Hilary C. McCrary

Development of a fresh cadaver model for instruction of ultrasound-guided breast biopsy during the surgery clerkship: pre-test and post-test results among third-year medical students.

BACKGROUND The aim of our study was to determine if a fresh cadaver model is a viable method for teaching ultrasound (US)-guided breast biopsy of palpable breast lesions. METHODS Third-year medical students were assessed both preinstruction and postinstruction on their ability to perform US-guided needle aspiration or biopsy of artificially created masses using a 10-item checklist. RESULTS Forty-one third-year medical students completed the cadaver laboratory as part of the surgery clerkship. Eight items on the checklist were found to be significantly different between pre-testing and post-testing. The mean preinstruction score was 2.4, whereas the mean postinstruction score was 7.10 (P < .001). CONCLUSIONS Fresh cadaver models have been widely used in medical education. However, there are few fresh cadaver models that provide instruction on procedures done in the outpatient setting. Our model was found to be an effective method for the instruction of US-guided breast biopsy among medical students.

The triple aim and its implications on the management of chronic rhinosinusitis

Introduction Accountable care organizations (ACO) and alternative payment models are a sign of the change in reimbursement from fee-for-service to value-based reimbursement. The focus of health care under ACOs is represented by the Triple Aim: to improve the experience of health care, improve the health of populations, and reduce the per capita costs. Individuals with chronic rhinosinusitis (CRS) are heavy consumers of health care services. Results of recent studies have indicated that there is the potential for improved outcomes and cost savings from early surgical intervention. Adhering to the principles of the Triple Aim may signal a paradigm shift in regard to timing of intervention for CRS in certain patients. Methods A scoping review was performed to analyze the current literature related to management of CRS and the impact on cost, population health outcomes, and the patients experience of health care. Results A growing body of literature indicates that, in appropriately selected patients, when compared with medical management, endoscopic sinus surgery has the potential to improve patient outcomes and reduce the long-term cost burden of CRS. Conclusion With the advent of ACOs, a paradigm shift in the treatment of CRS is inevitable to better conform to the goals of the Triple Aim. Future treatment algorithms will need to account for the heterogeneity within CRS and seek to identify appropriate timing and interventions for patients on an individual basis if the value of health care is to be improved.

Association between the CDHR3 rs6967330 risk allele and chronic rhinosinusitis

A retrospective, multi-center study of adults with and without chronic rhinosinusitis (CRS) identifies a significant association between rs6967330 in the viral receptor CDHR3 – known to be associated with wheezing and asthma in children – and the development of CRS.

A Systematic Review of the Association between Cigarette Smoke Exposure and Chronic Rhinosinusitis

Objectives Cigarette smoking and passive smoke exposure have been associated with chronic rhinosinusitis (CRS). Our goal in this systematic review was to (1) determine if there was a strong correlative effect in large population studies between cigarette smoke exposure and the prevalence of CRS, (2) investigate pathogenic mechanisms of cigarette smoke in the upper airway, and (3) determine if a history of cigarette smoking affects the medical and surgical outcomes of CRS. Data Sources MEDLINE, Embase, Cochrane CENTRAL, Web of Science SCI and CPCI-S, and websites. Methods A comprehensive literature review and quantitative meta-analysis of studies based on the PRISMA protocol and examining the relationship between cigarette smoke exposure and CRS was performed. A search strategy was developed using various terms such as sinusitis, rhinitis, rhinosinusitis, and smoking. The articles were categorized by (1) epidemiology, (2) pathophysiology, and (3) outcomes. Data regarding study design, population/setting, methods, and bias were collected. Results The initial search generated 2621 titles/abstracts with 309 articles undergoing secondary review and 112 articles for final review. We determined that there is a strong correlation between active and passive cigarette smoke with the prevalence of CRS. Cigarette smoke challenge to sinonasal epithelia results in the release of inflammatory mediators and altered ciliary beat frequency. Pediatric patients exposed to secondhand smoke appear to have particularly poor outcomes. Conclusion There is clear evidence that cigarette smoke is related to CRS, but longitudinal and mechanistic studies are required to determine a causative effect. This information is critical for greater understanding of CRS health outcomes.

Older individuals meeting medicare cochlear implant candidacy criteria in noise but not in quiet: Are these patients improved by surgery?

