure to the perception of timbre by cochlear implant (CI) users as compared to normal hearing (NH) listeners. Methods: This was a prospective cohort comparison study. Normal hearing and cochlear implant patients were tested. Three experiments were performed in sound field using musical notes altered to affect the characteristic pitch of an instrument and the acoustic envelope. Experiment 1 assessed the ability to identify the instrument playing each note, while experiments 2 and 3 assessed the ability to discriminate the different stimuli. Results: Normal hearing subjects performed better than CI subjects in all instrument identification tasks, reaching statistical significance for 4 of 5 stimulus conditions. Within the CI population, acoustic envelope modifications did not significantly affect instrument identification or discrimination. With envelope and pitch cues removed, fine structure discrimination performance was similar between normal hearing and CI users for the majority of conditions, but some specific instrument comparisons were significantly more challenging for CI users. Conclusions: Cochlear implant users perform significantly worse than normal hearing listeners on tasks of instrument identification. However, cochlear implant listeners can discriminate differences in envelope and some fine structure components of musical instrument sounds as well as normal hearing listeners. The results indicated that certain fine structure cues are important for cochlear implant users to make discrimination judgments, and therefore may affect interpretation toward associating with a specific instrument for identification. Keywords: Music, Timbre, Cochlear implant, Envelope, Fine-structure

Given the high incidence of dizziness and its frequent misdiagnosis, we aim to create a clinical support system to classify the presence or absence of benign paroxysmal positional vertigo with high accuracy and specificity. This paper describes a three-phase study currently underway for classification of benign paroxysmal positional vertigo, which includes diagnosis by a specialist in a clinical setting. Patient background information is collected by a survey on an Android tablet and machine learning techniques are applied for classification. Decision trees and wrappers are employed for their ability to provide information about the question set. One goal of the study is to attain an optimal question set. Each phase of the study presents a unique set and style of questions. Results achieved in the first two phases of the survey indicate that our approach using decision trees with filters or wrappers does a good job of identifying benign paroxysmal positional vertigo.

Importance Benign paroxysmal positional vertigo (BPPV) is an otologic pathologic condition defined as a sensation of spinning triggered by changes in head position relative to gravity and caused by an entrapment of fragmented endolymph debris most commonly in the posterior semicircular canal. Confirmation of diagnosis requires experience with procedures that are poorly known by those other than practitioners with advanced otologic training. The complexity in the diagnosis of BPPV inspired the design of a questionnaire-based algorithm that would be useful for determining a vestibular diagnosis and treatment options. Objective To assess a statistical algorithm for the diagnosis of BPPV in a busy tertiary care setting, with the long-term goal of implementing a clinical pathway to efficiently diagnose and treat patients with dizziness. Design, Setting, and Participants In this retrospective case series, 200 patients who visited the Department of Otolaryngology–Head and Neck Surgery at Johns Hopkins University School of Medicine for their initial vertigo symptoms from September 1, 2016, to December 31, 2016, were assessed. Interventions Use of a validated patient questionnaire as a tool to differentiate patients with dizziness in an electronic medical record review. Main Outcomes and Measures Linear predictor (LP) value based on the questionnaire for the diagnosis of BPPV. Results Of the 200 patient visits reviewed (132 [66%] female), 106 (53.0%; 68 [64%] female) had the information necessary to calculate the LP value and had a confirmed final diagnosis. On the basis of an LP value of 0.2 or greater, the sensitivity for a diagnosis of BPPV was 0.75 and the specificity was 1.0. The positive predictive value was 1.0, whereas the negative predictive value was 0.96. Patients with BPPV had a statistically significantly different LP value (odds ratio, 5.92; 95% CI, 2.73-12.83) than did patients without BPPV. Conclusions and Relevance The findings of this study suggest that the algorithm is efficient for the diagnosis of BPPV in a clinical care setting.

OBJECTIVE To report outcomes following modified tympanomastoidectomy with soft-wall reconstruction (MTMSWR). STUDY DESIGN Retrospective cohort. SETTING Tertiary referral center. PATIENTS Forty-seven patients (48 ears) with aggressive cholesteatoma undergoing MTMSWR. INTERVENTIONS Canal wall down (CWD) tympanomastoidectomy with temporalis fascia reconstruction of the posterior external auditory canal (EAC). MAIN OUTCOME MEASURES Cholesteatoma recidivism; hearing outcomes; degree of soft-wall retraction; time to epithelialization; otorrhea. RESULTS All ears had some form of ossicular compromise. There were 41 ears with completed surveillance of which 39% demonstrated recidivism for cholesteatoma. Of these, 68.8% had a small cholesteatoma foci averaging 3.7 mm. Air pure-tone average remained stable or improved for 60.0% and declined ≤ 20 dB for 85.7%. Excluding ears unable to undergo ossicular chain reconstruction, final air-bone gap was ≤ 30 dB for 66.7%. Retraction of the reconstructed wall was absent-to-mild in 34.7% and moderate-to-full in 52.1%. Thirteen percent had soft-wall breakdown. Average time to full epithelialization of the wall was 58.5 days. CONCLUSIONS MTMSWR is an option for restoring the posterior EAC wall following CWD surgery. Recidivism is comparable to canal wall up surgery, and hearing outcomes are generally better than CWD. Other advantages include rapid epithelialization, low rates of otorrhea, and restoration of a self-cleaning EAC regardless of retraction into the mastoid cavity.

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

Objectives: To identify the current practice patterns and professional activities of internal medicine–pediatrics (med-peds) hospitalists who have graduated in the past 5 years (June 2009–June 2013). Methods: The national Medicine-Pediatrics Program Directors Association (MPPDA) conducted a cross-sectional survey study of the 79 residency program directors who are members of the MPPDA regarding the practice patterns of recent graduates (from 2009–2013) currently practicing as hospitalists. The survey was distributed in the spring of 2014 on the MPPDA listserv. The survey inquired about time spent caring for hospitalized adults and children, medical school appointments, practice in freestanding children’s hospitals, and completion of hospital medicine (HM) fellowships. Results: Forty-nine program directors (62%) completed the survey and provided data on 1042 graduates from 46 programs. Of those graduates, 26.4% (n = 275) practice as hospitalists, and none had completed an HM fellowship. Approximately two-thirds (65%) of med-peds hospitalists provide care to hospitalized children and adults, with one-third providing care solely to hospitalized adults. Approximately one-half (53.5%) have an appointment with a medical school and roughly one-quarter (28%) practice in a freestanding children’s hospital. Conclusions: An increasing percentage of recent med-peds graduates are pursuing careers in HM, and two-thirds are providing care to hospitalized children. As consideration for an accredited pediatric HM fellowship continues, certifying and accrediting bodies should consider how this will impact the med-peds workforce and allow med-peds graduates flexibility in their training requirements that will permit them to acquire the necessary skills to care for hospitalized children and adults.