bluuebunny/crossref_metadata_2025 huggingface dataset:
Punishing Health Care Providers for Treating Terrorists
Authors: Rubenstein Leonard S.
Published: July 2015

Imagine that an American physician volunteered to treat wounded children through the Ministry of Health in Gaza, controlled by Hamas. Or that a Palestinian nurse attending to injured fighters in Gaza spoke out against the firing of rockets into Israel, was threatened with arrest, and sought asylum in the United States. Under U.S. law, the doctor could be subject to prosecution, and the nurse could be denied asylum—in the first case, because she provided medical care under the direction or control of a designated terrorist organization; in the second, because he knowingly provided care to a member of a terrorist organization. The question of whether a terrorist is entitled to medical care, though largely theoretical, has generated considerable discussion, with near unanimity that there is no moral basis to refuse to treat. But whether a health professional can be punished for providing medical care either to terrorists or under the auspices of a terrorist organization has received little attention from either a moral or legal perspective, although such situations arise throughout the world.
Thinking All Wrong about How You Die
Authors: Battin Margaret P.
Published: July 2015

How do we approach our deaths? By avoidance, for one thing—death, especially our own death, is hard to talk about, think about, even imagine in the dimmest way. Or we dwell on it, that black, feared vortex that will eventually engulf us, swallowing our identity and personhood. Mostly, we distract ourselves with things of the moment. But in our rational moments we make preparations. We write advance directives. We execute durable powers of attorney. We give instructions to loved ones: “No tubes, no machines.” That's the wrong approach, I think. All this stuff we put together doesn't guarantee that what we say we want will actually happen or that we'll have what we'd call a “good death”—what you would think of as a good death for you.
Safety concerns of herbal products and traditional Chinese herbal medicines: dehydropyrrolizidine alkaloids and aristolochic acid
Authors: Stegelmeier Bryan L. , Brown Ammon W. , Welch Kevin D.
Published: July 2015

In many countries, including the United States, herbal supplements, tisanes and vegetable products, including traditional Chinese medicines, are largely unregulated and their content is not registered, monitored or verified. Consequently, potent plant toxins including dehydropyrrolizidine alkaloids and other potential carcinogens can contaminate these products. As herbal and food supplement producers are left to their own means to determine the safety and purity of their products prior to marketing, disturbingly often good marketing practices currently in place are ignored and content is largely undocumented. Historical examples of poisoning and health issues relating to plant material containing dehydopyrrolizidine alkaloids and aristolochic acids were used as examples to demonstrate the risk and potential toxicity of herbal products, food supplements, or traditional medicines. More work is needed to educate consumers of the potential risk and require the industry to be more responsible to verify the content and insure the safety of their products. Published 2015. This article is a U.S. Government work and is in the public domain in the USA.
Biological effects and toxicity of diluted bitumen and its constituents in freshwater systems
Authors: Dew William A. , Hontela Alice , Rood Stewart B. , Pyle Greg G.
Published: July 2015

Approximately 50 billion cubic meters of bitumen resides within the oil sands region of Alberta, Canada. To facilitate the transport of bitumen from where it is extracted to where it is processed, the bitumen is diluted with natural gas condensate (‘dilbit’), synthetic crude from hydrocracking bitumen (‘synbit’), or a mixture of both (‘dilsynbit’). A primary consideration for the effects of diluted bitumen products on freshwater organisms and ecosystems is whether it will float on the water surface or sink and interact with the stream or lake sediments. Evidence from a spill near Kalamazoo, MI, in 2010 and laboratory testing demonstrate that the nature of the spill and weathering of the dilbit, synbit or dilsynbit prior to and during contact with water will dictate whether the product floats or sinks. Subsequent toxicological data on the effects of dilbit and other diluted bitumen products on freshwater organisms and ecosystems are scarce. However, the current literature indicates that dilbit or bitumen can have significant effects on a wide variety of toxicological endpoints. This review synthesizes the currently available literature concerning the fate and effects of dilbit and synbit spilled into freshwater, and the effects of bitumen and bitumen products on aquatic organisms and ecosystems. Dilbit is likely to provide ecological impacts that are similar to and extend from those that follow from exposure to lighter crude oil, but the prospect of bitumen settling after binding to suspended sediments elevates the risk for benthic impacts in streams and lakes. Copyright © 2015 John Wiley & Sons, Ltd.
Developing Xenopus embryos recover by compacting and expelling single wall carbon nanotubes
Authors: Holt Brian D. , Shawky Joseph H. , Dahl Kris Noel , Davidson Lance A. , Islam Mohammad F.
Published: July 2015

