Faculty Bibliography

The growing number of individuals with comorbidities experiencing care transitions represents a challenge to the current health care system. A qualitative study of empirical literature, using the Dimensional Analysis approach, was conducted to elucidate the theoretical underpinnings of the phenomenon of individuals with comorbidities undergoing care transitions. The findings were arranged in a novel schematic demonstrating that the relationship among individual attributes, comorbidities, and care processes informed the individual's risk for adverse outcomes. This schematic is useful for future nursing research studies evaluating innovative programs implemented to improve health outcomes among vulnerable populations undergoing care transitions.

OBJECTIVE: To reflect on lessons learned placing endotracheal nitinol stents in children. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care children's hospital. SUBJECTS AND METHODS: All children who underwent nitinol cervical tracheal stenting were included. Records were carefully reviewed for intraoperative and postoperative complications, management choices, outcomes, and factors that influenced results. RESULTS: Between 1999 and 2011, 7 children underwent 13 stent placements. Median follow-up was 5 years (range, 1-12 years). Six patients underwent stenting as a salvage procedure following open attempts at airway reconstruction. Four patients remain decannulated with their stent in place (median follow-up 7 years). The fifth patient had his stent removed endoscopically after 50 days because it became apparent that his obstruction was primarily laryngeal. The sixth child had his stent removed via a tracheal fissure after 14 months because of recalcitrant subglottic inflammation at the superior stent border. The seventh patient was decannulated for over 2 years but ultimately required tracheotomy replacement because of stenosis with the stent lumen. Complications included stent migration (23%), restenosis (29%), edema (29%), and granulation (57%). CONCLUSION: Endotracheal nitinol stents provide a realistic opportunity for decannulation in children for whom other options have failed but should be reserved only as a salvage procedure in severely complicated airways. Our experience has taught valuable lessons about stent indications, sizing, characteristics, and deployment, as well as means to avoid and manage their complications.

UNLABELLED:OBJECTIVES/HYPOTHOSES: TORS (Trans Oral Robotic Surgery) has been demonstrated to be an acceptable alternative to chemoradiation for the treatment of early stage malignant lesions of the oropharynx, with equivalent tumor control and enhanced functional outcomes. Surgical ablation of tumors of the oropharynx under conditions of limited access, however, creates the need to adapt the robotic platform to surgical reconstruction and to assess reconstructive outcomes. We present our experience with the Facial Artery Musculomucosal (FAMM) flap with robotic assistance for the reconstruction of defects of the soft palate. METHODS:We reviewed the records of five patients who underwent combined robot-assisted resection of malignant lesions of the oropharynx with immediate reconstruction. The reconstructions included four ispilateral and one bilateral FAMM flaps. Patients were assessed for complications and functional results. RESULTS:Successful closure of the defect was achieved in all five patients. There were no major complications; however, three patients developed minor wound dehiscence and two were revised at the time of planned subsequent lymphadenectomy. All five patients achieved a good functional outcome. CONCLUSIONS:The FAMM flap is reliable and easy to raise and transfer, with the surgical robot making it a good candidate for reconstruction of moderate-sized defects created by TORS applied to malignancies of the soft palate. Minor wound dehiscence is not infrequent, but reconstructive outcomes are nevertheless good. A unilateral FAMM flap will reach to the contralateral border of the uvula and is best limited to defects with a width of 2 cm or less.

OBJECTIVE: To analyze the effects of residual hearing on postoperative speech performance in traditional cochlear implant (CI) patients implanted with a conventional electrode. STUDY DESIGN: Retrospective review. SETTING: Academic tertiary referral center. PATIENTS: A total of 129 adults implanted by a single surgeon at a tertiary care facility between June 2005 and November 2010 with measurable preoperative pure tone thresholds at any frequency were included. INTERVENTION: Cochlear implantation with a conventional electrode via an anterior inferior cochleostomy. MAIN OUTCOME MEASURE: Speech perception using monosyllabic word scores in quiet and sentences in quiet and noise in the electric (CI-only) condition of the implanted ear. Preservation of hearing was defined as complete for postoperative thresholds within 10 dB of preimplant values and partial if greater than 11 dB. Pure tone audiometry and speech perception testing were performed preoperatively and at regular intervals postoperatively, with the 1-year evaluation being the final outcome period. RESULTS: Preservation at any frequency or level was not a factor in speech perception outcome, although preservation was more common in low frequencies. Hearing preservation was correlated with younger age at implantation, but was not related to length of hearing loss, cause of deafness, device type, sex, preoperative speech performance, or low-frequency pure-tone average. CONCLUSION: Hearing can be preserved in traditional CI patients implanted with a conventional electrode. Although preservation of hearing may have implications for future technology, it is not currently correlated with speech performance in the CI-only condition.

