Richard M. Rosenfeld

Validation of the Charlson Comorbidity Index in Patients With Head and Neck Cancer: A Multi‐institutional Study

Comorbid conditions are medical illnesses that accompany cancer. The impact of these conditions on the outcome of patients with head and neck cancer is well established. However, all of the comorbidity studies in patients with head and neck cancer reported in the literature have been performed using the Kaplan‐Feinstein index (KFI), which may be too complicated for routine use. This study was performed to introduce and validate the use of the Charlson comorbidity index (CI) in patients with head and neck cancer and to compare it with the Kaplan‐Feinstein comorbidity index for accuracy and ease of use. Study design was a retrospective cohort study. The study population was drawn for three academic tertiary care centers and included 88 patients 45 years of age and under who underwent curative treatment for head and neck cancer. All patients were staged by the KFI and the CI for comorbidity and divided into two groups based on the comorbidity severity staging. Group 1 included patients with advanced comorbidity (stages 2 or 3), and group 2 included those with low‐level comorbidity (stages 0 or 1). Outcomes were compared based on these divisions. The KFI was successfully applied to 80% of this study population, and the CI was successfully applied in all cases ( P < 0.0001). In addition, the KFI was found to be more difficult to use than the CI ( P < 0.0001). However, both indices independently predicted the tumor‐specific survival ( P = 0.007), even after adjusting for the confounding effects of TNM stage by multivariate analysis. Overall, the CI was found to be a valid prognostic indicator in patients with head and neck cancer. In addition, because comorbidity staging by the CI independently predicted survival, was easier to use, and more readily applied, it may be better suited for use for retrospective comorbidity studies.

Impact of comorbidity on outcome of young patients with head and neck squamous cell carcinoma

Comorbid conditions have a significant impact on the actuarial survival of patients with head and neck cancer. However, no studies have evaluated the impact of comorbidity on tumor‐ and treatment‐specific outcomes. This study was performed to evaluate the impact of comorbidity, graded by the Kaplan‐Feinstein comorbidity index (KFI) on the incidence and severity of complications, disease‐free interval, and tumor‐specific survival in patients undergoing curative treatment for head and neck cancer.

Clinical practice guideline development manual: A quality-driven approach for translating evidence into action

BACKGROUND: Guidelines translate best evidence into best practice. A well-crafted guideline promotes quality by reducing health-care variations, improving diagnostic accuracy, promoting effective therapy, and discouraging ineffective—or potentially harmful—interventions. Despite a plethora of published guidelines, methodology is often poorly defined and varies greatly within and among organizations. PURPOSE: This manual describes the principles and practices used successfully by the American Academy of Otolaryngology—Head and Neck Surgery to produce quality-driven, evidence-based guidelines using efficient and transparent methodology for action-ready recommendations with multidisciplinary applicability. The development process, which allows moving from conception to completion in 12 months, emphasizes a logical sequence of key action statements supported by amplifying text, evidence profiles, and recommendation grades that link action to evidence. CONCLUSIONS: As clinical practice guidelines become more prominent as a key metric of quality health care, organizations must develop efficient production strategies that balance rigor and pragmatism. Equally important, clinicians must become savvy in understanding what guidelines are—and are not—and how they are best utilized to improve care. The information in this manual should help clinicians and organizations achieve these goals.

Effect of Sinus Surgery on Pulmonary Function in Patients With Cystic Fibrosis

The impact of sinus surgery on the pulmonary status of cystic fibrosis patients is unknown. This retrospective study reviewed the charts of the cystic fibrosis patients presenting to our institutions cystic fibrosis center with nasal obstruction, recurrent sinusitis, and nasal polyposis. This group subsequently underwent endoscopic ethmoidectomy and antrostomy. Fourteen of the 15 patients, ages 5‐24 years, received preoperative and postoperative pulmonary function testing obtained by spirometry. The data were compiled and analyzed statistically. Our results suggested no significant improvement in the pulmonary function of cystic fibrosis patients after sinus surgery.

Diagnostic certainty for acute otitis media

Our primary objective was to assess diagnostic accuracy for acute otitis media (AOM) relative to the criterion standard established by the United States Agency for Healthcare Research and Quality: middle-ear effusion (MEE) plus onset in the past 48 h of signs or symptoms of middle-ear inflammation. A secondary objective was to assess the potential reduction in antibiotic usage that could be achieved if clinicians managed AOM according to a consensus guideline developed by the New York Region Otitis Project (NYROP). A convenience sample of primary care practitioners were surveyed after diagnosing AOM in 135 children aged 0.3-11.8 years (median 2.4 years). Clinicians expressed high certainty for AOM diagnosis in 122/135 episodes (90%). The prevalence of true AOM was 70% with a positive predictive value for high certainty of 76%. Of the 40 false-positive diagnoses, 35 did not have MEE and 5 did not have acute signs or symptoms. The relative risk for receiving an antibiotic was 1.50 times higher when clinicians expressed certainty (P=0.005), which produced 31/120 (26%) potentially unnecessary antibiotic prescriptions. Initial antibiotics would not have been prescribed for 29% of episodes using the NYROP guidelines. More judicious use of antibiotics may result if clinicians deferred initial therapy in children without definitive AOM, particularly when the presence of MEE is uncertain.

