bluuebunny/crossref_metadata_2025 huggingface dataset:
Evaluation of hospital glycemic control at US Academic Medical Centers
Authors: Boord Jeffrey B. , Greevy Robert A. , Braithwaite Susan S. , Arnold Pamela C. , Selig Patricia M. , Brake Helga , Cuny Joanne , Baldwin David
Published: January 2009

OBJECTIVE:

To evaluate contemporary hospital glycemic management in US academic medical centers.

DESIGN:

This retrospective cohort study was conducted on patients discharged from 37 academic medical centers between July 1 and September 30, 2004; 1,718 eligible adult patients met at least 1 of the inclusion criteria: 2 consecutive blood glucose readings >180 mg/dL within 24 hours, or insulin treatment at any time during hospitalization. We assessed 3 consecutive measurement days of glucose values, glycemic therapy, and additional clinical and laboratory characteristics.

RESULTS:

In this diverse cohort, 79% of patients had a prior diagnosis of diabetes, and 84.6% received insulin on the second measurement day. There was wide variation in hospital performance of recommended hospital diabetes care measures such as glycosylated hemoglobin (A1C) assessment (range, 3%–63%) and timely admission laboratory glucose measurement (range, 39%–97%). Median glucose was significantly lower for patients in the intensive care unit (ICU) compared to ward/intermediate care. ICU patients treated with intravenous insulin had significantly lower median glucose when compared to subcutaneous insulin. Only 25% of ICU patients on day 3 had estimated 6 AM glucose ≤110 mg/dL. Hyperglycemia was common, 50% of all patients had ≥1 glucose measurement ≥180 mg/dL on measurement days 2 and 3. Severe hypoglycemia (<50 mg/dL) occurred in 2.8% of all patient days.

CONCLUSIONS:

Despite frequent insulin use, glucose control was suboptimal. Academic medical centers have opportunities to improve care to meet current American Diabetes Association hospital diabetes care standards. Journal of Hospital Medicine 2009;4:35–44. © 2009 Society of Hospital Medicine.
Improved inpatient use of basal insulin, reduced hypoglycemia, and improved glycemic control: Effect of structured subcutaneous insulin orders and an insulin management algorithm
Authors: Maynard Greg , Lee Joshua , Phillips Gerard , Fink Ed , Renvall Marian
Published: January 2009

BACKGROUND:

Structured subcutaneous insulin order sets and insulin protocols are widely advocated. The intervention effects are not well reported.

OBJECTIVE:

Assess the impact of these interventions on insulin use patterns, hypoglycemia, and glycemic control.

DESIGN:

Prospective observational.

SETTING:

400‐bed academic center.

PATIENTS:

Adult non‐critical care inpatients with diabetes or hyperglycemia and point‐of‐care (POC) glucose testing.

INTERVENTIONS:

Structured insulin orders, insulin management algorithm.

MEASUREMENTS:

Percent of insulin orders with basal insulin. Percent uncontrolled patient‐stays (day‐weighted mean glucose ≥180 mg/dL) and uncontrolled patient‐days (patient‐day mean glucose ≥180 mg/dL). Percent of monitored patient‐days and patient‐stays with hypoglycemia (glucose ≤60 mg/dL) and severe hypoglycemia (glucose ≤40 mg/dL).

RESULTS:

The percent sliding scale only insulin regimens decreased (72% versus 26% with structured insulin orders, P < 0.0001 chi square). The percent of uncontrolled patient‐days was 37.8% versus 33.9% versus 30.1% (P < 0.005) (TP1–Baseline; TP2–Structured insulin orders; TP3–Orders plus Algorithm). Expressed as relative risk with 95% confidence interval (RR with CI), the RR of an uncontrolled patient‐stay was reduced from baseline to 0.91 (CI 0.85–0.96) in TP2, and to 0.84 (CI 0.77–0.89) in TP3, with more marked effects in the secondary analysis limited to patients with at least 8 POC values. The percent of patient‐days with hypoglycemia was 3.8%, 2.9%, and 2.6% in 3 time periods, representing a RR for hypoglycemic day in TP3:TP1 of 0.68 (CI 0.59‐0.78). Similar reductions were seen in risk for hypoglycemic patient‐stays.

CONCLUSIONS:

Hypoglycemia and glycemic control can be improved simultaneously with structured insulin orders and management algorithms. Journal of Hospital Medicine 2009;4:3–15. © 2009 Society of Hospital Medicine.
Evaluation of glycemic control following discontinuation of an intensive insulin protocol
Authors: Czosnowski Quinn A. , Swanson Joseph M. , Lobo Bob L. , Broyles Joyce E. , Deaton Paul R. , Finch Christopher K.
Published: January 2009

BACKGROUND:

Intensive insulin protocols (IIPs) have been demonstrated to reduce morbidity and mortality in critically ill patients. Currently, there are no published studies evaluating glycemic control after discontinuation of an IIP.

OBJECTIVE:

The purpose of this study was to compare blood glucose (BG) control during an IIP and for 5 days following its discontinuation (follow‐up period).

METHODS:

The study was a retrospective review of intensive care unit patients who received an IIP for ≥24 hours. Data were collected during the last 12 hours of the IIP and subsequent follow‐up period.