IMPORTANCE: Treatment of locally advanced head and neck squamous cell carcinoma (HNSCC) uses a multidisciplinary approach often limited by the toxicity and drug resistance of platinum agents. OBJECTIVES: To test whether a nanocarrier-conjugated cisplatin boosting locoregional drug delivery improves tumor efficacy while decreasing systemic toxicity over systemic cisplatin in a murine model of locally advanced HNSCC. DESIGN: A randomized, controlled, in vivo study compared standard cisplatin with nanocarrier (hyaluronan [HA])-conjugated cisplatin (HA-cisplatin) each at 50% of the maximum tolerated doses in a murine model of locally advanced HNSCC (10 mice/arm, each injected with 1 x 106 MDA-1986 HNSCC cells, with phosphate-buffered saline and HA-only control arms). Mice were treated for 3 weeks and observed for 3 additional weeks. SETTING: Academic medical center. PARTICIPANTS: Forty female Nu/Nu mice. Randomization and treatment arms were initiated once tumor volumes reached 30 mm3. INTERVENTION: Injection with MDA-1986 HNSCC cells followed by 3 weeks of treatment with cisplatin, HA-cisplatin, phosphate-buffered saline, or HA only. MAIN OUTCOMES AND MEASURES: Animal weights and tumor volumes were measured 3 times each week (modified RECIST [Response Evaluation Criteria in Solid Tumors]). At necropsy, animal kidneys were examined for nephrotoxic effects and cochleae were examined for ototoxic effects. RESULTS: The mice treated with HA-cisplatin showed superior tumor efficacy (1 with complete clinical response, 3 with partial response, 1 with stable disease, and 5 with progressive disease) compared with standard cisplatin (no animals with complete clinical response, 1 with partial response, 1 with stable disease, and 8 with progressive disease), which was statistically significant (P = .003). All control animals developed progressive disease. Weight loss and body score were surrogate measures of treatment toxicity. The HA-cisplatin group had the least weight loss (mean [SD], 10.8% [4.7%]) compared with the cisplatin group (13.6% [5.6%]; P = .25). Body score dropped to 2 or less in all cisplatin-treated mice but not in any HA-cisplatin-treated mice, which also lacked any histologic signs of nephrotoxic or ototoxic effects. CONCLUSIONS AND RELEVANCE: Nanoconjugated HA-cisplatin significantly improves tumor efficacy with lower toxicity compared with standard cisplatin in locally advanced HNSCC in vivo, justifying additional translational studies.

BACKGROUND: The extensive amount of medical literature available on the Internet is frequently accessed by patients. To effectively contribute to healthcare decision-making, these online resources should be worded at a level that is readable by any patient seeking information. The American Medical Association and National Institutes of Health recommend the readability of patient information material should be between a 4th to 6th grade level. In this study, we evaluate the readability of online patient education information available from the American Rhinologic Society (ARS) website using 9 different assessment tools that analyze the materials for reading ease and grade level of the target audience. METHODS: Online patient education material from the ARS was downloaded in February 2012 and assessed for level of readability using the Flesch Reading Ease, Flesch-Kincaid Grade Level, Simple Measure of Gobbledygook (SMOG) Grading, Coleman-Liau Index, Gunning-Fog Index, FORCAST formula, Raygor Readability Estimate, the Fry Graph, and the New Dale-Chall Readability Formula. Each article was pasted as plain text into a Microsoft(R) Word(R) document and each subsection was analyzed using the software package Readability Studio Professional Edition Version 2012.1. RESULTS: All healthcare education materials assessed were written between a 9th grade and graduate reading level and were considered "difficult" to read by the assessment scales. CONCLUSION: Online patient education materials on the ARS website are written above the recommended 6th grade level and may require revision to make them easily understood by a broader audience.