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Yalamanchi P, Marentette LJ, Fendrick AM, Chinn SB, Prince MEP, Rosko AJ, Shuman AG, Spector ME, Stucken CL, Malloy KM, Casper KA. Application of Time-Driven Activity-Based Costing for Head and Neck Microvascular Free Flap Reconstruction. Otolaryngol Head Neck Surg 2024. [PMID: 38643408 DOI: 10.1002/ohn.739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 01/22/2024] [Accepted: 02/05/2024] [Indexed: 04/22/2024]
Abstract
OBJECTIVE Traditional hospital accounting fails to provide an accurate cost of complex surgical care. Here we describe the application of time-driven activity-based costing (TDABC) to characterize costs of head and neck oncologic procedures involving free tissue transfer. STUDY DESIGN Retrospective cohort study. SETTING Single tertiary academic medical center. METHODS An analysis of head and neck oncologic procedures involving microvascular free flap reconstruction from 2018 to 2020 (n = 485) was performed using TDABC methodology to measure cost across operative case and postoperative admission, using quantity of time and cost per unit of each resource to characterize resource utilization. Univariate and generalized linear mixed models were used to examine associations between patient and hospital characteristics and cost of care delivery. RESULTS The total cost of care delivery was $41,905.77 ± 21,870.27 with operating room (OR) supplies accounting for only 10% of the total cost. Multivariable analyses identified significant cost drivers including operative time, postoperative length of stay, number of return trips to the OR, postoperative complication, number of free flaps performed, and patient transfer from another hospital or via emergency department admission (P < .05). CONCLUSION Operative time and postoperative length of stay, but not operative supplies, were primary drivers of cost of care for head and neck oncology cases involving free tissue transfer. TDABC offers granular cost characterization to inform cost optimization through unused capacity identification and postoperative admission efficiencies.
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Affiliation(s)
- Pratyusha Yalamanchi
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lawrence J Marentette
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - A Mark Fendrick
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan, USA
| | - Steven B Chinn
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Mark E P Prince
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Andrew J Rosko
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Andrew G Shuman
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Matthew E Spector
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Chaz L Stucken
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Kelly M Malloy
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Keith A Casper
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Yalamanchi P, Dombrowski J, Pynnonen MA, Malloy KM, Prince ME, Kupfer RA. Investigation of gender-based needs in academic otolaryngology. Laryngoscope Investig Otolaryngol 2024; 9:e1217. [PMID: 38525113 PMCID: PMC10958936 DOI: 10.1002/lio2.1217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/15/2023] [Accepted: 06/22/2023] [Indexed: 03/26/2024] Open
Abstract
Objective Gaps in gender-based equity persist in academic otolaryngology. Here we present a needs-based assessment of otolaryngology faculty and trainees regarding facilitators and barriers to professional satisfaction and career development in academic medicine. Methods A qualitative study of otolaryngology faculty, trainees, and administrators who identify as women at an academic tertiary care center was performed from 2020 to 2021 using focus groups and semi-structured interviews. Five confidential, virtual focus group sessions moderated by a third-party executive coach were audio-taped, transcribed, and reviewed for thematic content. Results Of 48 women invited, 77% participated (18 faculty/administrative leaders, 10 residents/fellows, 4 audiologists). Participants noted direct patient care, support from colleagues who identify as women, and the transition to virtual meetings as facilitators of current professional satisfaction. Five themes emerged as barriers to workplace satisfaction and career development including (1) limited professional schedule flexibility, (2) competing commitments such as childcare exacerbated by pandemic, (3) lack of visible departmental leadership who identify as women, (4) perceived lack of organic sponsorship within subspecialty divisions, and (5) frequent identity-associated microaggressions from patients and staff outside the department. Strategies identified for improving gender-based equity included (1) promoting department-wide awareness of workplace gender-based differences, (2) implicit bias training within established programming such as grand rounds conferences, and (3) novel faculty programming such as leadership development training and formal junior faculty mentorship. Conclusion Confidential needs-based assessment of otolaryngology faculty and trainees identified both persistent gaps and strategies to enhance recruitment, support career development, and grow professional satisfaction of women within academic otolaryngology. Level of Evidence 3.