RESULTS:

For all 65 included patients, the mean ± standard deviation for BG on the IIP was 123 ± 26 mg/dL versus 168 ± 50 mg/dL following discontinuation of the IIP (P < 0.001). The median (interquartile range) insulin that was administered decreased from 40 (22–65) units on the IIP to 8 (0–18) units after the IIP was stopped (P < 0.001). The mean daily BG during the follow‐up period was significantly higher than that during the IIP (P < 0.001). Additionally, an insulin requirement of >20 units during the last 12 hours of the IIP was identified as a risk factor for poor glycemic control during the follow‐up period (odds ratio: 4.62; 95% confidence interval: 1.17–18.17).

CONCLUSIONS:

This study demonstrates a significant increase in BG following discontinuation of an IIP. Higher insulin requirements during the last 12 hours of an IIP were identified as an independent risk factor for poor glycemic control following the IIP. A standardized insulin transition protocol may help better control BG after discontinuation of an IIP. Journal of Hospital Medicine 2009;4:28–34. © 2009 Society of Hospital Medicine.
Sleep in hospitalized medical patients, Part 2: Behavioral and pharmacological management of sleep disturbances
Authors: Young Julie S. , Bourgeois James A. , Hilty Donald M. , Hardin Kimberly A.
Published: January 2009

BACKGROUND:

As described in Part 1 of this article, multiple factors lead to disrupted sleep in hospitalized medical patients. Recognizing and addressing these factors can help clinicians more effectively manage patients' sleep complaints.

METHODS:

A PubMed search was conducted by cross‐referencing the terms “sleep deprivation,” “insomnia,” and “sleep”; “hospitalized,” “acutely ill,” and “critically ill”; and “medication,” “drugs,” “hypnotics,” “benzodiazepines,” and “sedatives.” The search was limited to English‐language articles published between 1997 and 2008. Subsequent PubMed searches were performed to clarify the data described in the initial search.

RESULTS:

Few articles addressed the topic of the assessment and management of sleep problems in hospitalized medical patients. In Part 2, we propose an evaluation and treatment algorithm that includes recommendations regarding the use of nonpharmacologic and pharmacologic therapies as clinicians consider relevant clinical data. The algorithm is accompanied by 5 tables that include pertinent and practical information to assist clinicians as they manage their inpatients' sleep complaints.

CONCLUSIONS:

Assessment of a sleep complaint should include a review of factors that could exacerbate patients' sleep. The treatment could then focus on ameliorating these factors, and the judicious use of nonpharmacologic strategies and psychopharmacologic agents. Journal of Hospital Medicine 2009;4:50–59. © 2009 Society of Hospital Medicine.
Limited communication and management of emergency department hyperglycemia in hospitalized patients
Authors: Ginde Adit A. , Savaser Davut J. , Camargo Carlos A.
Published: January 2009

BACKGROUND:

Hyperglycemia is often overlooked and unaddressed in hospitalized patients, and early and intensive management may improve outcomes.

OBJECTIVE:

To evaluate communication and early management of emergency department (ED) hyperglycemia.

METHODS:

This was a retrospective cohort study of patients with an initial serum glucose ≥140 mg/dL at an urban, academic institution. We randomly selected cases from a consecutive sample of ED visits with at least 1 serum glucose result during a 1‐year period. We recorded clinical data and compared the content of inpatient and ED‐written discharge instructions.

RESULTS:

Of the 27,688 initial ED glucose results during the study period, 3517 (13%) were 140‐199 mg/dL, and 2304 (8%) values were ≥200 mg/dL. In our sample of 385 patients, 293 (76%) patients were hospitalized. Inpatient or ED discharge instructions informed 36 (10%) patients of their hyperglycemia and 23 (6%) of a plan for further evaluation and management. There was no difference between inpatient and ED instructions for either of these variables (P = 0.73 and 0.16, respectively). Overall, 107 (55%) patients with glucose values 140‐199 mg/dL and 31 (16%) patients with glucose ≥200 mg/dL had no prior diabetes diagnosis. Only 61 (16%) received insulin in the ED for their hyperglycemia, and hyperglycemia was charted as a diagnosis in 36 (9%) cases.

CONCLUSIONS:

Most ED patients with even mild hyperglycemia were hospitalized. Recognition, communication, and management of ED hyperglycemia were suboptimal and represent a missed opportunity to identify undiagnosed diabetes and to initiate early glycemic control for hospitalized patients. Journal of Hospital Medicine 2009;4:45–49. © 2009 Society of Hospital Medicine.
Modeling the interaction between the N‐terminal domain of the tumor suppressor p53 and azurin
Authors: Taranta Monia , Bizzarri Anna Rita , Cannistraro Salvatore
Published: January 2009

It is known that the half life of the tumor suppressor p53 can be increased by the interaction with the bacterial protein azurin, resulting in an enhanced anti‐tumoral activity. The understanding of the molecular mechanisms on the basis of this phenomenon can open the way to new anti‐cancer strategies. Some experimental works have given evidence of an interaction between p53 and azurin (AZ); however the binding regions of the proteins are still unknown. Recently, fluorescence studies have shown that p53 partakes in the binding with the bacterial protein by its N‐terminal (NT) domain. Here we have used a computational method to get insight into this interacting mode. The model that we propose for the best complex between AZ and p53 has been obtained from a rigid‐body docking, coupled with a molecular dynamics (MD) simulation, a free energy calculation, and validated by mutagenesis analysis. We have found a high degree of geometric fit between the two proteins that are kept together by several hydrophobic interactions and numerous hydrogen bonds. Interestingly, it has emerged that AZ binds essentially to the helices HI and HIII of the p53 NT domain, which are also interacting regions for the foremost inhibitor of p53, MDM2. Copyright © 2009 John Wiley & Sons, Ltd.
Olfactory ensheathing glia and Schwann cells exhibit a distinct interaction behavior with meningeal cells
Authors: Franssen Elske H. P. , Roet Kasper C. D. , de Bree Freddy M. , Verhaagen Joost
Published: January 2009

