Christopher J. Gouveia

Lack of Association of BRAF Mutation With Negative Prognostic Indicators in Papillary Thyroid Carcinoma: The University of California, San Francisco, Experience

IMPORTANCE Papillary thyroid carcinoma (PTC) is the most common endocrine neoplasm. B-type raf kinase (BRAF) V600E mutation has been proposed as a negative prognostic indicator in PTC, and patients harboring it should receive more aggressive initial therapy. OBJECTIVE To assess the significance of BRAF V600E mutation in PTC in the largest US sample to date. DESIGN We identified patients from our institutions pathology archives diagnosed as having PTC and meeting criteria for BRAF mutation testing. Medical records were analyzed for BRAF status (positive or negative) and a list of standardized clinicopathologic features. PARTICIPANTS A total of 429 patients with PTC at an academic medical center. MAIN OUTCOMES AND MEASURES Clinicopathologic features in patients with PTC with and without BRAF mutation. RESULTS Of 429 cases with PTC, 314 (73.2%) were positive for the BRAF mutation and 115 (26.8%) tested negative. BRAF mutation was significantly associated with tumor margin positivity (P = .03) and lymph node metastasis (P = .002) on univariate analysis but not on multivariate study. BRAF mutation was a predictor of male sex (odds ratio [OR], 3.2; 95% CI, 1.4-7.2), total thyroidectomy (OR, 2.6; 95% CI, 1.1-6.2), and a negative predictor of follicular variant PTC (OR, 0.1; 95% CI, 0.1-0.4). There was no significant association between BRAF positivity and tumor multicentricity, lymphovascular invasion, extranodal extension, central neck involvement, advanced stage (stage III or IV), and distant metastasis. CONCLUSIONS AND RELEVANCE BRAF V600E mutation has been extensively studied in relation to negative prognostic indicators in PTC, with no consistent relationship emerging. Two recent meta-analyses showed an overall association between BRAF status and aggressive disease features and called for tailoring treatment plans in patients accordingly. In this, the largest US study to date, BRAF status was not significantly associated with most clinicopathologic features suggestive of more aggressive disease.

National Institutes of Health Funding for Obstructive Sleep Apnea An Opportunity for Otolaryngologists

Objective To describe current levels and trends of funding for the National Institutes of Health (NIH) in obstructive sleep apnea (OSA) and to recognize the current status of otolaryngologists in OSA research. Study Design Scientometric analysis. Methods The NIH RePORTER database was queried for the search term “obstructive sleep apnea” for all available years. Sex, degree, academic department, NIH funding source, geography, funding totals and years, and h-index of principal investigators (PIs) were collected and summarized. Results A total of 397 projects spanning 1242 total funding years were funded. Of the 273 individual PIs, 33.3% (91/273) were female. Regarding credentials, 52.4% of PIs (143/273) were MD or MD/PhD, and 41.0% (112/273) were PhD alone. Academic departments of PIs were most often medicine (34.1%), pediatrics (12.1%), cell biology/physiology (10.6%), and psychiatry (7.7%). Seven otolaryngology faculty members had received NIH funding for OSA research (2.6% of total PIs) since 2000. They accounted for 8 grants (0.25% of total grants) and

Opioid Stewardship in Otolaryngology: State of the Art Review:

7,235,729 (1.5% of total dollars) of research funding. Conclusion Despite studies showing increasing levels of OSA surgery being performed and major areas of research and clinical opportunity, otolaryngologists represent a small minority of OSA research funding. This information may help direct our specialty when setting priorities regarding research funding, as research into the basic science and clinical management of OSA represents a broad and interdisciplinary pursuit.