OBJECTIVE To investigate postoperative hearing outcomes in older patients who qualified for cochlear implant (CI) by Medicare criteria using AZBio sentence tests performed in noise but not in quiet. STUDY DESIGN Review of patient records. SETTING University-based otology/neurotology practice. PATIENTS The senior author performed 136 CI between January 2013 and September 2015. Starting in 2013, CI candidacy evaluation included AZBio sentence tests performed in quiet and noise. For the current study, older patients with preoperative AZBio scores greater than 40% in quiet but less than 40% in noise (+10 or +5 dB signal to noise ratio [SNR]) and follow up >/=6 months were included. INTERVENTION(S) Cochlear implantation in one ear. MAIN OUTCOME MEASURE(S) Pre- versus postoperative AZBio sentence test scores. RESULTS Fifteen patients with an average age of 73 years (range, 59-91) met inclusion criteria. Preoperative AZBio scores for the implanted ear averaged 47% points in quiet and 9% points in noise (+10 or +5 dB SNR). Preoperative bilateral AZBio scores averaged 70% points in quiet and 24% points in noise (+10 or +5 dB SNR). Postoperative AZBio scores for the implanted ear improved an average of 71% points in quiet and 51% points in noise. Postoperative bilateral hearing improved 23% points in quiet and 27% points in noise. CONCLUSION All patients undergoing CI candidacy testing should be tested in both quiet and noise conditions. For those who qualify only in noise, our results demonstrate that cochlear implantation typically improves hearing both in quiet and noise.

A Fresh Cadaver Model for the Instruction of Ultrasound-Guided Fine-Needle Aspiration of Thyroid Nodules

Objective The aim of our study is to determine if a fresh cadaver model (FCM) for the instruction of ultrasound (US)–guided fine-needle aspiration (FNA) of thyroid nodules is a practical method for instruction. Study Design Pre- and postinstruction assessment of medical students’ ability to perform US-guided FNA of artificially created thyroid nodules placed adjacent to the thyroid gland of a fresh cadaver. Setting University-based fresh cadaver laboratory. Subjects and Methods Study participants included a total of 17 first- and second-year medical students with minimal US training. Technical skills were assessed using a 10-item checklist. In addition, a cognitive assessment regarding the indications, contraindications, and complications of the procedure was completed. A postinstruction assessment was provided for participants 5 weeks after their initial assessment. Differences between pre- and postinstruction assessment scores of technical skills were analyzed using McNemar’s test. The mean cognitive knowledge gain was analyzed using a paired 2-sample t test. Results Eight of 10 items on the skills checklist were statistically significant between pre- and postinstruction skills assessment (P < .05). There was a statistically significant change in cognitive knowledge gain regarding the contraindications of the procedure (P = .001), but not for indications or complications (P = .104 and P = .111, respectively). Conclusion US-guided FNA continues to be an important diagnostic procedure in the workup of thyroid nodules, making it an essential skill to integrate into surgical skills lab. Our FCM for the instruction of US-guided FNA is the first of its kind, and this pilot study shows this is a viable method for instruction.

Penetrating Neck Trauma: An Unusual Case Presentation and Review of the Literature.

Objectives: The aim of this report is to describe a case of a retained projectile metal object to the neck that occurred after airbag deployment during a motor vehicle accident. Methods: Case report with literature review. Results: After a motor vehicle accident on the interstate, a 19-year-old man presents to the emergency department for several open extremity fractures, a neck laceration, and a C1 lateral mass fracture. The trauma surgery team repaired the neck laceration with no further evidence of injury. Several weeks later on follow-up, the patient presents with dysphagia and pain when turning his head to the right. A repeat computed tomography angiography (CTA) scan revealed a metallic foreign body in the left posterior pharyngeal, prevertebral soft tissues, which was subsequently removed during exploratory surgery 2 months after his initial accident. Conclusions: This is the first report, to our knowledge, of a projectile metal object to the neck that may be related to airbag deployment. The car involved in this accident was under recall for airbags that were associated with projectile objects, which warrants further investigation into the possible risks of such airbags.

Cystic Fibrosis Sinusitis.

Cystic fibrosis (CF) is an autosomal recessive genetic disorder caused by mutations in the CF transmembrane conductance regulator gene(CFTR) resulting in impaired ion transport. Nearly all people with CF will develop chronic rhino-sinusitis (CRS) and present with the characteristic viscous mucus, impaired mucociliary clearance and chronic inflammation/infection of the sinonasal cavity. While some individuals with CF can appear relatively asymptomatic in terms of their sinus disease, commonly reported symptoms include anosmia, headache, facial pain, nasal obstruction, chronic congestion and nasal discharge. Nasal endoscopy typically reveals mucosal edema, purulent discharge and nasal polyposis. Computed tomography (CT) imaging classically demonstrates the distinguishing findings of sinus hypoplasia or aplasia with generalized opacification, medial bulging of the lateral sinonasal sidewall and a demineralized uncinate process. Current treatment for CF sinusitis includes the use of hypertonic saline, topical and systemic steroids, antibiotics and endoscopic surgery. Research investigating novel therapies designed at targeting the primary defect of CF is showing promise for reversal of CF sinus disease, in addition to potential for disease prevention.

