Citations

Introduction We examined the suitability of using a video visit platform to perform postoperative parotidectomy evaluation at a tertiary care, multiple-surgeon otolaryngology center. Methods A retrospective case review was conducted of patients who underwent parotidectomy and postoperative video visits between November 2019 and December 2020. Success of video visit, plan if applicable, and post-visit outcomes were reviewed. Video visits were designated as successful if the physician could assess for complications in the postoperative course (e.g. first bite pain, Frey syndrome, ear numbness, unplanned visits to the emergency department, unplanned return to the operating room), perform examination of facial nerve function, and formulate care recommendations per clinical judgement without deferment of recommendations for a subsequent in-person visit. Results There were 96 postoperative video visits with 91 unique parotidectomy patients. Demographics: 28/63 male/female; average age, 54y. All video visits were suitable for successful postoperative parotidectomy patient evaluation. Eight visits (8.3%) consisted of patients presenting with common postoperative complications (e.g. eye dryness, first bite pain) and warranted care recommendations. In only two cases did the patient require further in-person procedural (hematoma evacuation, seroma aspiration) follow-ups. For the other 91.7% of visits (n = 88), no additional recommendations were required as patients experienced uncomplicated postoperative courses. Of all the patients, 26.1% (n = 23) were instructed to follow-up for routine surveillance. All other patients, 73.9% (n = 65) were instructed to follow-up as needed. Conclusion Postoperative parotidectomy evaluation is highly amenable to being performed by video. A telemedicine option offers convenience for patients in the majority of cases without compromising clinical assessment and judgment for the physician.

Retinal pigmented epithelial (RPE) cells play an important role in retinal fibrotic diseases such as proliferative vitreoretinopathy (PVR). The purpose of this study was to elucidate the involvement of dopamine receptor signaling in regulating the fibrotic activation of RPE cells. Dopamine receptor expression, the effect of dopamine on fibrotic activity, and dopamine production were measured in the human RPE cell line ARPE-19. The fibrotic activation of RPE cells was evaluated in response to treatments with selective dopamine receptor agonists and antagonists by measuring gene expression, migration, proliferation, and fibronectin deposition. DRD2 and DRD5 are the dominant dopaminergic receptors expressed in ARPE-19 cells and TGF-β stimulation enhances the autocrine release of dopamine, which we show further exasperates fibrotic activation. Finally, treatment with D2 dopamine receptor antagonists or D5 dopamine receptor agonists inhibits profibrotic gene expression, migration, proliferation, and fibronectin deposition and thus may serve as effective mechanisms for treating retinal fibrosis including PVR.

The NCCN Guidelines for Hematopoietic Growth Factors provide recommendations for the appropriate use of growth factors in the clinical management of febrile neutropenia (FN), chemotherapy-induced thrombocytopenia (CIT), and chemotherapy-induced anemia (CIA). Management and prevention of these sequelae are an integral part of supportive care for many patients undergoing cancer treatment. The purpose of these guidelines is to operationalize the evaluation, prevention, and treatment of FN, CIT, and CIA in adult patients with nonmyeloid malignancies and to enable the patient and clinician to assess management options for FN, CIT, and CIA in the context of an individual patient’s condition. These NCCN Guidelines Insights provide a summary of the important recent updates to the NCCN Guidelines for Hematopoietic Growth Factors, with particular emphasis on the incorporation of a newly developed section on CIT.