Schwann cells (SCs) and olfactory ensheathing glia (OEG) have both been used as cellular transplants to promote spinal cord repair. Both cell types support axonal regeneration and have beneficial effects on functional recovery. A significant difference between SCs and OEG is the effect of these cell types on astrocytes (ACs) present in the neural scar. In contrast to OEG, which associate and intermingle with ACs, SCs and ACs form separate cellular territories. Here, we show that OEG and SCs also interact differently with meningeal cells (MCs), another major cellular component of the neural scar. Whereas OEG intermingle with MCs in cocultures, SCs aggregate into well‐defined cell clusters. Our data suggest that (a) soluble factor(s) as well as direct cellular contact are involved in the MC‐induced SC clustering. Furthermore, the cluster formation of SCs in coculture with MCs is different from the previously reported segregation of SCs and ACs in coculture. The present results help to understand the differential behavior of both cell types after transplantation in the injured spinal cord and will be important to either determine which cell has optimal capacities to render the scar more permissive for regeneration, or to exploit the transplantation of both cell types in combination. © 2009 Wiley‐Liss, Inc.
Analysis of the 2006 floods over northern Tanzania
Authors: Kijazi Agnes L. , Reason C. J. C.
Published: January 2009

This study analyses the circulation features over the Indian Ocean that may be responsible for anomalous wet seasons over Tanzania, giving specific focus to the heavy floods that occurred during the short rainfall season of October–December (OND) 2006. These floods caused devastating loss of life and property over the northern part of the country. A comparison of the 2006 event with a previous severe flooding episode (OND 1997) is conducted.

Our results indicate that very heavy rainfall events experienced within a short duration exacerbated the 2006 flood. The circulation features show that the heavy rainfall recorded during OND 2006 can be associated with strong warming over the Indian Ocean, coupled with a convective zone over the western Indian Ocean and East African region, with enhanced moisture flux convergence and uplift over the western Indian Ocean and Tanzania. In turn, this warming was related to the ongoing El Niño and the positive phase of the Indian Ocean dipole mode that occurred during this season, as in OND 1997. In both cases, the severe flooding in Tanzania seemed to be preceded by warming near the Somali coast and an easterly moisture flux anomaly over the eastern equatorial Indian Ocean. Copyright © 2009 Royal Meteorological Society
Present status of the teaching of the deaf
Authors: Goldstein Max A.
Published: January 2009

(Original Communications are received with the understanding that they are contributed exclusively to The Laryngoscope.)
Vacuum‐assisted closure therapy in the management of head and neck wounds
Authors: Dhir Karan , Reino Anthony J. , Jon Lipana
Published: January 2009

Objectives:

The wound vacuum‐assisted closure (VAC) has been used in many areas of surgery to promote healing and facilitate secondary reconstruction. Until recently, this treatment modality was overlooked in the otolaryngology literature, and the authors propose that its use should be routine in the treatment of complex head and neck wounds.

Study Design:

An unbiased cohort study without conflict of interest at two tertiary care centers.

Materials and Methods:

All patients treated by the authors presented with complex head and neck wounds from 2005 to 2007 and were subjected to wound VAC therapy. The wound VAC dressing was changed every 72 hours, and the wound etiology, wound site, history of chemotherapy and radiation, hospital duration, gender, outcome, and ancillary procedures were recorded.

Results:

Nineteen patients with 33 wounds were treated using VAC therapy. Eighty‐four percent of these patients healed completely without the need for further surgical intervention. The mean age of this cohort was 63.2 years, with a range of 48–75 years. Males far outnumbered females in this study (17:2). Outpatient therapy commenced at discharge after an average of 11.4 days following a hospital stay ranging between 5 and 28 days. Adjunctive procedures performed during and after VAC therapy included hyperbaric oxygen treatment, dermal grafts, salivary diversion, and regional flap reconstruction.

Conclusions:

This study shows the applicability and versatility of vacuum‐assisted wound closure in the head and neck. Based on our results the authors feel that this mode of therapy should be a routine part of the Otolaryngologist's armamentarium for the treatment of complex and refractory head and neck wounds. Laryngoscope, 119:54–61, 2009
The predictive and therapeutic value of thymidine phosphorylase and dihydropyrimidine dehydrogenase in capecitabine (Xeloda)‐based chemotherapy for head and neck cancer
Authors: Saito Koichiro , Khan Khurram , Yu Shu‐Zhen , Ronson Steve , Rhee Joung , Li Gouyan , Van Echo David , Suntharalingam Mohan , O'Malley Bert W. , Li Daqing
Published: January 2009

Objectives:

To evaluate whether two molecular biomarkers, thymidine phosphorylase (TP) and dihydropyrimidine dehydrogenase (DPD), could be clinically useful in predicting and improving the chemotherapeutic outcome of the oral fluoropyrimidine capecitabine (5′‐DFUR or Xeloda®), in the treatment of human head and neck squamous cell carcinoma (HNSCC).