Single wall carbon nanotubes are high aspect ratio nanomaterials being developed for use in materials, technological and biological applications due to their high mechanical stiffness, optical properties and chemical inertness. Because of their prevalence, it is inevitable that biological systems will be exposed to nanotubes, yet studies of the effects of nanotubes on developing embryos have been inconclusive and are lacking for single wall carbon nanotubes exposed to the widely studied model organism Xenopus laevis (African clawed frog). Microinjection of experimental substances into the Xenopus embryo is a standard technique for toxicology studies and cellular lineage tracing. Here we report the surprising finding that superficial (12.5 ± 7.5 µm below the membrane) microinjection of nanotubes dispersed with Pluronic F127 into one‐ to two‐cell Xenopus embryos resulted in the formation and expulsion of compacted, nanotube‐filled, punctate masses, at the blastula to mid‐gastrula developmental stages, which we call “boluses.” Such expulsion of microinjected materials by Xenopus embryos has not been reported before and is dramatically different from the typical distribution of the materials throughout the progeny of the microinjected cells. Previous studies of microinjections of nanomaterials such as nanodiamonds, quantum dots or spherical nanoparticles report that nanomaterials often induce toxicity and remain localized within the embryos. In contrast, our results demonstrate an active recovery pathway for embryos after exposure to Pluronic F127‐coated nanotubes, which we speculate is due to a combined effect of the membrane activity of the dispersing agent, Pluronic F127, and the large aspect ratio of nanotubes. Copyright © 2015 John Wiley & Sons, Ltd.
Atomic‐resolution dissection of the energetics and mechanism of isomerization of hydrated ATP‐Mg2+ through the SOMA string method
Authors: Branduardi Davide , Marinelli Fabrizio , Faraldo‐Gómez José D.
Published: July 2015

The atomic mechanisms of isomerization of ATP‐Mg2+ in solution are characterized using the recently developed String Method with Optimal Molecular Alignment (SOMA) and molecular‐dynamics simulations. Bias‐Exchange Metadynamics simulations are first performed to identify the primary conformers of the ATP‐Mg2+ complex and their connectivity. SOMA is then used to elucidate the minimum free‐energy path (MFEP) for each transition, in a 48‐dimensional space. Analysis of the per‐atom contributions to the global free‐energy profiles reveals that the mechanism of these transitions is controlled by the Mg2+ ion and its coordinating oxygen atoms in the triphosphate moiety, as well as by the ion‐hydration shell. Metadynamics simulations in path collective variables based on the MFEP demonstrate these isomerizations proceed across a narrow channel of configurational space, thus validating the premise underlying SOMA. This study provides a roadmap for the examination of conformational changes in biomolecules, based on complementary enhanced‐sampling techniques with different strengths. © 2015 Wiley Periodicals, Inc.
A theoretical study of imine hydrocyanation catalyzed by halogen‐bonding
Authors: Heinz Norah , Dolg Michael , Berkessel Albrecht
Published: July 2015

A detailed theoretical study of the mechanism and energetics of an organocatalysis based on CN activation by halogen‐bonding is presented for the hydrocyanation of N‐benzylidenemethylamine. The calculations at the level of scalar‐relativistic gradient‐corrected density functional theory give an insight in this catalytic concept and provide information on the characteristics of four different monodentate catalyst candidates acting as halogen‐bond donors during the reaction. © 2015 Wiley Periodicals, Inc.
The effects of listener training on discriminative control by elements of compound stimuli in children with disabilities
Authors: Ribeiro Daniela M. , Miguel Caio F. , Goyos Celso
Published: July 2015

The purpose of the current study was to assess whether the establishment of listener relations with compound stimuli as samples and comparisons would lead to the emergence of: (1) speaker behavior in the form of tacts of the compound stimuli; (2) listener and tact responses for untaught compounds; and (3) listener and tact responses for the isolated properties of compounds. Participants were four boys diagnosed with autism and one diagnosed with intellectual disability. We taught participants to select among three compound comparisons consisting of combinations of shapes and patterns in the presence of the corresponding dictated word. Subsequently, we tested for the emergence of tacts for the trained compounds, as well as tact and listener relations for six untaught compounds and their properties. In general, results showed that the acquisition of listener relations led to the emergence of the corresponding tacts, as well as the emergence of listener and tact responses for untaught combinations for three out of five participants. By contrast, the other two participants showed responding characteristic of restricted stimulus control. These results suggest that the establishment of bidirectional relations between listener and speaker behaviors may facilitate the emergence of control by properties of compound stimuli.
Hospitalist intervention for appropriate use of telemetry reduces length of stay and cost
Authors: Svec David , Ahuja Neera , Evans Kambria H. , Hom Jason , Garg Trit , Loftus Pooja , Shieh Lisa
Published: July 2015

BACKGROUND

Telemetry monitoring is a widely used, labor‐intensive, and often‐limited resource. Little is known of the effectiveness of methods to guide appropriate use.

OBJECTIVE

Our intervention for appropriate use included: (1) a hospitalist‐led, daily review of bed utilization, (2) hospitalist‐driven education module for trainees, (3) quarterly feedback of telemetry usage, and (4) financial incentives.

DESIGN/METHODS

Hospitalists were encouraged to discuss daily telemetry utilization on rounds. A module on appropriate telemetry usage was taught by hospitalists during the intervention period (January 2013–August 2013) on medicine wards. Pre‐ and post‐evaluations measured changes regarding telemetry use. We compared hospital bed–use data between the baseline period (January 2012–December 2012), intervention period, and extension period (September 2014–March 2015). During the intervention period, hospital bed–use data were sent to the hospitalist group quarterly. Financial incentives were provided after a decrease in hospitalist telemetry utilization.

SETTING

Stanford Hospital, a 444‐bed, academic medical center in Stanford, California.

RESULTS

Hospitalists saw reductions for both length of stay (LOS) (2.75 vs 2.13 days, P = 0.005) and total cost (22.5% reduction) for telemetry bed utilization in the intervention period. Nonhospitalists telemetry bed utilization remained unchanged. We saw significant improvements in trainee knowledge of the most cost‐saving action (P = 0.002) and the least cost‐saving action (P = 0.003) in the pre‐ and post‐evaluation analyses. Results were sustained in the hospitalist group, with telemetry LOS of 1.93 days in the extension period.

