Faculty Bibliography

INTRODUCTION/BACKGROUND:). Clinical guidelines recommend multicomponent lifestyle programmes to promote modest, clinically significant body mass (BM) loss. Primary care providers (PCPs) often lack time to counsel and refer patients to intensive programmes (≥6 sessions over 3 months). Using peer coaches to deliver obesity counselling in primary care may increase patient motivation, promote behavioural change and address the specific needs of veterans. We describe the rationale and design of a cluster-randomised controlled trial to test the efficacy of the Peer-Assisted Lifestyle (PAL) intervention compared with enhanced usual care (EUC) to improve BM loss, clinical and behavioural outcomes (aim 1); identify BM-loss predictors (aim 2); and increase PCP counselling (aim 3). METHODS AND ANALYSIS/UNASSIGNED:We are recruiting 461 veterans aged 18-69 years with obesity or overweight with an obesity-associated condition under the care of a PCP at the Brooklyn campus of the Veterans Affairs NY Harbor Healthcare System. To deliver counselling, PAL uses in-person and telephone-based peer support, a tablet-delivered goal-setting tool and PCP training. Patients in the EUC arm receive non-tailored healthy living handouts. In-person data collection occurs at baseline, month 6 and month 12 for patients in both arms. Repeated measures modelling based on mixed models will compare mean BM loss (primary outcome) between study arms. ETHICS AND DISSEMINATION/UNASSIGNED:The protocol has been approved by the Institutional Review Board and the Research and Development Committee at the VA NY Harbor Health Systems (#01607). We will disseminate the results via peer-reviewed publications, conference presentations and meetings with stakeholders. TRIAL REGISTRATION NUMBER/BACKGROUND:NCT03163264; Pre-results.

BACKGROUND:The misuse and abuse of opioids, including overprescription, has led to the current opioid epidemic and national crisis. There is a national effort to eliminate the unnecessary prescription of opioids for analgesia. METHODS:Seventy patients were randomized to receive postoperative analgesia with either 5 mg hydrocodone with 325 mg acetaminophen (opioid control group) or 400 mg of ibuprofen [nonsteroidal antiinflammatory drug (NSAID) experimental group]. Pain levels were assessed on postoperative days 1, 2, and 7. Outcome measures included numeric pain rating scores and assessments of frequency and amount of analgesic used. RESULTS:There was no significant difference in gender (p = 0.81) or age (p = 0.61) between groups. On postoperative day 0, the NSAID group (mean ± SD, 2.54 ± 1.57) was found to be noninferior to the opioid group (mean ± SD, 3.14 ± 1.75; p = 0.003). On postoperative day 1, the NSAID group showed a lower mean pain score (mean ± SD, 1.84 ± 1.29) than the opioid group (mean ± SD, 2.46 ± 1.90; p = 0.01). However, on postoperative day 7, the difference in pain scores between the NSAID (mean ± SD, 3.29 ± 2.14) and opioid (mean ± SD, 3.14 ± 2.12; p = 0.17) groups lost statistical significance. There was no significant difference in mean day of medication cessation between the NSAID (mean ± SD, 4.73 ± 1.57) and opioid (mean ± SD, 4.28 ± 2.23; p = 0.26) groups. Seventy-six percent of patients who were prescribed opioids took fewer than eight tablets. Five patients escalated from NSAIDs to opioids. There were no adverse effects related to NSAID use. CONCLUSIONS:NSAIDs are an acceptable and safe alternative to opioids for postoperative analgesia in rhinoplasty and potentially lead to better overall pain control in some patients. Significantly reducing or eliminating opioid prescriptions may be considered in light of the current opioid epidemic. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, II.