Background Intensive care unit (ICU) sedation guidelines recommend targeting a light sedation level, but light sedation has no accepted definition, and inconsistent levels have been proposed. Objective To determine Sedation-Agitation Scale and Richmond Agitation-Sedation Scale scores that best describe patients’ ability to follow voice commands. Methods This prospective, observational pilot study enrolled a convenience sample of ICU patients receiving mechanical ventilation. Pairs of trained investigators evaluated scores on the Sedation-Agitation Scale and Richmond Agitation-Sedation Scale and ability to follow commands before and up to 2 hours after sedation lightening in a blind, independent, simultaneous fashion. Positive predictive values (PPVs) and likelihood ratios (LRs) of Sedation-Agitation Scale and Richmond Agitation-Sedation Scale scores associated with light sedation (ability to follow at least 3 commands) were calculated. Results Ninety-six assessments (50 before and 46 after lightening of sedation) were performed in medical ICU patients. Scores best associated with ability to follow at least 3 commands were Sedation-Agitation Scale score of 4 (PPV, 0.88; 95% CI, 0.70-0.98; LR, 14.0) and Richmond Agitation-Sedation Scale score of −1 (PPV, 0.81; 95% CI, 0.61-0.93; LR, 10.7), superior to previously recommended thresholds of Sedation-Agitation Scale score of 3 (PPV, 0.62; 95% CI, 0.48-0.75; LR, 3.1) and Richmond Agitation-Sedation Scale score of −3 (PPV, 0.52; 95% CI, 0.39-0.64; LR, 2.0). Conclusions The level of sedation most associated with the ability to follow commands appears higher than previously recommended. Further study is needed regarding the effects of sedation level on ICU patients’ ability to follow commands and assessment of delirium, pain, and patient preferences.

AbstractIntroduction/AimsGraduate medical education programs must ensure residents and fellows acquire skills needed for independent practice. Workplace‐based observational assessments are informative but can be time‐ and resource‐intensive. In this study we sought to gather “relations‐to‐other‐variables” validity evidence for scores generated by the Electromyography Direct Observation Tool (EMG‐DOT) to inform its use as a measure of electrodiagnostic skill acquisition.MethodsScores on multiple assessments were compiled by trainees during Clinical Neurophysiology and Electromyography rotations at a large US academic medical center. Relationships between workplace‐based EMG‐DOT scores (n = 298) and scores on a prerequisite simulated patient exercise, patient experience surveys (n = 199), end‐of‐rotation evaluations (n = 301), and an American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM) self‐assessment examination were assessed using Pearson correlations.ResultsAmong 23 trainees, EMG‐DOT scores assigned by physician raters correlated positively with end‐of‐rotation evaluations (r = 0.63, P = .001), but EMG‐DOT scores assigned by technician raters did not (r = 0.10, P = .663). When physician and technician ratings were combined, higher EMG‐DOT scores correlated with better patient experience survey scores (r = 0.42, P = .047), but not with simulated patient or AANEM self‐assessment examination scores.DiscussionEnd‐of‐rotation evaluations can provide valid assessments of trainee performance when completed by individuals with ample opportunities to directly observe trainees. Inclusion of observational assessments by technicians and patients provides a more comprehensive view of trainee performance. Workplace‐ and classroom‐based assessments provide complementary information about trainee performance, reflecting underlying differences in types of skills measured.