Experimental Design:

Quantitative reverse‐transcriptase polymerase chain reaction was used to determine the TP and DPD expression levels in different HNSCC cell lines. The TP to DPD ratio was calculated and compared to the relative chemosensitivity between cell lines after treatment with 5′‐DFUR. The effect of TP transgene expression to alter the TP to DPD ratio and hence optimize the therapeutic outcome of capecitabine treatment was further evaluated in a murine model of human HNSCC using immunohistochemistry to detect TP and DPD expression in vivo.

Results:

No correlation was detected between sensitivity to 5′‐DFUR and the relative expression levels of TP or DPD in the multiple HNSCC cell lines tested. However, significant correlation was observed between the TP to DPD ratio versus drug resistance of the HNSCC cells (r = −0.914, p = 0.0281). In addition, we demonstrate that transgene expression of TP significantly enhanced the tumoricidal effect of capecitabine in HNSCC tumors with otherwise low endogenous TP to DPD ratios. This antitumor effect was observed up to 30 days after treatment.

Conclusions:

The results of this study suggest that HNSCC patients who would most benefit from capecitabine‐based chemotherapy could be identified by examining the TP to DPD ratio of their tumors. Furthermore, we demonstrate the potential role of TP gene therapy in TP to DPD ratio manipulation to optimize the tumoricidal effect of capecitabine. Laryngoscope, 119:82–88, 2009
Genes involved in radiation therapy response in head and neck cancers
Authors: Dumur Catherine I. , Ladd Amy C. , Wright Harry V. , Penberthy Lynne T. , Wilkinson David S. , Powers Celeste N. , Garrett Carleton T. , DiNardo Laurence J.
Published: January 2009

Objectives:

This is a pilot study designed to identify gene expression profiles able to stratify head and neck squamous cell carcinoma (HNSCC) tumors that may or may not respond to chemoradiation or radiation therapy.

Study Design:

We prospectively evaluated 14 HNSCC specimens, arising from patients undergoing chemoradiotherapy or radiotherapy alone with curative intent. A complete response was assessed by clinical evaluation with no evidence of gross tumor after a 2‐year follow‐up period.

Methods:

Residual biopsy samples from eight complete responders (CR) and six nonresponders (NR) were evaluated by genome‐wide gene expression profiling using HG‐U133A 2.0 arrays. Univariate parametric t‐tests with proportion of false discoveries controlled by multivariate permutation tests were used to identify genes with significantly different gene expression levels between CR and NR cases. Six different prediction algorithms were used to build gene predictor lists. Three representative genes showing 100% crossvalidation support after leave‐one‐out crossvalidation (LOOCV) were further validated using real‐time QRT‐PCR.

Results:

We identified 167 significant probe sets that discriminate between the two classes, which were used to build gene predictor lists. Thus, 142 probe sets showed an accuracy of prediction ranging from 93% to 100% across all six prediction algorithms. The genes represented by these 142 probe sets were further classified into different functional networks that included cellular development, cellular movement, and cancer.

Conclusions:

The results presented herein offer encouraging preliminary data that may provide a basis for a more precise prognosis of HNSCC, as well as a molecular‐based therapy decision for the management of these cancers. Laryngoscope, 119:91–101, 2009
Iatrogenic esophageal submucosal dissection after attempted diagnostic gastroscopy (with videos)
Authors: Tang Shou‐jiang , Tang Linda , Jazrawi Saad F. , Meyer Dan , Wait Michael A. , Myers Larry L.
Published: January 2009

Diagnostic esophagogastroduodenoscopy (EGD) is generally a very safe procedure. We report the first case of iatrogenic esophageal submucosal dissection after an attempted diagnostic gastroscopy in a patient with a small previously undiagnosed Zenker's diverticulum (ZD). After EGD, she developed severe dysphagia with the inability to swallow solids, liquids, and even her own saliva. On barium swallow study, there was a column of contrast below the upper esophageal sphincter, and this was misdiagnosed as a large ZD by the radiologist. The resultant stricture was successfully managed with endoscopic balloon dilatation under fluoroscopy with wire‐guided cannulation. The ZD was treated with flexible endoscopic clip‐assisted diverticulotomy. Iatrogenic submucosal dissection is a unique complication of upper endoscopy. Endoscopists, otolaryngologists, radiologists, and cardiothoracic surgeons should be aware of this condition and prepare to manage it appropriately. If the patient is stable and the possibility of perforation is small, conservative and supportive care can be tried first. A surgical gastrostomy tube can be placed for enteral feeding. In patients with ZD, ZD recognition and gentle manipulation is strongly recommended during esophageal intubation. Laryngoscope, 119:36–38, 2009
Transforming growth factor‐β1 shows an incremental osteoinductive dose‐response relationship
Authors: Moxham J. Paul , Wong Kevin K. , Kibblewhite Douglas J.
Published: January 2009

Objective:

To determine if there is a dose–response curve for TGF‐β1 in a rabbit calvarial defect model.

Study Design:

Controlled animal study using arms of increasing concentrations of TGF‐β1 to evaluate the osteoinductive potential of each arm.

Methods:

Sixteen skeletally mature New Zealand white rabbits were randomized into control and experimental arms. Incremental doses of TGF‐β1 delivered in an inactivated guanidine‐extracted demineralized bone matrix (Gu‐DBM) carrier were implanted into a critically sized calvarial defect. The animals were sacrificed at 4 weeks and histomorphometric analysis was then accomplished.