BACKGROUND: The work-up and diagnosis of indeterminate lung nodules at time of bladder cancer diagnosis may delay or change treatment. OBJECTIVE: To quantify the incidence of synchronous and metachronous lung cancers in adults with bladder cancer and compare these rates to the incidence of bladder cancer metastases in the lung. METHODS: We retrospectively analyzed all adults diagnosed with bladder cancer in the Surveillance, Epidemiology and End Results (SEER) registry (2010- 2015) and identified second primary lung cancers defined as being either synchronous (diagnosed within 6 months of bladder cancer diagnosis) or metachronous (more than 6 months following index bladder cancer diagnosis). The risk of second primary lung cancers were reported as a standardized incidence ratio (SIR) reflecting observed and expected case ratios. RESULTS: A total of 88,335 patients diagnosed with bladder cancer were included. Among adults with NMIBC (n=66,071) and MIBC (n=18,879), 0.3% and 3.9% had bladder cancer metastatic to the lungs at diagnosis. Synchronous second primary lung cancers were diagnosed in 0.4% and 0.7% of patients with NMIBC and MIBC, respectively. Compared to the general population, the SIR for synchronous lung cancers among adults with NMIBC was 2.5 (95% CI 2.3- 2.9) and was 4.7 (95% CI 4.0- 5.6) for adults with MIBC. CONCLUSIONS: Bladder cancer metastatic to the lung is more common in adults with MIBC compared to NMIBC. There are similar frequencies of synchronous second primary lung cancers regardless of initial bladder cancer stage.

OBJECTIVE:To investigate and improve compliance of thyroid function monitoring in head and neck cancer patients who received radiotherapy to the cervical region before and after instituting quality improvement interventions. METHODS:Using the Plan, Do, Study, Act (PDSA) methodology, patients with head and neck malignancies who received radiotherapy to the cervical region from 2013-2015 were identified at a tertiary medical center. The status of the patients' thyroid monitoring and related characteristics were recorded. A quality improvement project was subsequently implemented by data sharing and providing feedback to practitioners involved in head and neck cancer care and creating a tracking database for all patients who received radiotherapy to the neck. After implementation of these interventions, data was collected on patients meeting the inclusion criteria from 2015-2017. RESULTS:One hundred fifty-six patients met criteria pre-intervention and ninety-eight patients met criteria post-intervention. Compliance of thyroid monitoring went up from 34% to 80% after interventions (P < .0001). There was a significant increase in thyroid testing performed by radiation oncologists after interventions from 2% to 21%, while medical oncologists and otolaryngologists remained consistent in their compliance rates. CONCLUSION/CONCLUSIONS:It is possible to improve compliance with evidence-based recommendations and improve the quality-of-care for head and neck cancer survivors through simple, cost effective interventions. LEVEL OF EVIDENCE/METHODS:2 Laryngoscope, 2019.

IMPORTANCE/OBJECTIVE:Foreign body (FB) aspiration into the airway is a significant cause of pediatric morbidity and mortality, yet the clinical presentation is diverse and dynamic. There are conflicting recommendations which pre-procedural findings support performing a bronchoscopy, the gold standard for diagnosis and removal of FBs, however a procedure that entails general anesthesia and possible risks. OBJECTIVE:Decision whether to proceed to a bronchoscopy may be challenging. Our goal was to enhance decision-making by analyzing the diagnostic values of the different pre-procedural findings in this setting. DATA SOURCES/METHODS:A comprehensive search was performed in PUBMED, EMBASE and Cochrane Review databases to find studies from the last 19 years that reported pre-procedural history, physical examination and radiological findings in patients who had bronchoscopies. STUDY SELECTION/METHODS:Studies were included of pediatric populations if they contained bronchoscopy results (positive and negative for foreign body) with a breakdown according to pre-intervention findings. DATA EXTRACTION AND SYNTHESIS/METHODS:Titles and abstracts retrieved from our search were screened. Thereafter, full-texts were carefully reviewed and selected for inclusion if the aforementioned criteria were met. PRISMA guidelines for systematic review and meta-analyses were followed. MAIN OUTCOME(S) AND MEASURE(S)/UNASSIGNED:Cumulative weighted prevalence, sensitivity, specificity, positive and negative predictive values of each pre-procedural finding were calculated, as well as for the "classic triad" (history of an acute event, wheezing, and unilateral decreased breath sounds). Calculation for other combinations of findings, or optimally, constructing a weighted score based on all the findings for each specific patient were not possible to perform, as the specific data breakdown is rarely reported. RESULTS:Fifteen studies met inclusion criteria, totaling 5606 patients who underwent bronchoscopies. All studies but one were single center based and all except one were retrospective. No single finding has both positive and negative predictive values over 50%. The "classic triad" has 90% specificity, however only 35% sensitivity. CONCLUSIONS:The data is very heterogeneous with regard to pre-procedural findings and how best to guide treatment according to them. This meta-analysis provides cumulative weighted metrics for each finding, to optimize decision-making for the individual patient. Future reporting of data should be enhanced, so that combinations of findings for a specific patient can be used to optimize management. LEVEL OF EVIDENCE/METHODS:4.