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Affiliation(s)
- Pratyusha Yalamanchi
- Department of Otolaryngology‐Head and Neck SurgeryMichigan MedicineAnn ArborMichiganUSA
| | | | - Melissa A. Pynnonen
- Department of Otolaryngology‐Head and Neck SurgeryMichigan MedicineAnn ArborMichiganUSA
| | - Kelly M. Malloy
- Department of Otolaryngology‐Head and Neck SurgeryMichigan MedicineAnn ArborMichiganUSA
| | - Mark E. Prince
- Department of Otolaryngology‐Head and Neck SurgeryMichigan MedicineAnn ArborMichiganUSA
| | - Robbi A. Kupfer
- Department of Otolaryngology‐Head and Neck SurgeryMichigan MedicineAnn ArborMichiganUSA
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Yalamanchi P, Faucett EA, Shuman AG. Otolaryngologists and Reproductive Rights. Otolaryngol Head Neck Surg 2023; 169:1393-1396. [PMID: 37210612 DOI: 10.1002/ohn.371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 03/19/2023] [Accepted: 04/23/2023] [Indexed: 05/22/2023]
Abstract
Our nation faces contentious questions regarding reproductive rights and access to abortion which have long been viewed as beyond the scope of otolaryngology. The broad implications of the recent Supreme Court ruling in Dobbs v Jackson Women's Health Organization (Jackson) impact all people who are, or can become, pregnant and their health care providers. The consequences for otolaryngologists are thus far-reaching and poorly understood. Here we describe how the post-Dobbs landscape is relevant to the practice of otolaryngology and offer suggestions for how otolaryngologists can best respond, prepare, and support their patients in this tenuous political landscape.
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Affiliation(s)
- Pratyusha Yalamanchi
- Department of Otolaryngology-Head & Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Erynne A Faucett
- Department of Otolaryngology-Head and Neck Surgery, UC Davis Children's Hospital, Sacramento, USA
| | - Andrew G Shuman
- Department of Otolaryngology-Head & Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Yalamanchi P, Peddireddy NS, McMichael B, Keilin C, Casper KA, Malloy KM, Moyer JS, Prince MEP, Rosko AJ, Stucken CL, Spector ME, Chinn SB. Team-Based Surgical Approach to Head and Neck Microvascular Free Flap Reconstruction. JAMA Otolaryngol Head Neck Surg 2023; 149:1021-1026. [PMID: 37796525 PMCID: PMC10557027 DOI: 10.1001/jamaoto.2023.3028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 08/13/2023] [Indexed: 10/06/2023]
Abstract
Importance Because microvascular free flap reconstruction is increasingly used to restore function in patients with head and neck cancer, there is a growing need for evidence-based perioperative care. Objective To assess the association of different team-based surgical approaches with intraoperative and postoperative outcomes for patients undergoing head and neck free flap reconstruction. Design, Setting, and Participants This retrospective cohort study of 733 patients was conducted at an academic tertiary care medical center. Head and neck oncologic procedures involving microvascular free flap reconstruction with available intraoperative data collected from January 1, 2000, to December 31, 2021, were included. Main Outcomes and Measures Patient characteristics including demographic characteristics and comorbid conditions, operative variables, length of stay, and postoperative outcomes were measured. Descriptive statistics and effect size measures were performed to compare the 3 intraoperative surgical team approaches, specifically single surgeon, separate 2-team approach, and integrated 2-team approach; 1:1 nearest neighbor matching without caliper was performed to compare single- vs 2-team and separate and integrated 2-team approaches. Effect size measures including Cramer V for dichotomous variables, the Kendall W coefficient of concordance for ordinal variables, and η2 for continuous variables were reported with 95% CIs to describe precision. Results Among 733 cases, there were no clinically significant differences in patient demographic characteristics, clinicopathologic characteristics, and choice of free flap reconstruction based on intraoperative surgical team approach. The mean (SD) age was 58.7 (12.4) years, and 514 were male (70.1%). In terms of operative and postoperative variables, there was a difference in operative times and intraoperative fluid requirements among the 3 different techniques, with the integrated 2-team approach demonstrating a mean reduction in operative time of approximately 2 hours (η2 = 0.871; 95% CI, 0.852-0.887; mean [SD] operative time = 541 [191] minutes for the single-surgeon approach, 399 [175] minutes for the integrated 2-team approach, and 537 [200] minutes for the separate 2-team approach) and lower fluid requirements of greater than 1 L (η2 = 0.790; 95% CI, 0.762-0.817). In both unadjusted analyses and propensity score matching, there were no clinically significant differences in terms of ischemia time, use of pressors, postoperative complications (including free flap failure, number of return trips to the operating room, length of stay, or 30-day readmission) based on intraoperative team approach. Conclusions and Relevance Findings suggest that the integrated 2-team surgical approach for complex head and neck microvascular reconstruction can be used to safely decrease operative time, with no difference in postoperative outcomes.