Results:

TGF‐β1 showed a dose–response relationship, with the higher doses chosen for this study causing more robust osteoinduction.

Conclusions:

In this pilot dosing study, TGF‐β1 demonstrates increasing osteoinduction with increasing dose levels in this animal model. Laryngoscope, 119:126–130, 2009
Stellate cells in the human child vocal fold macula flava
Authors: Sato Kiminori , Nakashima Tadashi
Published: January 2009

Objectives:

Vitamin A‐storing vocal fold stellate cells (SCs) in the macula flava (MF) are hypothesized to be involved in the metabolism of extracellular matrices (EM) of the human vocal fold mucosa (VFM). The SCs in the child VFM were examined.

Study Design:

Histologic analysis of cadaveric human child VFM.

Methods:

Light and electron microscopic investigations of SCs in the human child VFM were carried out on three excised human child larynges.

Results:

The SCs were stellate and dense in the child MF. They had cytoplasmic processes, possessed lipid droplets, and stored vitamin A in their cytoplasm. The SCs had a small nucleus‐cytoplasm ratio and rough endoplasmic reticula, suggesting constant protein synthesis in these cells. There were vesicles along the periphery of the cytoplasm, and newly released amorphous materials were seen on the cell surface. There were dense reticular, collagenous, and elastic fibers around SCs. The SCs exhibited strong cytoplasm staining with periodic acid‐Schiff stain and type III collagen. Most of the VFSCs showed CD44 (a cell surface receptor for hyaluronic acid) expression, and a large amount of hyaluronic acid was present immediately adjacent to SCs. This study revealed several morphologic differences between the SCs in the MF and the conventional fibroblasts in the VFM.

Conclusions:

The SCs in the child MF constantly synthesized EM, essential for viscoelastic properties of the lamina propria of the human VFM, in the stage of vocal fold growth and development. The SCs in the MF were inferred to be involved in the growth and development of human VFM. Laryngoscope, 119:203–210, 2009
Incidence and indications for revision cochlear implant surgery in adults and children
Authors: Brown Kevin D. , Connell Sarah S. , Balkany Thomas J. , Eshraghi Adrien E. , Telischi Fred F. , Angeli Simon A.
Published: January 2009

Objectives/Hypothesis:

To identify the incidence of and common causes for cochlear implant revision.

Study Design:

Retrospective case series.

Methods:

Operative records were reviewed for all cases of revision cochlear implantation from 1992 to 2006. The causes for reimplantation were classified as hard device failure, soft device failure, exposure/infection, receiver/stimulator migration, and electrode migration. Manufacturers' failure analysis of explanted devices was likewise determined.

Results:

Eight hundred and six cochlear implants were performed during the study period including 44 (5.5%) revision procedures. The revision rate was 7.3% for children and 3.8% for adults and reached statistical significant difference. The most common reasons for revision were device failure (78%; 55% hard failure, 23% soft failure) followed by electrode migration (9%) and receiver/stimulator migration (7%). Manufacturers' analysis of failed devices revealed loss of hermetic seal and cracked cases to be the most common causes of failure. Bench analysis of 5/10 explanted devices that were soft failures demonstrated identifiable device defects.

Conclusions:

Revision cochlear implant surgery is an infrequent occurrence. Its incidence appears to be higher in children than in adults, although in this series does not appear to be due to increased wound complications, infections, or trauma. Explanted implants that have soft failure as the etiology may have demonstrable defects on bench testing. Laryngoscope, 119:152–157, 2009
Monitoring stress levels in postgraduate medical training
Authors: Hill Justin D. , Smith Richard J. H.
Published: January 2009

Objectives:

The Accreditation Council for Graduate Medical Education (ACGME) mandates that residency Program Directors (PD) monitor resident well‐being, including stress. Burnout, as a measure of work‐related stress, is defined by a high degree of emotional exhaustion and depersonalization, and a low degree of personal accomplishment using the Maslach Burnout Inventory‐Human Services Survey (MBI‐HSS). The purpose of this study is to describe the use of the MBI‐HSS as a method of monitoring stress levels in an academic otolaryngology residency training program and introduce this survey as a tool for wider use in meeting ACGME requirements.

Methods:

The MBI‐HSS was administered to residents in an academic otolaryngology residency training program on three separate occasions: at the beginning, middle, and end of different academic years. In addition, at the time of the third administration, the MBI‐HSS was completed by faculty and staff in the same department. Surveys were completed and collected anonymously. Responses were scored against normative data from the MBI‐HSS overall sample and the medicine subscale. Low, average, and high levels of burnout were identified for the individual categories of emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA); average levels for each category were calculated.

Results:

Twenty‐two residents completed the first survey, taken near the end of an academic year; 19 completed the second administration in the middle of the following academic year; and 24 completed the third survey at the beginning of the subsequent academic year. Thirteen faculty and 23 staff also completed the third survey. We found that three, one, and one residents reported high levels of burnout on the first, second, and third surveys, respectively. These figures compare to one faculty member and no staff members in the same department reporting high levels of burnout.

Conclusions:

The MBI‐HSS is an established and validated tool for identifying burnout in resident physicians. Residency PDs may find the MBI‐HSS useful as an aid in monitoring resident well‐being and stress. In our own department, we found levels of burnout comparable to those previously reported for residents and faculty in this specialty. Laryngoscope, 119:75–78, 2009
An early detection protocol for invasive fungal sinusitis in neutropenic patients successfully reduces extent of disease at presentation and long term morbidity
Authors: DelGaudio John M. , Clemson Lindsey A.
Published: January 2009

Objectives:

To evaluate a multidisciplinary early intervention protocol for invasive fungal sinusitis (IFS) in neutropenic patients and its effect on degree of tissue involvement at time of presentation and effect on morbidity and mortality.