Otolaryngology Resident Education and the Accreditation Council for Graduate Medical Education Core Competencies: A Systematic Review

Importance To date, there have been no reports in the current literature regarding the use of the Accreditation Council for Graduate Medical Education (ACGME) core competencies in otolaryngology residency training. An evaluation may help educators address these core competencies in the training curriculum. Objectives To examine the quantity and nature of otolaryngology residency training literature through a systematic review and to evaluate whether this literature aligns with the 6 core competencies. Evidence Review A medical librarian assisted in a search of all indexed years of the PubMed, Embase, Education Resources Information Center (via EBSCOhost), Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and Cochrane Methodology Register), Thomson Reuters Web of Science (Science Citation Index Expanded, Social Sciences Citation Index Expanded, Conference Proceedings Citation Index–Science, and Conference Proceedings Citation Index–Social Science and Humanities), Elsevier Scopus, and ClinicalTrials.gov databases to identify relevant English-language studies. Included studies contained original human data and focused on otolaryngology resident education. Data regarding study design, setting, and ACGME core competencies addressed were extracted from each article. Initial searches were performed on May 20, 2015, and updated on October 4, 2016. Findings In this systematic review of 104 unique studies, interpersonal communication skills were reported 15 times; medical knowledge, 48 times; patient care, 44 times; practice-based learning and improvement, 31 times; professionalism, 15 times; and systems-based practices, 10 times. Multiple studies addressed more than 1 core competency at once, and 6 addressed all 6 core competencies. Conclusions and Relevance Increased emphasis on nonclinical core competencies is needed, including professionalism, interpersonal and communication skills, and systems-based practices in the otolaryngology residency training curriculum. A formal curriculum addressing nonclinical core competencies should be integrated into otolaryngology residency training.

Association of the Patient Protection and Affordable Care Act With Insurance Coverage for Head and Neck Cancer in the SEER Database

Importance Patients with head and neck squamous cell cancer (HNSCC) are often uninsured or underinsured at the time of their diagnosis. This access to care has been shown to influence treatment decisions and survival outcomes. Objective To examine the association of the Patient Protection and Affordable Care Act (ACA) health care legislation with rates of insurance coverage and access to care among patients with HNSCC. Design, Setting, and Participants Prospectively gathered data from the Surveillance, Epidemiology, and End Results (SEER) database were used to examine rates of insurance coverage and access to care among 89 038 patients with newly diagnosed HNSCC from January 2007 to December 2014. Rates of insurance were compared between states that elected to expand Medicaid coverage in 2014 and states that opted out of the expansion. Statistical analysis was performed from January 1, 2007, to December 31, 2014. Main Outcomes and Measures Rates of insurance coverage and disease-specific and overall survival. Results Among 89 038 patients newly diagnosed with HNSCC (29 384 women and 59 654 men; mean [SD] age, 59.8 [7.6] years), there was an increase after implementation of the ACA in the percentage of patients enrolled in Medicaid (16.2% after vs 14.8% before; difference, 1.4%; 95% CI, 1.1%-1.7%) and private insurance (80.7% after vs 78.9% before; difference, 1.8%; 95% CI, 1.2%-2.4%). In addition, there was a large decrease in the rate of uninsured patients after implementation of the ACA (3.0% after vs 6.2% before; difference, 3.2%; 95% CI, 2.9%-3.5%). This decrease in the rate of uninsured patients and the associated increases in Medicaid and private insurance coverage were only different in the states that adopted the Medicaid expansion in 2014. No survival data are available after implementation of the ACA, but prior to that point, from 2007 to 2013, uninsured patients had reduced 5-year overall survival (48.5% vs 62.5%; difference, 14.0%; 95% CI, 12.8%-15.2%) and 5-year disease-specific survival compared with insured patients (56.6% vs 72.2%; difference, 15.6%; 95% CI, 14.0%-17.2%). Conclusions and Relevance Access to health care for patients with HNSCC was improved after implementation of the ACA, with an increase in rates of both Medicaid and private insurance and a 2-fold decrease in the rate of uninsured patients. These outcomes were demonstrated only in states that adopted the Medicaid expansion in 2014. Uninsured patients had poorer survival outcomes.