Sleep Surgery in the Elderly: Lessons from the National Surgical Quality Improvement Program

Objective The United States is facing an epidemic of opioid addiction. Deaths from opioid overdose have quadrupled in the past 15 years and now surpass annual deaths during the height of the human immunodeficiency virus epidemic. There is a link between opioid prescriptions after surgery, opioid misuse, opioid diversion, and use of other drugs of abuse. As surgeons, otolaryngologists contribute to this crisis. Our objective is to outline the risk of abuse from opioids in the management of acute postoperative pain in otolaryngology–head and neck surgery (OHNS) and strategies to avoid misuse. Data Sources PubMed/MEDLINE. Review Methods We conducted a review of the literature on the rate of opioid abuse after surgery, methods of safe opioid use, and strategies to minimize the dangers of opioids. Conclusions Otolaryngologists have a responsibility to treat pain. This begins preoperatively by discussing perioperative pain control and developing a personalized pain control plan. Patients should be aware that opioids carry significant risks of adverse events and abuse. Perioperative use of multimodal nonopioid agents enables pain control and avoidance of opioids in many otolaryngologic cases. When this approach is inadequate, opioids should be used in short duration under close surveillance. Institutional standards for opioid prescribing after common procedures can minimize misuse. Implications for Practice Otolaryngologists need to acknowledge the potential harm that opioids cause. It is essential that we evaluate our practices to ensure that opioids are used responsibly. Furthermore, opioid stewardship should become a priority in otolaryngology.

Management of hearing loss and the normal ear in cases of unilateral Microtia with aural atresia

Objective Assess the frequency and nature of postoperative complications following sleep surgery. Examine these issues specifically in elderly patients to provide guidance for their perioperative care. Study Design Retrospective cohort study. Setting American College of Surgeons National Surgical Quality Improvement Program. Methods We identified patients with obstructive sleep apnea undergoing sleep surgery procedures from 2006 to 2013 in the American College of Surgeons National Surgical Quality Improvement Program, a multi-institutional outcomes program designed to improve surgical quality. We analyzed patients by comparing age groups: <65 and ≥65 years. Summary data were analyzed, and multivariate regression was used to adjust for patient characteristics, comorbidities, and surgical procedure. Results We identified 2230 patients who had sleep surgery, which included 2123 patients <65 years old and 107 patients ≥65 years old. Elderly patients were significantly more likely to have hypertension requiring medication (P < .001) and higher American Society of Anesthesiologists scores (P < .001). There were no significant differences in the rates of nasal (P = .87), palate (P = .59), tongue base (P = .73), and multilevel (P = .95) surgery being performed on both groups of patients. Elderly patients had higher rates of wound complications and urinary tract infections as compared with younger patients. On multivariate analysis, age ≥65 was significantly associated with complications from sleep surgery (odds ratio, 2.35; 95% CI, 1.04-5.35). Conclusion Elderly patients undergoing sleep surgery have increased postoperative complication risk as compared with younger patients treated similarly. This information can help direct quality improvement efforts in the care of older patients.

Neuromuscular function of the soft palate and uvula in snoring and obstructive sleep apnea: A systematic review

To identify the rate of hearing loss related to middle ear disease and the frequency of tympanostomy tube (TT) insertion in the contralateral ear of patients with unilateral microtia/aural atresia.

An assessment of online information related to surgical obstructive sleep apnea treatment

OBJECTIVE A collapsible upper airway is a common cause of obstructive sleep apnea. The exact pathophysiology leading to a more collapsible airway is not well understood. A progressive neuropathy of the soft palate and pharyngeal dilators may be associated with the progression of snoring to OSA. The purpose of this study is to systematically review the international literature investigating the neurophysiologic changes in the soft palate and uvula that contribute to progression from snoring to OSA. METHODS PubMed/MEDLINE and 4 other databases were systematically searched through July 4, 2017. Eligibility: (1) Patients: controls, snoring or OSA patients (2) Intervention: neuromuscular evaluation of the palate and/or uvula (3) Comparison: differences between controls, snoring and OSA patients (4) Outcomes: neuromuscular outcomes (5) Study design: Peer reviewed publications of any design. RESULTS 845 studies were screened, 76 were downloaded in full text form and thirty-one studies met criteria. Histological studies of the soft palate demonstrated diffuse inflammatory changes, muscular changes consistent with neuropathy, and neural aberrancies. Sensory testing studies provided heterogeneous outcomes though the majority favored neuronal dysfunction. Studies have consistently demonstrated that increasing severity of snoring and sleep apnea is associated with worsening sensory nerve function of the palate in association with atrophic histological changes to the nerves and muscle fibers of the soft palate and uvula. CONCLUSIONS Recent evidence highlighted in this systematic review implicates the role of neurogenic pathology underlying the loss of soft palate and/or uvular tone in the progression of snoring to sleep apnea.