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Affiliation(s)
- Pratyusha Yalamanchi
- Department of Otolaryngology–Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Nithin S. Peddireddy
- Department of Otolaryngology–Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Brennan McMichael
- Department of Otolaryngology–Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Charles Keilin
- Department of Otolaryngology–Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Keith A. Casper
- Department of Otolaryngology–Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Kelly M. Malloy
- Department of Otolaryngology–Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Jeffrey S. Moyer
- Department of Otolaryngology–Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Mark E. P. Prince
- Department of Otolaryngology–Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Andrew J. Rosko
- Department of Otolaryngology–Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Chaz L. Stucken
- Department of Otolaryngology–Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Matthew E. Spector
- Department of Otolaryngology–Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Steven B. Chinn
- Department of Otolaryngology–Head and Neck Surgery, Michigan Medicine, Ann Arbor
- Rogel Cancer Center, University of Michigan, Ann Arbor
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5
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Chang JL, Goldberg AN, Alt JA, Alzoubaidi M, Ashbrook L, Auckley D, Ayappa I, Bakhtiar H, Barrera JE, Bartley BL, Billings ME, Boon MS, Bosschieter P, Braverman I, Brodie K, Cabrera-Muffly C, Caesar R, Cahali MB, Cai Y, Cao M, Capasso R, Caples SM, Chahine LM, Chang CP, Chang KW, Chaudhary N, Cheong CSJ, Chowdhuri S, Cistulli PA, Claman D, Collen J, Coughlin KC, Creamer J, Davis EM, Dupuy-McCauley KL, Durr ML, Dutt M, Ali ME, Elkassabany NM, Epstein LJ, Fiala JA, Freedman N, Gill K, Boyd Gillespie M, Golisch L, Gooneratne N, Gottlieb DJ, Green KK, Gulati A, Gurubhagavatula I, Hayward N, Hoff PT, Hoffmann OM, Holfinger SJ, Hsia J, Huntley C, Huoh KC, Huyett P, Inala S, Ishman SL, Jella TK, Jobanputra AM, Johnson AP, Junna MR, Kado JT, Kaffenberger TM, Kapur VK, Kezirian EJ, Khan M, Kirsch DB, Kominsky A, Kryger M, Krystal AD, Kushida CA, Kuzniar TJ, Lam DJ, Lettieri CJ, Lim DC, Lin HC, Liu SY, MacKay SG, Magalang UJ, Malhotra A, Mansukhani MP, Maurer JT, May AM, Mitchell RB, Mokhlesi B, Mullins AE, Nada EM, Naik S, Nokes B, Olson MD, Pack AI, Pang EB, Pang KP, Patil SP, Van de Perck E, Piccirillo JF, Pien GW, Piper AJ, Plawecki A, Quigg M, Ravesloot MJ, Redline S, Rotenberg BW, Ryden A, Sarmiento KF, Sbeih F, Schell AE, Schmickl CN, Schotland HM, Schwab RJ, Seo J, Shah N, Shelgikar AV, Shochat I, Soose RJ, Steele TO, Stephens E, Stepnowsky C, Strohl KP, Sutherland K, Suurna MV, Thaler E, Thapa S, Vanderveken OM, de Vries N, Weaver EM, Weir ID, Wolfe LF, Tucker Woodson B, Won CH, Xu J, Yalamanchi P, Yaremchuk K, Yeghiazarians Y, Yu JL, Zeidler M, Rosen IM. International Consensus Statement on Obstructive Sleep Apnea. Int Forum Allergy Rhinol 2023; 13:1061-1482. [PMID: 36068685 PMCID: PMC10359192 DOI: 10.1002/alr.23079] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 08/12/2022] [Accepted: 08/18/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA). METHODS Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus. RESULTS The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated. CONCLUSION This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.
