Citations

Objective To report the feasibility and potential utility of monitoring acoustic hearing on awake patients using intraoperative behavioral responses to threshold and suprathreshold stimuli while undergoing cochlear implantation (CI) under local anesthesia, without any form of sedation. Study Design Retrospective review of the first five cases performed by one surgeon. Setting Tertiary care academic medical center. Patients Adult patients with residual acoustic hearing undergoing CI. Interventions CI under local anesthesia, without any form of sedation. Main Outcome Measures Procedural tolerance, reliability of intraoperative pure tone threshold and suprathreshold audiometry, and correlation of intraoperative findings with early postoperative residual hearing. Results Five ears in four patients underwent CI, including three males and one female, with a median age of 61 years. Intraoperatively, patients reported reliable behavioral responses to pure tone threshold and suprathreshold stimuli and provided real-time feedback on perceived stimulus change to the surgeon just prior to, during, and immediately following electrode insertion. All patients were able to complete the operation under local anesthesia. During electrode insertion, three cases reported no change and two cases reported diminished stimulus perception that reversed with limited electrode pull back near terminal insertion. Immediate postoperative audiograms demonstrated preservation of bone conduction thresholds within 10 dB of their preoperative baseline for all cases, suggesting hearing preservation. Three-month postoperative AzBio in quiet scores were available for two patients, measuring 45% and 94%, respectively. Conclusions This report describes the feasibility of intraoperative behavioral audiometry during CI under local anesthesia, using patient feedback during electrode insertion to optimize hearing preservation surgery. Akin to other surgical subspecialties that use real-time patient feedback where objective intraoperative measures of neurofunction are imperfect, we demonstrate feasibility and potential utility of live acoustic monitoring during CI.

Introduction: Melanoma is a deadly type of skin cancer that develops from melanocytes and can manifest on the skin or other regions of the body. Its incidence is increasing rapidly, with approximately 100,000 diagnoses and 7000 deaths per year in the US alone. We conducted a cross-sectional study with the aim of determining an association between the cost of care for invasive melanoma and the specialty involved in the treatment to adequately guide future treatment. Methods: We analyzed data from 3817 patients (2013–2018) using the Florida inpatient/outpatient dataset, CMS cost reports, and the National Plan and Provider Enumeration System. Covariates included age, sex, race/ethnicity, insurance type, region, county rurality, the number of procedures, the comorbidity index, obesity, metastatic cancer presence, hospital size, and physician volume. Multivariable mixed linear regression was used to analyze the data, and the cost was adjusted to the 2019 USD. Results: Dermatology had the largest decrease in the overall and outpatient costs compared to general surgery, followed by plastic surgery. The inpatient costs for dermatology and plastic surgery were lower than those for general surgery, but not significantly so. Conclusions: The costs associated with surgical procedures may vary depending on the specialty of the physician treating the patient. Dermatology was associated with lower treatment costs for invasive melanoma compared to other specialties, indicating that physician specialty influences the cost of care.

Abstract Background The NIH Pragmatic Trials Collaboratory supports the design and conduct of 31 embedded pragmatic clinical trials, and many of these trials use patient-reported outcome measures (PROMs) to provide valuable information about the patients' health and wellness. Often these trials enroll medically underserved patients, including people with incomes below the federal poverty threshold, racial or ethnic minority groups, or rural or frontier communities. Objectives In this series of trial case reports, we provide lessons learned about collecting PROMs in these populations. Unbiased collection of PROM data is critical to increase the generalizability of trial outcomes and to address health inequities. Use of electronic health records (EHRs) and other digital modes of PROM administration has gained traction. However, engagement with these modes is often low among populations prone to disparity due to lower digital proficiency, device access, and uptake of EHR portals and web interfaces. Methods To maximize the completeness and representativeness of their trial outcome data, study teams tested a range of strategies to improve PROM response rates with emphasis on disparities prone and underserved patient groups. This manuscript describes the approaches, their implementation, and the targeted populations. Conclusion Optimized PROM collection required hybrid approaches with multiple outreach modes, high-touch methods, creativity in promoting digital uptake, multimodal participant engagement, and text messaging.

Abstract Background and Aims Patients with inflammatory bowel disease (IBD) have a higher risk of developing colorectal dysplasia and colorectal cancer compared to the general population. Although the use of surveillance protocols has improved the ability to detect dysplasia, some lesions are still missed at colonoscopy. This study aims to determine the rate of dysplastic lesions that are undetected at colonoscopies in IBD patients undergoing colectomy and to identify factors associated with missed dysplasia. Methods Patients who had received a total or subtotal colectomy at Mayo Clinic (Rochester, Minnesota), between January 2003 and December 2022, and had a complete colonoscopy within 5 years before surgery were retrospectively enrolled. Data abstracted included demographic information, disease-related data, colonoscopy and pathology reports, and surgery pathology reports. Colonoscopy and surgery findings were compared, and patients were divided into 3 groups: no dysplasia at both, detected dysplasia, and undetected dysplasia. Results Among 1320 IBD patients undergoing colectomy, 5.4% had undetected dysplastic lesions identified only at surgery. Factors independently associated with dysplasia detection were endoscopic remission or mild endoscopic disease activity (odds ratio [OR], 2.326; P = .0081; 95% CI, 1.246-4.342), prior dysplasia detection (OR, 1.876; P = .0491; 95% CI, 1.002-3.511), colonoscopy performed for surveillance (OR, 2.380; P = .0048; 95% CI, 1.302-4.350), and longer disease duration at surgery (OR, 1.039; P = .0085; 95% CI, 1.010-1.070). Conclusions Clinicians should be aware of the risk of missing dysplastic lesions, especially when endoscopic disease activity is moderate/severe, and not only for longstanding disease. Efforts should be made to obtain endoscopic remission to make the “invisible” visible.

Radiology plays an integral role in guiding management of dermatologic disease and allows evaluation deep to the skin, determination of subcutaneous extent and spread, pretreatment detection of metastatic nodal disease, and posttreatment detection of persistence, recurrence, or unexpected complications.

A 46-year-old woman is referred for a second opinion with recent onset of suspected seizures and imbalance. Fundus examination revealed bilateral discrete perifoveal circular areas of atrophy. What would you do next?

Abstract Drug development for chronic myelomonocytic leukemia (CMML) has failed to parallel the recent success observed in related myeloid neoplasms. To address these shortcomings, the US Food and Drug Administration (FDA) held a “Mini-symposium on CMML: Current State of the Art and Trial Design” in September 2023. This symposium brought together a panel of key FDA regulators and academic experts in CMML drug development to discuss challenges and provide perspectives on future drug development for this disease. The panel explored unique challenges that underlie the lack of therapeutic advances in CMML to date and discussed relevant topics such as clinical trial design, study end points, and key regulatory considerations. This article summarizes the key points of discussion from this symposium to facilitate advancements in the field.