CONCLUSIONS

A multipronged, hospitalist‐driven intervention to improve appropriate use of telemetry reduces LOS and cost, and increases knowledge of cost‐saving actions among trainees. Journal of Hospital Medicine 2015;10:627–632. © 2015 Society of Hospital Medicine
Synthesis and application of isotopically labeled flavin nucleotides
Authors: Mishanina Tatiana V. , Kohen Amnon
Published: July 2015

Flavin nucleotides, i.e. flavin mononucleotide (FMN) and flavin adenine dinucleotide (FAD), are utilized as prosthetic groups and/or substrates by a myriad of proteins, ranging from metabolic enzymes to light receptors. Isotopically labeled flavins have served as invaluable tools in probing the structure and function of these flavoproteins. Here we present an enzymatic synthesis of several radio‐ and stable‐isotope labeled flavin nucleotides from commercially available labeled riboflavin and ATP. The synthetic procedure employs a bifunctional enzyme, Corynebacterium ammoniagenes FAD synthetase, that sequentially converts riboflavin to FMN and then to FAD. The final flavin product (FMN or FAD) is controlled by the concentration of ATP in the reaction. Utility of the synthesized labeled FAD cofactors is demonstrated in flavin‐dependent thymidylate synthase. The described synthetic approach can be easily applied to the production of flavin nucleotide analogues from riboflavin precursors.
Usefulness of non–contrast‐enhanced MRI with two‐dimensional balanced steady‐state free precession for the acquisition of the pulmonary venous and left atrial anatomy pre catheter ablation of atrial fibrillation: Comparison with contrast enhanced CT in clinical cases
Authors: Shigenaga Yutaka , Okajima Katsunori , Ikeuchi Kazushi , Kiuchi Kunihiko , Ikeda Takayuki , Shimane Akira , Yokoi Kiminobu , Teranishi Jin , Aoki Kousuke , Chimura Misato , Yamada Shinichiro , Taniguchi Yasuyo , Yasaka Yoshinori , Kawai Hiroya
Published: July 2015

Background

To investigate the feasibility of substituting non–contrast‐enhanced MR (non–CE‐MR) imaging with a two‐dimensional (2D) balanced steady‐state free precession (b‐SSFP) sequence for contrast‐enhanced computed tomography (CE‐CT) for atrial fibrillation (AF) ablation.

Methods

Fifty‐four patients that underwent AF ablation under the guidance of a 3D electro‐anatomical mapping system with CE‐CT (n = 27) or non–CE‐MR images (n = 27) were studied. Procedural results were compared between the two groups. Furthermore, in 22 patients who underwent both CE‐CT and non–CE‐MRI, two cardiologists independently scored the multiplanar reformatted images on a scale of 1 to 4 (from 1, poor, to 4, excellent).

Results

The image score was nearly 0.5 point higher with the CE‐CT method. However, the procedural results such as the surface registration error (1.0 [0.8–1.6] mm versus 1.0 [0.8–1.35] mm, P = 0.88) and procedure time (185 [159–199] min versus 185 [142–221] min, P = 0.86) did not significantly differ between the CE‐CT and non–CE‐MR groups.

Conclusion

The non–CE‐MR method with a 2D‐b‐SSFP sequence can give us adequate information on AF ablation without any radiation exposure or contrast medium usage. J. Magn. Reson. Imaging 2016;43:495–503.
Use of WKB approximation for analytical boundary conditions in numerical solution of Schrödinger equation: application to semiconductor–high‐k dielectric interfaces
Authors: Bayoumi Amr M.
Published: July 2015

Numerical methods used to solve 1D Schrödinger's equation in quantum structures, such as Numerov's integration of wavefunction or the shooting method iterative solution of energy levels, require knowledge of two‐point boundary conditions at interfaces. This is especially true when the interfaces are not symmetrical or where exponential decay of wavefunction at asymptotically large distances does not hold. A closed‐form expression for boundary conditions, which is not sensitive to intermediate solutions at interfaces, can minimize possible divergence during iterations and relax simulation grid size and simulation time. In this work, the Wentzel‐Kramers‐Brillouin (WKB) approximation within potential barriers is proposed to analytically calculate the boundary conditions for abrupt interfaces, such as dielectric–semiconductor interface. An analytical expression for the slope at the interface is derived, and the errors are estimated with respect to numerical methods. An application is shown for self‐consistent solution of coupled Poisson–Schrödinger's equations at multi‐layer HfO2‐SiO2 dielectric gate stack corresponding to International Technology Roadmap for Semiconductors‐projected 10 nm bulk single‐gate Complementary Metal‐Oxide‐Semiconductor (CMOS) technology node, where wavefunction penetration into the dielectric is of critical importance. Application to dual gate structures with 5 nm fin width and high‐k dielectric with 0.5 nm equivalent oxide thickness is also shown. A quantum mechanical simulator ‘hksim’ based on this principle is posted for public domain usage. Copyright © 2015 John Wiley & Sons, Ltd.
Social processes and team creativity in multicultural teams: A socio‐technical framework
Authors: Leung Kwok , Wang Jie
Published: July 2015