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Affiliation(s)
- Jolie L. Chang
- University of California, San Francisco, California, USA
| | | | | | | | - Liza Ashbrook
- University of California, San Francisco, California, USA
| | | | - Indu Ayappa
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | | | | | - Maurits S. Boon
- Sidney Kimmel Medical Center at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Pien Bosschieter
- Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands
| | - Itzhak Braverman
- Hillel Yaffe Medical Center, Hadera Technion, Faculty of Medicine, Hadera, Israel
| | - Kara Brodie
- University of California, San Francisco, California, USA
| | | | - Ray Caesar
- Stone Oak Orthodontics, San Antonio, Texas, USA
| | | | - Yi Cai
- University of California, San Francisco, California, USA
| | | | | | | | | | | | | | | | | | - Susmita Chowdhuri
- Wayne State University and John D. Dingell VA Medical Center, Detroit, Michigan, USA
| | - Peter A. Cistulli
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - David Claman
- University of California, San Francisco, California, USA
| | - Jacob Collen
- Uniformed Services University, Bethesda, Maryland, USA
| | | | | | - Eric M. Davis
- University of Virginia, Charlottesville, Virginia, USA
| | | | | | - Mohan Dutt
- University of Michigan, Ann Arbor, Michigan, USA
| | - Mazen El Ali
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | | | | | | | - Kirat Gill
- Stanford University, Palo Alto, California, USA
| | | | - Lea Golisch
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | | | | | | | - Arushi Gulati
- University of California, San Francisco, California, USA
| | | | | | - Paul T. Hoff
- University of Michigan, Ann Arbor, Michigan, USA
| | - Oliver M.G. Hoffmann
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | | | - Jennifer Hsia
- University of Minnesota, Minneapolis, Minnesota, USA
| | - Colin Huntley
- Sidney Kimmel Medical Center at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | | | - Sanjana Inala
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | | | | | | | | | | | | | | | - Meena Khan
- Ohio State University, Columbus, Ohio, USA
| | | | - Alan Kominsky
- Cleveland Clinic Head and Neck Institute, Cleveland, Ohio, USA
| | - Meir Kryger
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | | | - Derek J. Lam
- Oregon Health and Science University, Portland, Oregon, USA
| | | | | | | | | | | | | | - Atul Malhotra
- University of California, San Diego, California, USA
| | | | - Joachim T. Maurer
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | - Anna M. May
- Case Western Reserve University, Cleveland, Ohio, USA
| | - Ron B. Mitchell
- University of Texas, Southwestern and Children’s Medical Center Dallas, Texas, USA
| | | | | | | | | | - Brandon Nokes
- University of California, San Diego, California, USA
| | | | - Allan I. Pack
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | | | | | | | | | | | | | - Mark Quigg
- University of Virginia, Charlottesville, Virginia, USA
| | | | - Susan Redline
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Armand Ryden
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | | | - Firas Sbeih
- Cleveland Clinic Head and Neck Institute, Cleveland, Ohio, USA
| | | | | | | | | | - Jiyeon Seo
- University of California, Los Angeles, California, USA
| | - Neomi Shah
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | - Ryan J. Soose
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Erika Stephens
- University of California, San Francisco, California, USA
| | | | | | | | | | - Erica Thaler
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sritika Thapa
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Nico de Vries
- Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands
| | | | - Ian D. Weir
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | | | - Josie Xu
- University of Toronto, Ontario, Canada
| | | | | | | | | | | | - Ilene M. Rosen
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
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6
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Benjamin WJ, Yalamanchi P, Taylor JMG, Lenze N, Worden FP, Chinn SB, Chen MM. Impact of monoclonal antibody therapy for head and neck cancer on end-of-life care utilization and costs. Head Neck 2023; 45:1468-1475. [PMID: 36976786 DOI: 10.1002/hed.27359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 03/08/2023] [Accepted: 03/20/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND The impact of monoclonal antibody therapy (mAB) for advanced head and neck cancer on end-of-life health care utilization and costs has yet to be adequately studied. METHODS Retrospective cohort study of patients aged 65 and over with a diagnosis of head and neck cancer between 2007 and 2017 within the SEER-Medicare registry assessing the impact of mAB therapy (i.e., cetuximab, nivolumab, or pembrolizumab) on end-of-life health care utilization (ED visits, inpatient admissions, ICU admissions, and hospice claims) and costs. RESULTS Of 12 544 patients with HNC, 270 (2.2%) utilized mAB therapy at the end-of-life period. On multivariable analyses adjusting for demographic and clinicopathologic characteristics, there was a significant association between mAB therapy and emergency department visits (OR: 1.38, 95% CI: 1.1-1.8, p = 0.01) and healthcare costs (β: $9760, 95% CI: 5062-14 458, p < 0.01). CONCLUSIONS mAB use is associated with higher emergency department utilization and health care costs potentially due to infusion-related and drug toxicity expenses.