ABSTRACT Introduction Erectile dysfunction (ED) is a common consequence of Diabetes Mellitus (DM). The medical literature is inconclusive as to which DM related morbidities improve with better glycemic control. Surgical literature often associates infection outcomes with DM and with glycemic control. There is limited research on the relationship between Hemoglobin A1c and severity of vascular ED. Objective To evaluate the relationship between hemoglobin A1c (HbA1c) and severity of vascular ED in men with DM diagnosed with vascular ED by penile color duplex Doppler ultrasound (CDDU). Methods We retrospectively analyzed patients with a history of DM who underwent intracavernous injection followed by CDDU at our institution between 2005 and 2019. CDDU findings including peak systolic velocities (PSV), primary diagnosis after CDDU, and resistive indices (RIs) were recorded. Doppler diagnosis was based on post stimulation PSV and RI. Arterial Insufficiency (AI) was classified as PSV < 25 cm/s (severe), or (moderate) PSV 25-34.9 cm/s with RI ≥ 0.90. Corporal veno-occlusive disease (CVOD) was classified as PSV ≥ 35 cm/s with RI < 0.90. Mixed ED was classified as PSV 25-34.9 cm/s with RI < 0.90. HbA1c was recorded at time of assessment. Among our cohort of 1490 men who had CDDU, 520 had DM: 130 with CDDU diagnosis of ED, 270 with CDDU diagnosis of ED + Peyronie's disease (PD), 94 with PD alone and 26 with normal vascular erections on CDDU and no PD. The 130 patients with DM diagnosed with ED without presence of PD were included in our analysis. We used a Kruskal-Wallis rank sum test to evaluate the overall association between HgA1c and CDDU diagnosis (AI, CVOD, and mixed ED). Spearman rank correlation tests were used to explore the relationship of HbA1C with PSV and RI. Results Among the 130 men with DM + ED without PD, the median age was 61 y (range 20-79 y), 76 (58%) had hypertension, 37 (28%) had heart disease, median BMI was 30.7 kg/m2 (range 21.2-48.9 kg/m2), and median HgbA1C was 7.0 (range 5.0-11.0). PDE-5 inhibitor use was reported in 119/129 (92.2%) and among those who reported using it 108/119 (90.8%) reported PDE-5 inhibitor failure. CDDU diagnoses were 53 (40.8%) AI, 44 (33.8%) CVOD, and 33 (25.4%) mixed vascular (25%). The median (interquartile range) HbA1c was 7.0 (6.1-7.8) in men with AI, 7.1 (6.3-8.0) in men with CVOD, and 6.7 (6.1-7.0) in men with mixed ED. We did not find evidence of a relationship between HbA1c and severity of vascular ED (Kruskal-Wallis test P = 0.25). We also did not find evidence of a correlation of HbA1c with either post-stimulation PSV (Spearman rank correlation = 0.04, P=0.68) or RI (Spearman rank correlation = -0.03, P = 0.79). Conclusions Median HbA1c did not vary with the vascular diagnosis of men with DM + ED (AI vs. CVOD vs. Mixed Vascular). DM is a significant risk factor for ED and HbA1c is used to monitor and advise patients. We found no predictive relationship between HbA1c and type of vascular ED as defined by CDDU. Disclosure No

Background: Cranial dural arteriovenous fistulas with cortical venous drainage are rare lesions that can present with hemorrhage. A high rate of rebleeding in the early period following hemorrhage has been reported, but published long-term rates are much lower. No study has examined how risk of rebleeding changes over time. Our objective was to quantify the relative incidence of rebleeding in the early and later periods following hemorrhage. Methods: Patients with dural arteriovenous fistula and cortical venous drainage presenting with hemorrhage were identified from the multinational CONDOR (Consortium for Dural Fistula Outcomes Research) database. Natural history follow-up was defined as time from hemorrhage to first treatment, rebleed, or last follow-up. Rebleeding in the first 2 weeks and first year were compared using incidence rate ratio and difference. Results: Of 1077 patients, 250 met the inclusion criteria and had 95 cumulative person-years natural history follow-up. The overall annualized rebleed rate was 7.3% (95% CI, 3.2–14.5). The incidence rate of rebleeding in the first 2 weeks was 0.0011 per person-day; an early rebleed risk of 1.6% in the first 14 days (95% CI, 0.3–5.1). For the remainder of the first year, the incidence rate was 0.00015 per person-day; a rebleed rate of 5.3% (CI, 1.7–12.4) over 1 year. The incidence rate ratio was 7.3 (95% CI, 1.4–37.7; P , 0.026). Conclusions: The risk of rebleeding of a dural arteriovenous fistula with cortical venous drainage presenting with hemorrhage is increased in the first 2 weeks justifying early treatment. However, the magnitude of this increase may be considerably lower than previously thought. Treatment within 5 days was associated with a low rate of rebleeding and appears an appropriate timeframe.