Cultural diversity is widely believed to broaden the knowledge and perspectives in a team and hence benefit team creativity. However, cultural diversity can at the same time suppress team creativity through the negative social processes it engenders, and this negative mechanism has received little theoretical attention. We present a theoretical analysis to explicate how cultural diversity creates cultural identity and intercultural obstacles, which hinder knowledge sharing and integration among team members and hence team creativity. Drawing on the socio‐technical systems perspective, we identify two types of contextual variables that moderate the negative, mediated impact of cultural diversity on team creativity: information and communication technology and task environment in terms of task characteristics. We provide an analysis of how each type of variables moderates the negative impact of cultural diversity on social processes and the impact of social processes on knowledge sharing and integration. Several future research directions based on the socio‐technical systems perspective are discussed. Copyright © 2015 John Wiley & Sons, Ltd.
Preparation of “dummy” l‐phenylalanine molecularly imprinted microspheres by using ionic liquid as a template and functional monomer
Authors: Li Ji , Hu Xiaoling , Guan Ping , Song Dongmen , Qian Liwei , Du Chunbao , Song Renyuan , Wang Chaoli
Published: July 2015

In this study, dummy imprinting technology was employed for the preparation of l‐phenylalanine‐imprinted microspheres. Ionic liquids were utilized as both a “dummy” template and functional monomer, and 4‐vinylpyridine and ethylene glycol dimethacrylate were used as the assistant monomer and cross‐linker, respectively, for preparing a surface‐imprinted polymer on poly(divinylbenzene) microspheres. By the results obtained by theoretical investigation, the interaction between the template and monomer complex was improved as compared with that between the template and the traditional l‐phenylalanine‐imprinted polymer. The batch experiments indicated that the imprinting factor reached 2.5. Scatchard analysis demonstrated that the obtained “dummy” molecularly imprinted microspheres exhibited an affinity of 77.4 M·10−4, significantly higher that of a traditional polymer directly prepared by l‐phenylalanine, which is in agreement with theoretical results. Competitive adsorption experiments also showed that the molecularly imprinted polymer with the dummy template effectively isolated l‐phenylalanine from l‐histidine and l‐tryptophan with separation factors of 5.68 and 2.68, respectively. All these results demonstrated that the polymerizable ionic liquid as the dummy template could enhance the affinity and selectivity of molecularly imprinted polymer, thereby promoting the development of imprinting technology for biomolecules.
Enantioseparation tuned by solvent polarity on a β‐cyclodextrin clicked chiral stationary phase
Authors: Tang Jian , Pang Limin , Zhou Jie , Tang Weihua
Published: July 2015

The efficient enantioseparation of 26 racemates has been achieved with the perphenylcarbamoylated cyclodextrin clicked chiral stationary phase by screening the optimum composition of mobile phase in high‐performance liquid chromatography. The chromatographic results indicate that both the retention and chiral resolution of racemates are closely related to the polarity of the mobile phases and the structures of analytes. The addition of alcohols can significantly tune the enantioseparation in normal‐phase high‐performance liquid chromatography. The addition of methanol and the ratio of ethanol/methanol or isopropanol/methanol played a key role on the resolution of flavonoids in ternary eluent systems. The chiral separation of flavonoids with pure organic solvent as mobile phase indicates the preferential order for chiral resolution is methanol>ethanol>isopropanol>n‐propanol>acetonitrile.
Epstein‐Barr virus in the enlarged salivary tissues of patients with IgG4‐related disease
Authors: Furukawa Takatoshi , Shimotai Yoshitaka , Ohta Nobuo , Ishida Akihiro , Kurakami Kazuya , Suzuki Hitoshi , Yamakawa Mitsunori , Hongo Seiji , Kakehata Seiji
Published: July 2015

Objective

Immunoglobulin G4‐related disease (IgG4‐RD) is a recently recognized disease entity characterized by high‐serum IgG4 concentration and IgG4‐producing plasma cell production with fibrotic or sclerotic changes in affected organs. We aimed to clarify the roles of Epstein‐Barr virus (EBV) in patients with IgG4‐RDs.

Study Design and Setting

A retrospective clinical study at the Yamagata University School of Medicine, Yamagata, Japan.

Methods

The patient group consisted of four males and four females with an average age of 62 years (range: 48–73). Expression of IgG4, latent member protein 1, EBV nuclear antigens‐2, and EBV‐encoded RNA in affected salivary glands from patients with IgG4‐RD was examined by using immunohistochemistry and in situ hybridization. The copy number of EBV DNA in the salivary glands was also investigated by real‐time polymerase chain reaction.

Results

All patients had hard masses in the salivary or lacrimal glands, or both, bilaterally. Serum concentrations of IgG4 were elevated in all cases (mean 589.1, range 129–1750), and IgG4‐positive plasmacytes were observed in the involved salivary glands. Four patients developed potentially life‐threatening systemic involvement after initial salivary gland swelling. EBV‐associated molecules (EBNA and EBER) were overexpressed in the affected salivary glands. The copy number of EBV DNA was significantly higher in patients with potentially life‐threatening systemic involvement than in patients without systemic involvement (P < 0.05).

Conclusion

These results suggest that the copy number of EBV DNA could be useful as diagnostic findings in IgG4‐RD to predict potentially life‐threatening systemic involvement.