Study Design:

Retrospective review.

Methods:

A chart review was performed for cases of acute fulminant IFS in neutropenic patients at Emory University Hospital from 1995 to 2007. Inclusion required tissue diagnosis of IFS, neutropenia, and adequate records of the following: tissue involvement at presentation, number and extent of surgical procedures performed, morbidity, and mortality. Group 1 included patients prior to 2001, and group 2 included patients after protocol initiation in 2001. The groups were compared for the number of tissue sites involved at presentation, number of surgical procedures performed, long‐term morbidity, and mortality.

Results:

Twenty‐eight cases of IFS were identified. The average number of sites involved at presentation was 2.5 in group 1 and 1.5 in group 2 (P = .059). The average number of procedures was 2.2 in group 1 and 1.0 in group 2 (P = .026). Long‐term morbidity occurred in 43% (6/14) of group 1 patients compared with 7.1% (1/14) of group 2 patients (P = .029). Mortality from IFS was 7.1% in group1 and 7.1% in group 2.

Conclusions:

IFS requires early diagnosis and treatment for optimum outcome. A protocol of early intervention for neutropenic patients is effective in early detection of IFS with fewer sites of involvement at diagnosis, fewer surgeries, and less long‐term morbidity. No difference in survival was found, as this is more a factor of the underlying cause of the neutropenia. Laryngoscope, 119:180–183, 2009
Tonsillectomy vs. deep tonsil biopsies in detecting occult tonsil tumors
Authors: Waltonen Joshua D. , Ozer Enver , Schuller David E. , Agrawal Amit
Published: January 2009

Objectives:

To compare the yield of detecting occult tumors by performing tonsillectomy and deep tonsil biopsies in patients with metastatic carcinoma to the neck in whom a primary tumor was not evident on physical examination, radiography, or panendoscopy.

Study Design:

Retrospective study.

Methods:

Over a 10‐year period, the charts of all patients diagnosed with metastatic carcinoma to the neck in whom a primary tumor was not evident on examination, imaging, and panendoscopy were reviewed. Specifically, we compared groups of patients who had undergone diagnostic tonsillectomy with those who had undergone deep tonsil biopsies in search of an occult primary tumor.

Results:

One hundred twenty‐two patients were identified as meeting study criteria. All underwent directed biopsies of the tongue base, hypopharynx, and nasopharynx as well as either deep tonsil biopsies or diagnostic tonsillectomy. Deep tonsil biopsies were performed in 95 patients. In this group, 11 primary tumors were subsequently identified (11.6%): three in the tonsil, six in the tongue base, one in the hypopharynx, and one in the nasopharynx. Tonsillectomy was performed in 27 patients. Eleven primary tumors were identified (40.7%): eight in the tonsils, two in the tongue base, and one in the hypopharynx. All tonsil primary tumors identified were ipsilateral to the presenting neck mass. The overall yield of finding an occult primary carcinoma in the tonsil was 3.2% for deep tonsil biopsies vs. 29.6% for tonsillectomies (P < .0002).

Conclusions:

Tonsillectomy offers a significantly higher likelihood of finding occult tonsillar tumors than deep tonsil biopsy. Laryngoscope, 119:102–106, 2009
Evolution of endoscopic surgical therapy for Zenker's diverticulum
Authors: Hillel Alexander T. , Flint Paul W.
Published: January 2009

Zenker's diverticulum is a rare anatomic defect that physicians have confronted for almost 250 years. Its location at the interface of the pharynx, neck, and mediastinum makes surgical access difficult and risks severe morbidity. Minimally invasive endoscopic surgical repair of Zenker's diverticulum has been attempted for more than a century as an alternative to reduce morbidity of an open transcervical approach. However, limitations due to available antibiotics, instrumentation, and laryngoscopes, as well as a general discomfort with a sutureless closure of the mucosal excision, have delayed widespread adoption of minimally invasive repair until the last 10 to 15 years. This manuscript will detail the historical evolution of endoscopic surgical therapy for Zenker's diverticulum and highlight the work of two otolaryngologists, Chevalier Jackson and Gosta Dohlman, who were critical in advancing the surgical technique and reducing morbidity. Lastly, this manuscript will analyze the delay in widespread application of endoscopic surgical repair of Zenker's diverticulum. Laryngoscope, 119:39–44, 2009
Comparison of three common tonsillectomy techniques: A prospective randomized, double‐blinded clinical study
Authors: Wilson YuShan L. , Merer David M. , Moscatello Augustine L.
Published: January 2009

Objective:

To evaluate three current tonsillectomy techniques—intracapsular microdebridement, intracapsular coblation, and traditional extracapsular electrocautery dissection—comparing surgical parameters, efficacy, and morbidity in the treatment for obstructive sleep disordered breathing in children.

Study Design:

Prospective, double‐blinded study with follow‐up by telephone interview.

Method:

From February 2004 to July 2006, a total of 156 patients between the ages of 6 months and 22 years scheduled for adenotonsillectomy were randomly assigned to electrocautery, coblator, and microdebrider groups.