CARE OF THE CHILD WITH TYMPANOSTOMY TUBES

More than two million tympanotomy tubes are placed annually in the United States, making this operation the most common performed on children. This article provides an overview of the applications of tympanotomy tubes for the treatment for otitis media in childhood. The indications for tube placement are discussed; a visual guide for managing children with tympanostomy tubes is presented; an approach to dealing with tube complications is outlined; and guidelines for referral to a pediatric otolaryngologist are suggested.

Observation option toolkit for acute otitis media.

The observation option for acute otitis media (AOM) refers to deferring antibiotic treatment of selected children for up to 3 days, during which time management is limited to analgesics and symptomatic relief. With appropriate follow-up complications are not increased, and clinical outcomes compare favorably with routine initial antibiotic therapy. Although used commonly in the Netherlands and certain Scandinavian countries, this approach has not gained wide acceptance in Europe and the United States. This article describes an evidence-based toolkit developed by the New York Region Otitis Project for judicious use of the observation option. The toolkit is not intended to endorse the observation option as a preferred method of management, nor is it intended as a rigid practice guideline to supplant clinician judgement. Rather, it presents busy clinicians with the tools needed to implement the observation option in everyday patient care should they so desire.

Nonsurgical management of surgical otitis media with effusion.

The objective of this paper was to determine the effectiveness of combined steroid-antimicrobial therapy for otitis media with effusion (OME) of sufficient duration to justify tympanostomy tube insertion. A consecutive sample of 122 children with bilateral OME of at least three months duration, or unilateral OME of at least six months duration, despite treatment with one or more beta-lactamase stable antibiotics was studied. The treatment group received prednisolone plus a beta-lactamase stable antibiotic for 10 days, with responders receiving an additional six weeks of chemoprophylaxis. The control group received no medication. The childs caregiver decided which group the child should be in. Resolution of effusion in all affected ears occurred in 32 per cent of steroid-treated children and in 2 per cent of controls (p < 0.001) at three to four weeks post-therapy. Relapse of effusion occurred in over 40 per cent of initial responders within six months, reducing the final resolution rate to 25 per cent (95 per cent CI: 15-36 per cent). It was concluded that treatment with oral steroids should be considered in selected children with chronic OME prior to surgical intervention. One in every four children whose caregiver consents to this therapy may avoid or postpone surgery for at least six months.

How to review journal manuscripts

Reviewing manuscripts is central to editorial peer review, which arose in the early 1900s in response to the editors need for expert advice to help select quality articles from numerous submissions. Most reviewers learn by trial and error, often giving up along the way because the process is far from intuitive. This primer will help minimize errors and maximize enjoyment in reviewing. Topics covered include responding to a review invitation, crafting comments to editors and authors, offering a recommended disposition, dealing with revised manuscripts, and understanding roles and responsibilities. The target audience is primarily novice reviewers, but seasoned reviewers should also find useful pearls to assist their efforts.

First Place—Resident Clinical Science Award 1998: Parents cannot detect mild hearing loss in children

Otitis media with effusion is among the most common illnesses of childhood and is often associated with chronic or persistent middle ear effusion (MEE). Our goal was to develop and validate a self-administered parent survey that would identify children at high risk for mild hearing loss caused by MEE. We evaluated 115 children. Parents rated their childs hearing using the HL-7, a 7-item self-administered survey, and a global visual-analog scale. Static admittance and gradient were recorded. Test-retest reliability, internal consistency, and validity of the HL-7 were compared with the 4-frequency pure-tone average (PTA) hearing level (HL) for the better hearing ear. The HL-7 had good test-retest reliability and internal consistency. Survey scores correlated well with the global hearing rating (R = 0.67, P < 0.001) but did not correlate with PTA (R = 0.10, P = 0.29). Tympanometric gradient was unrelated to ear-specific PTA, but not abnormal static admittance (<0.2 cc), which produced a mean 7-dB HL decrease in hearing (ANOVA, P = 0.02). The HL-7 is a reliable and internally consistent measure of parent perception of child hearing, but unfortunately these perceptions are inaccurate for mild hearing loss. Abnormal static admittance is a risk factor for hearing loss.