Level of Evidence

4. Laryngoscope, 125:2079–2084, 2015
Sedation after airway reconstruction in children: A protocol to reduce withdrawal and length of stay
Authors: Fauman Karen R. , Durgham Rashed , Duran Carlos I. , Vecchiotti Mark A. , Scott Andrew R.
Published: July 2015

Level of Evidence

Laryngoscope, 125:2216–2219, 2015
Outcomes for multilevel surgery for sleep apnea: Obstructive sleep apnea, transoral robotic surgery, and uvulopalatopharyngoplasty
Authors: Thaler Erica R. , Rassekh Christopher H. , Lee Jonathan M. , Weinstein Gregory S. , O'Malley Bert W.
Published: July 2015

Objectives/Hypothesis

This study evaluates the outcomes of multilevel surgery for patients with obstructive sleep apnea (OSA) who underwent transoral robotic surgery (TORS) (i.e., posterior glossectomy and limited lateral pharyngectomy) with uvulopalatopharyngoplasty (UPPP).

Study Design

Prospective, nonrandomized trial with historical controls.

Methods

All patients underwent pre‐ and postoperative polysomnography, preoperative magnetic resonance imaging of the neck, preoperative drug‐induced sleep endoscopy, surgery, including UPPP if this had not occurred previously, and OSA TORS. Outcomes measures included apnea‐hypopnea index (AHI), Epworth Sleepiness Scale (ESS), O2 saturation nadir, and total sleep time spent at <90% O2 saturation.

Results

Patients who had no prior surgery achieved an average AHI reduction from 58.4 to 19.5 (67%, P < .0001), a surgical success rate of 56%, and a surgical response rate of 73%. Patients with prior pharyngeal surgery achieved an AHI reduction from 55.0 to 45 (24%, P = .19), a surgical success rate of 30%, and a surgical response rate of 40%. Total sleep time spent at <90% O2 saturation was improved from 14% to 3.6% (P < .0003) for patients without prior surgery, and 21.1% to 12.5% (P < .17)for those with prior surgery. ESS improved for all patients combined from 12.8 to 5.8 (P < .0001).

Conclusions

Outcomes for the combined approach of OSA TORS and UPPP provide strong evidence in favor of this multilevel approach for the surgical management of OSA. The benefit of the current surgical approach is most significant for previously unoperated patients.

Level of Evidence

4. Laryngoscope, 126:266–269, 2016
The double‐barreled radial forearm osteocutaneous free flap
Authors: Gonzalez‐Castro Javier , Petrisor Daniel , Ballard Daniel , Wax Mark K.
Published: July 2015

Objectives/Hypothesis

The radial forearm osteocutaneous free flap (RFOCFF) provides a thin pliable skin paddle with up to 11 cm of bone. A limitation of this flap is the thin bone that is obtained and the lack of suitability for dental implants. A minimum depth of 5 mm and height of 10 mm is required for a bony flap to accept osteointegrated implants. We propose that by double barreling the radial bone, it is possible to reconstruct osseous defects with bone of sufficient caliber to accept dental implants.

Study Design

Retrospective review of our experience with double‐barreled RFOCFF.

Methods

We reviewed all free flaps performed from July 2000 to September 2014 and analyzed patients in whom a radial forearm osteocutaneous flap was used. We then reviewed those who had an osteotomy to form a double‐barrel reconstruction. Descriptive data and outcomes were tabulated.

Results

A total of 458 osteocutaneous free flaps were performed; 75 were RFOCFF and 18 of these were double barreled. All 18 flaps survived. The reconstructed defect size was between 2.6 and 6.8 cm. One patient had dental implants placed at time of surgery that successfully osteointegrated. Postoperative computed tomography scans were available in nine patients and were used to calculate bone dimensions. Bone depth ranged from 7.91 to 13.22 mm, with a mean of 9.77 ± 1.53 mm. Bone height ranged from 8.42 to 17.81 mm, with a mean of 13.82 ± 3.2 mm.

Conclusions

The double‐barreled RFOCFF provides dependable long‐lasting bone with adequate bone dimensions to support osteointegrated dental implants.

Level of Evidence

4 Laryngoscope, 126:340–344, 2016
Voice outcomes following reoperative central neck dissection for recurrent/persistent thyroid cancer
Authors: Starmer Heather , Noureldine Salem I. , Ozgursoy Ozan B. , Tufano Ralph P.
Published: July 2015

Objectives/Hypothesis

We aimed to assess voice outcomes following reoperative central neck dissection (RCND) to characterize postoperative voice difficulties experienced, determine the natural progression of vocal recovery, and identify risk factors for the development of voice disorders postoperatively.

Study Design

Prospective cohort study.

Methods

Consecutive patients with recurrent/persistent thyroid cancer who were deemed appropriate candidates for RCND were eligible for participation in this study. A battery of voice evaluation measures was administered both preoperatively and 2 to 4 weeks postoperatively.

Results

Twenty consecutive patients were included. Postoperatively, six (30%) new incidents of vocal fold motion impairment (VFMI) were identified, with two (10%) being due to intentional recurrent laryngeal nerve (RLN) transection. On 1‐year follow‐up, two patients had full restoration of vocal fold mobility and four had persistent VFMI. No preoperative voice/laryngeal exam factors were predictive of postoperative VFMI. Clinically relevant change in postoperative Voice Handicap Index score was absent in all patients without VFMI and present in five of six patients with VFMI (P = .0004). Patients with VFMI had significantly poorer overall dysphonia grade, less glottic closure, and elevated jitter in contrast to those individuals without VFMI. Patients with malignant tissue in the remnant thyroid were four times more likely to develop VFMI than those with central neck lymph node metastases alone (P = .06).