The Association of External Transfer Status with Adverse Outcomes in Otolaryngology

BackgroundPatients are accessing online health information frequently and using it to guide treatment decisions. Few studies have been done assessing obstructive sleep apnea (OSA) information, and no studies have examined surgical resources for these patients.MethodsThis was a cross-sectional analysis. “Sleep surgery” and “sleep apnea surgery” were entered into Google, MSN Bing, and Yahoo! search engines. The first 25 results of each individual search were evaluated. Each unique site was assessed for content quality, accessibility, usability, reliability, and readability using validated instruments. The date of last update for each site was also documented.Results“Sleep surgery” was searched for an average of 1,703,991 (SD = 166,585) times per month from June 2015 to June 2016. 33 unique websites were identified. Sites were most often academically/government affiliated (10/33, 30.3%), health information sites (8/33, 24.2%), or non-profit/hospital related (8/33, 24.2%). The mean overall DISCERN score for quality was “good,” at 56.6 (range, 22–79). The mean overall LIDA score for accessibility, usability, and reliability was “moderate,” at 123.9 (range, 97–152). The mean Flesch Reading Ease score for readability was 49.77 (range 22.7-74.3); 7/33 (21.2%) scored above 60, the recommended range for average visitors. 60.6% (20/33) of the sites had been updated since January 1, 2014. There was no significant correlation between a websites’ position on a browser’s search and its DISCERN, LIDA, FRE, or total score.ConclusionsWith patients’ increasing reliance on Internet information, efforts to understand and improve websites’ quality and usefulness present unique opportunities in OSA surgery and beyond.

Publication trends and levels of evidence in obstructive sleep apnea literature: Trends and LOE in OSA Literature

Objective To compare rates of morbidity and mortality in patients treated by otolaryngologists who undergo interhospital transfers vs those who do not and to quantify conditions requiring interhospital transfers in this population. Study Design Cohort study. Setting American College of Surgeons National Surgical Quality Improvement Program. Subjects and Methods We identified patients requiring surgery by otolaryngologists in the National Surgical Quality Improvement Program database from 2006 to 2013. We compared patients who were transferred from an outside institution to those admitted from home. Multivariate regression was used to adjust for patient characteristics, comorbidities, and case mix. The primary outcome was overall morbidity and mortality within 30 days of surgery. Results We identified 60,498 patients; 488 (0.8%) were transferred from another institution. Operations that were more common in the transferred group were incision and drainage (24.0% vs 1.2%), facial trauma repair (9.0% vs 3.1%), and oropharyngeal hemorrhage control (3.9% vs 0.4%). External transfer patients had significantly longer hospital stays (44.1% vs 4.4% >7 days, P < .05). On unadjusted analysis, transferred patients had a significantly higher rate of morbidity and mortality (odds ratio [OR], 11.3; 95% confidence interval [CI], 9.4-13.5). On multivariate analysis, transferred patients had a significantly greater rate of morbidity and mortality (OR, 3.1; 95% CI, 2.4-4.0). Conclusion Transfer from another institution is associated with worse outcomes independent of case mix, demographics, and preoperative comorbidities in acute otolaryngology conditions requiring surgery. Practitioners should be aware of this when caring for transfer patients, and transfer status should be considered when measuring hospital quality.

Clinical Trials in Obstructive Sleep Apnea: Recognizing Trends and Future Opportunities: Clinical Trials in Obstructive Sleep Apnea

Examine trends in clinical research and levels of evidence related to obstructive sleep apnea (OSA) in the medical literature. Describe the features and trends of OSA research within otolaryngology journals.