A significant proportion of veterans continue to experience depression or anxiety following treatment with the empirically supported psychotherapies offered by the Veterans Health Administration. Continued development and testing of new treatments may be useful. Brief dynamic interpersonal therapy (DIT) is a short-term psychodynamic therapy developed for depression in the United Kingdom and is being disseminated as an alternative to cognitive behavioral therapy within the National Health Service. This study represents the first evaluation of DIT in the United States, implemented at a veterans affairs medical center for veterans with depression and/or anxiety. Electronic medical records of veterans receiving DIT from 2012 to 2018 at a New York-based veterans affairs medical center were reviewed. Linear mixed-effects models were used to analyze depression and anxiety scores collected at each session from the Patient Health Questionnaire and the Generalized Anxiety Disorder seven-item scale. Following DIT, patients presenting with clinically significant depression and/or anxiety reported a 46% reduction in Patient Health Questionnaire-9 scores (N = 60) and a 43% reduction in Generalized Anxiety Disorder seven-item scale scores (N = 46). Large effect sizes on both measures were found (d = 1.17, 95% CI [0.88, 1.47], p < .0001; d = 1.24, 95% CI [0.90, 1.58], p < .0001, respectively). DIT is a promising alternative to currently offered psychotherapies for veterans with depression and anxiety. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

OBJECTIVES/UNASSIGNED:Recurrent respiratory papillomatosis can be treated in the office or operating room (OR). The choice of treatment is based on several factors, including patient and surgeon preference. However, there is little data to guide the decision-making. This study examines the available literature comparing operative treatment in-office versus OR. METHODS/UNASSIGNED:A systematic review was performed following Preferred Reporting Items for Systematic Reviews guidelines. Of 2,864 articles identified, 78 were reviewed full-length and 18 were included. Outcomes of interest were recurrence and complication rates, number of procedures, time interval between procedures, and cost. RESULTS/UNASSIGNED:Only one study compared outcomes of operative in-office to OR treatments. The weighted average complication rate for OR procedures was 0.02 (95% confidence interval [CI] 0.00-0.32), n = 8, and for office procedures, 0.17 (95% CI 0.08-0.33), n = 6. The weighted average time interval between OR procedures was 10.59 months (5.83, 15.35) and for office procedures 5.40 months (3.26-7.54), n = 1. The weighted average cost of OR procedures was $10,105.22 ($5,622.51-14,587.83), n = 2 versus $2,081.00 ($1,987.64-$2,174.36), n = 1 for office procedures. CONCLUSION/UNASSIGNED:Only one study compares office to OR treatment. The overall data indicate no differences aside from cost and imply that office procedures may be more cost-effective than OR procedures. However, the heterogeneous data limits any strong comparison of outcomes between office and OR-based treatment of laryngeal papillomas. More studies to compare the two treatment settings are warranted.