Conclusion

Patients undergoing RCND are at risk for postoperative VFMI, even when the RLN is anatomically preserved, with subsequent impact on quality of life. Presence of malignant disease in the remnant thyroid appears to be the best predictor for postoperative VFMI.

Level of Evidence

2b. Laryngoscope, 125:2621–2625, 2015
Effect of injection augmentation on need for framework surgery in unilateral vocal fold paralysis
Authors: Francis David O. , Williamson Kelly , Hovis Kristen , Gelbard Alexander , Merati Albert L. , Penson David F. , Netterville James L. , Garrett C. Gaelyn
Published: July 2015

Objectives/Hypothesis

To determine whether injection augmentation reduces the likelihood of ultimately needing definitive framework surgery in unilateral vocal fold paralysis (UVFP) patients.

Study Design: Retrospective cohort study.

Methods

All patients diagnosed with UVFP (2008–2012) at the academic center were identified. The time from symptom onset to presentation to either community otolaryngologist and/or academic center, as well as any directed treatment(s), were recorded. Stepwise, multivariate logistic regression analysis was used to determine whether injection augmentation independently affected odds of needing definitive, framework surgery among patients who were seen within 9 months of symptom onset and had not undergone any prior rehabilitative procedures.

Results

Cohort consisted of 633 patients (55% female, 80% Caucasian, median age 60 years) with UVFP. The majority of etiologies were either surgery (48%) or idiopathic (37%). Duration to presentation at community otolaryngologist was shorter than to the academic center (median 2 vs. 6 months). Overall, less than half of UVFP patients had any operation (46%). Multivariate logistic regression found that earlier injection augmentation did not affect odds of ultimately undergoing framework surgery (odds ratio 1.13; confidence interval, 0.92–1.40; P = 0.23).

Conclusion

Nearly half of UVFP patients do not require any rehabilitative procedure. When indicated, early injection augmentation is effective at temporarily alleviating associated symptoms but does not reduce likelihood of needing a definitive framework operation in patients with UVFP. Understanding practice patterns and fostering early detection and treatment may improve quality of life in this patient population.

Level of Evidence

4. Laryngoscope, 126:128–134, 2016
Nasolabial cysts: A systematic review of 311 cases
Authors: Sheikh Ahmed B. , Chin Oliver Y. , Fang Christina H. , Liu James K. , Baredes Soly , Eloy Jean Anderson
Published: July 2015

Objectives/Hypothesis

Nasolabial cysts are rare nonodontogenic cysts arising commonly in the nasal alar region. Intraoral sublabial resection of nasolabial cysts is considered the standard treatment modality. In the past 16 years, transnasal endoscopic marsupialization has emerged as an alternative approach for these lesions. A systematic review on this entity was performed to evaluate management and outcomes.

Data Sources

PubMed/MEDLINE Database.

Methods

A search of literature including nasolabial cysts, nasoalveolar cysts, and Klestadt's cysts was performed using the PubMed/MEDLINE database. Parameters regarding presentation, treatment, imaging, histology, and complications were extracted and subsequently analyzed.

Results

Seventy‐nine articles with 311 patient cases were included in this analysis. In cases reporting location, nasolabial cysts occurred 46.9%, 37.5%, and 10.9% on the left, right, and bilaterally, respectively. The most common presenting complaint was facial swelling in 168 out of 237 patients (70.9%). Computed tomography was the most commonly employed imaging study (n = 170). Surgical excision of nasolabial cysts was performed using an intraoral sublabial approach in 184 patients. Seventy‐nine patients underwent endoscopic transnasal marsupialization. The most common complication following surgical treatment of nasolabial cysts was postoperative facial/perinasal swelling. Three and two recurrences were reported in the sublabial excision group and transnasal marsupialization group, respectively. Mean follow‐up time was 20.0 months.

Conclusions

Endoscopic transnasal marsupialization is a relatively new alternative to intraoral sublabial resection of nasolabial cysts, with similar efficacy. The rates of postoperative swelling, pain, and recurrence are similar in both groups. Laryngoscope, 126:60–66, 2016
Improving skills development in residency using a deliberate‐practice and learner‐centered model
Authors: Bhatti Nasir I. , Ahmed Aadil
Published: July 2015

Objectives/Hypothesis

Work‐hour restrictions, increased workload, and subjective assessment of competency are major threats to the efficacy of the traditional apprenticeship model of surgical training in modern surgical practice. In response, medical educators are developing time‐ and resource‐efficient competency‐based models of surgical training. The purpose of our project was to develop, implement, and measure the outcomes of such objective and structured programs in otolaryngology. We also investigated factors affecting the learning curve, especially deliberate practice, formative feedback, and learners' autonomy.

Study Design

Prospective, longitudinal study.

Methods

To measure the surgical skills of residents, we first developed and tested objective tools for otolaryngology procedures. Based on these instruments, we identified milestones of the procedures. Training on a virtual‐reality simulator was validated to shorten the learning curve. We also studied a learner‐centered approach of training, factors affecting the learning curve, and barriers to a competency‐based model.

Results

The objective tools were found to be a feasible, reliable, and valid opportunity for measuring competency in both the laboratory and operating room. With the formative assessment from these tools, residents had a remediation target to be achieved by deliberate practice. The milestones helped identify the threshold of competency, and deliberate practice on the simulator gave an opportunity for improving skills. The learner‐centered approach allowed flexibility and personalized learning by shifting the responsibility of the learning process to the learners.