Outcome Measures:

1) Patient demographics; 2) Intraoperative time; 3) Surgeon's perception of difficulty; 4) Indicators of postoperative morbidity: pain, use of pain medication, return to diet, and activity level; 5) Complications; 6) Cost.

Results:

Microdebrider technique produced the shortest total surgical time, averaging 16 minutes. Use of coblation resulted in 2 less days of pain medication compared to electrocautery. Patients in the coblator and microdebrider groups returned to a normal diet 1.51 days and 1.77 days earlier, respectively, than in the electrocautery group. They also returned to preoperative activity levels 1.85 days and 2.06 days earlier than in the electrocautery group. Of all three methods, the microdebrider was the most cost effective. The coblator and microdebrider did not differ significantly from each other in all other parameters. The three techniques showed no statistically significant difference in assessment of difficulty, average pain scores, or postoperative complications.

Conclusions:

Postoperative recovery following intracapsular adenotonsillectomy in children with obstructive sleep apnea is significantly earlier with use of either the coblator or microdebrider versus traditional extracapsular tonsillectomy with electrocautery. Microdebrider and coblator were comparable in all other areas except for shorter operative time and less cost for the microdebrider. Laryngoscope, 119:162–170, 2009
Subcutaneous implants coated with tissue‐engineered cartilage
Authors: Kim Soo Whan , Dobratz Eric J. , Ballert John A. , Voglewede Andrew T. , Park Stephen S.
Published: January 2009

Objective:

To investigate the ability to coat two alloplastic implants, porous high‐density polyethylene (PHDPE) and expanded polytetrafluoroethylene (e‐PTFE), with tissue‐engineered cartilage (TEC) from human septal chondrocytes in a mouse model.

Study Design:

Prospective study.

Methods:

PHDPE and e‐PTFE disks were coated with alginate impregnated with human septal chondrocytes and implanted into athymic nude mice. A control group consisting of PHDPE and e‐PTFE disks coated with alginate only were implanted. Gross, histological, and biochemical characteristics of the TEC constructs were examined at 10 and 20 weeks following implantation.

Results:

One animal in the experimental group and one animal in the control group died. Implants coated with TEC were successfully generated in 18 (94.7%) mice in the experimental group (n = 19) and in zero (0%) of the control group (n = 17). The final weight of each harvested specimen decreased in the control group and increased in the experimental group, when compared with preimplant weight. Mean decrease in weight in the control group was greater at 20 weeks than at 10 weeks (P = .017). Mean increase in weight in the experimental group was greater at 20 weeks than at 10 weeks (P = .009). The diameter of the control group decreased, while the diameter of the experimental group was maintained. The reduction in diameter was less in the experimental group than in the control group at 10 (P = .018) and 20 weeks (P = .01). Gross and histological examination confirmed the formation of neocartilage, with characteristics similar to native cartilage, in the experimental group at 10 and 20 weeks. Glycosaminoglycan content in the experimental group at 20 weeks was approximately 80% of that measured in implanted human septal cartilage. Cartilaginous and fibrovascular ingrowth into implant pores was more extensive in the PHDPE than the e‐PTFE experimental group.

Conclusions:

Implants coated with TEC from human septal cartilage can be reliably produced in the athymic nude mouse model. Maintenance of shape, as measured by the conservation of construct diameter, is possible. Fibrovascular ingrowth and cartilage formation into the pores of the alloplastic implants was observed. This integration of a construct composed of a synthetic implant coated with TEC may improve the performance of alloplastic implants through better long‐term fixation and increased resistance to infection. Laryngoscope, 119:62–66, 2009
Role of vortices in voice production: Normal versus asymmetric tension
Authors: Khosla Sid , Murugappan Shanmugam , Paniello Randal , Ying Jun , Gutmark Ephraim
Published: January 2009

Objectives:

Decreasing the closing speed of the vocal folds can reduce loudness and energy in the higher frequency harmonics, resulting in reduced voice quality. Our aim was to study the correlation between higher frequencies and the intraglottal vorticity (which contributes to rapid closing by producing transient negative intraglottal pressures).

Methods:

Using six excised canine larynges (three with symmetric and three with asymmetric, periodic vocal fold motion), intraglottal vorticity was calculated from 2D velocity fields measured using particle imaging velocimetry.

Results:

There is a strong correlation between intraglottal vorticity and acoustic energy in the higher frequencies; in periodic asymmetric motion, the vorticity and higher frequencies are both reduced.

Conclusions:

For unilateral vocal fold paralysis, these findings suggest one reason why periodic, asymmetric motion, may produce an abnormal voice. Further study will help determine when and why reinnervation, as opposed to medialization, may result in better voice quality. Laryngoscope, 119:216–221, 2009
Endoscopic endonasal surgery for petrous apex lesions
Authors: Zanation Adam M. , Snyderman Carl H. , Carrau Ricardo L. , Gardner Paul A. , Prevedello Daniel M. , Kassam Amin B.
Published: January 2009

Background:

Endoscopic endonasal approaches to the ventral skull base are categorized based on their orientation in coronal and sagittal planes. For all of these approaches, the sphenoid sinus is the starting point, and provides orientation to important vascular and neural structures. Surgical approaches to the petrous apex include 1) a medial approach, 2) a medial approach with internal carotid artery (ICA) lateralization, and 3) a transpterygoid infrapetrous approach (inferior to the petrous internal carotid artery). The choice of a surgical approach depends on the relationship of the lesion to the internal carotid artery (medial or inferior), degree of medial expansion, and pathology. The purpose of this paper is to discuss the anatomic and technical features of endoscopic surgical approaches to the petrous apex, provide a new classification for approaches that focuses on the relationship of the lesion to the petrous internal carotid artery, and provide outcomes data on our first 20 endoscopic petrous apex approaches.