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Affiliation(s)
| | - Pratyusha Yalamanchi
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Jeremy M G Taylor
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Nicholas Lenze
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Francis P Worden
- Division of Hematology and Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Steven B Chinn
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Michelle M Chen
- Department of Otolaryngology - Head and Neck Surgery, Stanford University, Stanford, California, USA
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7
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Peddireddy NS, Yalamanchi P, Kashlan O, Park P, Reddy RM, Chinn SB, Casper KA, Malloy KM, Stucken CL, Prince MEP, Rosko AJ, Spector ME. Anterior spinal hardware erosion of the pharyngoesophagus: A difficult reconstructive challenge-Our experience in nine patients. Clin Otolaryngol 2023; 48:264-268. [PMID: 36536995 DOI: 10.1111/coa.14025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 08/24/2022] [Accepted: 12/04/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Nithin S Peddireddy
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Pratyusha Yalamanchi
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Osama Kashlan
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Paul Park
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Rishindra M Reddy
- Section of Thoracic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Steven B Chinn
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Keith A Casper
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Kelly M Malloy
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Chaz L Stucken
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Mark E P Prince
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Andrew J Rosko
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Matthew E Spector
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, USA
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8
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Benjamin WJ, Lenze NR, Yalamanchi P, Farlow JL, Mihalic AP, Bohm LA, Thorne MC, Kupfer RA. Impact of applicant and program factors on preference signaling outcomes in otolaryngology. Laryngoscope Investig Otolaryngol 2023; 8:401-408. [PMID: 37090886 PMCID: PMC10116966 DOI: 10.1002/lio2.1025] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 02/06/2023] [Accepted: 02/09/2023] [Indexed: 03/02/2023] Open
Abstract
Objectives To assess the impact of applicant and program characteristics on preference signaling outcomes during the 2021 and 2022 application cycles in otolaryngology. Methods The Texas Seeking Transparency in Applications to Residency survey was used for otolaryngology applicants during the 2021 and 2022 match years. The primary outcome of interest was signal yield, defined as the number of interviews at signaled programs divided by the total number of signals sent. Associations with applicant-reported characteristics, geographic connections to programs, and program reputation were assessed. Results On average 59.5% of signals resulted in an interview (signal yield). There was a positive correlation between the number of signals sent to a program with a reported geographic connection and signal yield, with each additional signal resulting in a 3.4% increase in signal yield (p = .03). Signal yield was positively associated with number of publications (p < .001); number of abstracts, posters, and presentations (p = .04); and whether the applicant took a research year (p = .003). Applicants with higher USMLE Step 1 (p = .01) and Step 2 (p = .003) scores, publications (p = .03), volunteer (p = .008) and leadership (p = .001) experiences received a lower percentage of their total interviews from signaled programs whereas applicants from the 3rd (p < .001) and 4th (p = .03) cumulative class ranked quartiles received a higher percentage of their total interviews from signaled programs. Conclusions Signal yield appears to have a significant association with geographic connections to programs and applicant competitiveness. This study may help applicants, advisors, and programs maximize the benefit of the preference signaling system.Levels of evidence: Level 4.