Conclusion

The competency‐based model of residency, based on the principles of deliberate practice and a learner‐centered approach, is a feasible model of residency training that allows development of competent surgeons and hence improves patient outcomes. Despite these advantages, challenges to this model require a concerted effort to overcome and fully implement these principles of training beyond just technical skills, ultimately creating well‐rounded medical professionals and leaders in the surgical field.

Level of Evidence

N/A. Laryngoscope, 125:S1–S14, 2015
The role of radiation therapy in the management of sialorrhea: A systematic review
Authors: Hawkey Nathan M. , Zaorsky Nicholas G. , Galloway Thomas J.
Published: July 2015

Purpose

Up to 80% of patients with Parkinson disease and 30% of patients with amyotrophic lateral sclerosis (ALS) suffer from sialorrhea. Patients who fail medical and surgical therapy should be considered for external beam radiation therapy (EBRT). In this study, we conduct a systematic review to determine the dose and techniques used that result in greatest efficacy and lowest toxicity for the administration of EBRT in patients with Parkinson disease or ALS‐associated sialorrhea.

Methods and Materials

This review included 216 patients from four prospective and six retrospective studies published from 1998 to 2014, with ALS or Parkinson disease who were treated with electron or photon EBRT for sialorrhea.

Results

A total of 216 patients were treated with EBRT from 10 studies. The indication for EBRT was failure of alternative medical treatment in all ALS patients. For patients with Parkinson disease, EBRT was the primary mode of treatment in 68% of cases. Overall, 176 (81%) of 216 patients treated with EBRT for sialorrhea reported symptomatic improvement from baseline. The most common target was the inferior two‐thirds of the bilateral parotid glands and the entire bilateral submandibular glands. The total number of patients who experienced short‐term toxicity was 86 of 216 patients (40%). The total number of patients who experienced long‐term toxicity was 24 of 207 (12%).

Conclusions

EBRT is an effective treatment for sialorrhea in patients suffering from ALS or Parkinson disease. Treatment to the bilateral submandibular glands and caudal parotid glands is the most common field arrangement.

Level of Evidence

NA Laryngoscope, 126:80–85, 2016
Seasonal affective disorder in patients with chronic tinnitus
Authors: Kim Young H.
Published: July 2015

Objectives/Hypothesis

To investigate the point prevalence of SAD, degrees of anxiety/depression/sleep disturbance, and characteristics of tinnitus in patients with chronic tinnitus.

Study Design

Cross‐sectional survey study.

Methods

From December 2012 to February 2014, 100 patients with chronic persistent or intermittent tinnitus (>3 months) were enrolled. Audiograms, tinnitograms, and Visual Analogue Scales (VAS) were used to assess tinnitus. Tinnitus Handicap Inventory (THI) assessment and questionnaires about anxiety/depression/sleep disturbance/SAD were administered.

Results

The male:female ratio was 48:52, and the mean age was 55.0 years. The numbers of patients with suspected SAD and subsyndromal SAD (S‐SAD) were nine (9.0%) and 11 (11.0%), respectively. Winter was the most uncomfortable season. Nine patients had a catastrophic THI score >76 (11.1% in the SAD group, 27.3% in the S‐SAD group, and 6.3% in the control group), suggesting a significant correlation between SAD/S‐SAD and THI (P = .042). Audiogram, tinnitogram, VAS assessment, and sleep disturbance testing revealed no significant differences among the three groups. Anxiety tests yielded more abnormal findings in the SAD group than in the control group (State Anxiety Inventory score: 33.3% vs. 3.3%, respectively, P = .012; Trait Anxiety Inventory score: 22.2% vs. 1.3%, respectively, P = .002). Depression test scores were significantly higher in the SAD/S‐SAD groups than in the control group (35.0% vs. 21.3%, respectively; P = .005).

Conclusions

Suspected SAD and/or S‐SAD in chronic tinnitus patients were correlated with THI, anxiety, and depression. Understanding SAD in tinnitus patients may be important to manage these patients effectively.

Level of Evidence

4 Laryngoscope, 126:447–451, 2016
Cognitive load in distributed and massed practice in virtual reality mastoidectomy simulation
Authors: Andersen Steven Arild Wuyts , Mikkelsen Peter Trier , Konge Lars , Cayé‐Thomasen Per , Sørensen Mads Sølvsten
Published: July 2015

Objectives/Hypothesis

Cognitive load theory states that working memory is limited. This has implications for learning and suggests that reducing cognitive load (CL) could promote learning and skills acquisition. This study aims to explore the effect of repeated practice and simulator‐integrated tutoring on CL in virtual reality (VR) mastoidectomy simulation.

Study Design

Prospective trial.

Methods

Forty novice medical students performed 12 repeated virtual mastoidectomy procedures in the Visible Ear Simulator: 21 completed distributed practice with practice blocks spaced in time and 19 participants completed massed practice (all practices performed in 1 day). Participants were randomized for tutoring with the simulator‐integrated tutor function. Cognitive load was estimated by measuring reaction time in a secondary task. Data were analyzed using linear mixed models for repeated measurements.