Methods:

A retrospective clinical outcome study of endoscopic petrous apex surgeries was performed at the University of Pittsburgh Medical Center. The medical records from patients with endoscopic endonasal approaches to isolated petrous apex lesions were reviewed for demographics, diagnoses, presentation, endoscopic approach, and clinical outcomes. Patients with lesions that extended into the petrous apex but were not isolated to the petrous apex were excluded (e.g., clival chordoma with extension into the petrous apex).

Results:

Twenty patients were included in the analysis: 13 inflammatory cystic lesions (9 cholesterol granulomas and four petrous apicitis) and 7 solid lesions. Chondrosarcoma was the most common solid petrous apex lesion in our series. Twelve of 13 cystic lesions were drained endoscopically (one surgery was aborted early in the series). All drained patients had resolution of presenting symptoms. One patient had closure of the outflow tract without return of symptoms and one patient had revision endoscopic drainage due to scarring and neo‐osteogenesis and return of unilateral headache. No carotid injuries and no new cranial neuropathies occurred perioperatively. The advantages and limitations of the medial transsphenoidal approaches (with and without carotid mobilization) and the transpterygoid infrapetrous approach are discussed.

Conclusions:

The endoscopic endonasal approach to petrous apex lesions is safe and effective for appropriately selected patients in the hands of experienced endoscopic skull base surgeons. If offers advantages of removing the hearing and facial nerve risks from the transtemporal/transcranial approaches and allows for a larger and more natural drainage pathway into the sinuses. Laryngoscope, 119:19–25, 2009
Control of vocal fold cover stiffness by laryngeal muscles: A preliminary study
Authors: Chhetri Dinesh K. , Berke Gerald S. , Lotfizadeh Ali , Goodyer Eric
Published: January 2009

Objectives:

To perform preliminary measurements of the shear modulus of the vocal fold cover layer during intrinsic laryngeal muscle contraction.

Study Design:

Shear modulus was measured in an in vivo canine larynx and an ex vivo human larynx.

Methods:

Shear stress was applied to the transverse axis of the vocal fold using a modified linear skin rheometer (LSR) via an attached suction probe. The probe displacement in response to the applied force was measured at various levels of laryngeal muscle contraction. The force‐displacement data were used to derive the shear modulus using a simple shear model. In the ex vivo human larynx, lateral cricoarytenoid (LCA) muscle and cricothyroid (CT) muscle activity was simulated with arytenoid adduction and cricothyroid approximation sutures, respectively. In the in vivo canine, adductor muscle and CT muscle contraction was induced with graded stimulation of the recurrent laryngeal nerve (RLN) and the superior laryngeal nerves (SLN), respectively.

Results:

Baseline shear modulus was between 1,076 and 1,307 Pascals. In the ex vivo human larynx, the shear modulus increased gradually to a maximum of 1.6 times baseline value with graded arytenoid adduction and 3.7 times baseline value with cricothyroid approximation. In the in vivo larynx, the shear modulus increased to a maximum of 1.6 times baseline value with RLN stimulation and 2.5 times baseline value with SLN stimulation.

Conclusions:

Findings are in agreement with the cover‐body model in that cricothyroid muscle activity generates a greater change in cover stiffness than laryngeal adductors. The role of the individual laryngeal adductors (thyroarytenoid [TA] vs. LCA) in control of vocal fold cover stiffness remains to be further elucidated. Laryngoscope, 119:222–227, 2009
Application of the vibrant soundbridge® to unilateral osseous atresia cases
Authors: Frenzel Henning , Hanke Frauke , Beltrame Millo , Steffen Armin , Schönweiler Rainer , Wollenberg Barbara
Published: January 2009

Objectives/Hypothesis:

Patients with high‐grade atresia‐microtia suffer from a combined malformation of the outer and middle ears, typically leading to a severe hearing impairment. Long‐term results of middle ear reconstruction with tympanoplasty are often insufficient due to persistent air‐bone gaps, and new techniques in hearing rehabilitation are required. The objective of this research is to evaluate the active middle ear implant, the Vibrant Soundbridge® (VSB), for hearing rehabilitation of patients with unilateral osseous aural atresia.

Study Design:

Prospective analysis of a consecutive cohort of seven atresia patients (mean age = 15 years).

Methods:

During plastic auricular reconstruction of unilateral atresia‐microtia cases, an access through the bony atresia plate was drilled. The floating mass transducer was coupled to the stapes (or remaining stapes suprastructure), ossicular chain, or round window, depending on the anatomic needs of the patient. Audiometric testing, including pure‐tone thresholds, and speech testing in quiet and noise were performed.

Results:

The mean threshold with the VSB activated in the free field warble tone audiometry was 23.8 dB hearing level (HL). Mean functional gain was 45.5 dB HL. Mean aided free field speech discrimination in quiet was 64% at 50 dB, 99% at 65 dB, and 100% at 80 dB.

Conclusions:

By circumventing the malformed middle ear and directly stimulating the cochlea, the VSB provides a new rehabilitation option for atresia patients. We conclude that the procedure is safe and effective and can be implemented in combination with outer ear reconstruction. Laryngoscope, 119:67–74, 2009