Results

The mean reaction time increased by 37% during the procedure compared with baseline, demonstrating that the procedure placed substantial cognitive demands. Repeated practice significantly lowered CL in the distributed practice group but not in massed practice group. In addition, CL was found to be further increased by 10.3% in the later and more complex stages of the procedure. The simulator‐integrated tutor function did not have an impact on CL.

Conclusion

Distributed practice decreased CL in repeated VR mastoidectomy training more consistently than was seen in massed practice. This suggests a possible effect of skills and memory consolidation occurring over time. To optimize technical skills learning, training should be organized as time‐distributed practice rather than as a massed block of practice, which is common in skills‐training courses.

Level of Evidence

N/A. Laryngoscope, 126:E74–E79, 2016
United States multicenter clinical trial of the cochlear nucleus hybrid implant system
Authors: Roland J. Thomas , Gantz Bruce J. , Waltzman Susan B. , Parkinson Aaron J. ,   The Multicenter Clinical Trial Group
Published: July 2015

Objectives/Hypothesis

To evaluate the safety and efficacy of acoustic and electric sound processing for individuals with significant residual low‐frequency hearing and severe‐to‐profound high‐frequency sensorineural hearing loss.

Study Design

Prospective, single‐arm repeated measures, single‐subject design.

Methods

Fifty individuals, ≥ 18 years old, with low‐frequency hearing and severe high‐frequency loss were implanted with the Cochlear Nucleus Hybrid L24 implant at 10 investigational sites. Preoperatively, subjects demonstrated consonant‐nucleus‐consonant word scores of 10% through 60% in the ear to be implanted. Subjects were assessed prospectively, preoperatively, and postoperatively on coprimary endpoints of consonant‐nucleus‐consonant words, AzBio sentences in noise, and self‐assessment measures.

Results

Significant mean improvements were observed for coprimary endpoints: consonant‐nucleus‐consonant words (35.8 percentage points) and AzBio sentences in noise (32.0 percentage points), both at P < 0.001. Ninety‐six percent of subjects performed equal or better on speech in quiet and 90% in noise. Eighty‐two percent of subjects showed improved performance on speech in quiet and 74% in noise. Self‐assessments were positive, corroborating speech perception results.

Conclusion

The Nucleus Hybrid System provides significant improvements in speech intelligibility in quiet and noise for individuals with severe high‐frequency loss and some low‐frequency hearing. This device expands indications to hearing‐impaired individuals who perform poorly with amplification due to bilateral high‐frequency hearing loss and who previously were not implant candidates.

Level of Evidence

2b. Laryngoscope, 126:175–181, 2016
Factors important in laryngology fellow and laryngology fellowship selection
Authors: Yung Katherine C. , Courey Mark S.
Published: July 2015

Objectives/Hypothesis

To determine factors that laryngology fellowship directors believe are most important in choosing a fellow and that laryngology applicants believe are most important in choosing a program.

The number of laryngology fellowship programs and the number of laryngology fellowship applicants have been increasing in recent years. Selection criteria in choosing a fellow or fellowship program have not been studied.

Methods

Survey study using anonymous online questionnaires of laryngology fellowship directors and recent laryngology fellowship applicants. Directors were asked to rate qualities for judging the strength of a fellowship applicant. Applicants were assessed for the importance of various factors in choosing a fellowship.

Results

Sixteen of 27 fellowship directors (59%) and 33 of 53 fellowship applicants (62%) contacted responded to the survey. Program directors listed interview performance, letters of recommendation, and personal knowledge of applicant as the most important factors. Gender or ethnicity, previous research in laryngology, and likelihood that the applicant will rank the director's program highly were ranked as least important factors. Applicants ranked personal rapport with fellowship mentor(s), large experience in endoscopic surgeries, and reputation of mentor(s) as most important, whereas call schedule, salary, and having more than one fellow per year were ranked as least important factors.

Conclusion

Interview performance, trusted colleague's recommendation, and personal knowledge were ranked as the most important factors in fellow selection. These criteria are consistent with previous research on otolaryngology residency and pediatric otolaryngology fellow selection. When selecting a fellowship, laryngology fellowship applicants choose based on personal rapport with mentor, opportunity to learn endoscopic surgeries, and mentor reputation.

Level of Evidence

N/A. Laryngoscope, 125:2543–2546, 2015
Endoscopic cochlear implantation: Call for caution
Authors: Tarabichi Muaaz , Nazhat Omar , Kassouma Jamal , Najmi Murtaza
Published: July 2015

Objectives/Hypothesis

To assess whether transcanal endoscopic access to the basal turn of the cochlea for cochlear implantation is appropriate.

Study Design

Case series study.

Methods

We reviewed 100 consecutive computed tomographic studies of the sinuses and temporal bone in our institution. We excluded studies that demonstrated evidence of congenital anomalies, chronic ear disease, or inadequate visualization of the cochlea. On axial sections, the angles of the basal turn of the cochlea and of the ear canal in reference to the sagittal plane were recorded as a function of age.

Results

Eighty‐four studies were included and 16 were excluded. There was significant variability in the relationship between the ear canal and the basal turn of the cochlea in reference to the sagittal plane. A clear majority of images demonstrated the basal turn of the cochlea to align with a more posterior angle than that of the ear canal.

Conclusion

The trajectory provided by posterior tympanotomy aligns more favorably with the basal turn of the cochlea than transcanal access. Endoscopic technique, primarily an ear canal intervention, may not be useful in cochlear implant surgery.

Level of Evidence

4. Laryngoscope, 126:689–692, 2016