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Affiliation(s)
| | - Nicholas R. Lenze
- Department of Otolaryngology—Head and Neck Surgery University of Michigan Medical School Ann Arbor Michigan USA
| | - Pratyusha Yalamanchi
- Department of Otolaryngology—Head and Neck Surgery University of Michigan Medical School Ann Arbor Michigan USA
| | - Janice L. Farlow
- Department of Otolaryngology—Head and Neck Surgery The Ohio State University Wexler Medical Center Columbus Ohio USA
| | - Angela P. Mihalic
- Department of Pediatrics University of Texas Southwestern Medical Center Dallas Texas USA
| | - Lauren A. Bohm
- Department of Otolaryngology—Head and Neck Surgery University of Michigan Medical School Ann Arbor Michigan USA
| | - Marc C. Thorne
- Department of Otolaryngology—Head and Neck Surgery University of Michigan Medical School Ann Arbor Michigan USA
| | - Robbi A. Kupfer
- Department of Otolaryngology—Head and Neck Surgery University of Michigan Medical School Ann Arbor Michigan USA
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Mayo CS, Mierzwa M, Yalamanchi P, Evans J, Worden F, Medlin R, Schipper M, Schonewolf C, Shah J, Spector M, Swiecicki P, Mayo K, Casper K. Machine Learning Model of Emergency Department Use for Patients Undergoing Treatment for Head and Neck Cancer Using Comprehensive Multifactor Electronic Health Records. JCO Clin Cancer Inform 2023; 7:e2200037. [PMID: 36638327 DOI: 10.1200/cci.22.00037] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
PURPOSE To use a hybrid method, combining statistical profiling, machine learning (ML), and clinical evaluation to predict emergency department (ED) visits among patients with head and neck cancer undergoing radiotherapy. MATERIALS AND METHODS Patients with head and neck cancer treated with radiation therapy from 2015 to 2019 were identified using electronic health record data. Records from 60 days before 90 days after treatment were analyzed. Statistical profiling and ML were used to create a predictive model for ED visits during or after radiation therapy. A comprehensive set of variables were studied. Multiple ML models were developed including extreme gradient-boosted decision tree and generalized logistic regression with comparison of multiple predictive performance metrics. RESULTS Of the 1,355 patients studied, 13% had an ED visit during or after treatment. Our hybrid methodology enabled evidence-based winnowing of candidate features from 141 to 11 with clinically applicable, evidence-based thresholds. Extreme gradient boosting had the highest area under the curve (0.81 ± 0.06) with a sensitivity of 0.89 ± 0.10 and exceeded generalized logistic regression (area under the curve 0.64 ± 0.02). Significant predictors of ED visits during treatment included increasingly complex opioid use, number of prior ED visits, tumor volume, rate of change of blood urea nitrogen, total bilirubin, body mass index, and distance from hospital. CONCLUSION Our approach combining bootstrapped statistical profiling and ML importance analysis supported integration of clinician input to identify a distilled set of phenotypical characteristics for developing ML models predicting which patients undergoing head and neck cancer radiation therapy were at risk for ED visits.
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Affiliation(s)
- Charles S Mayo
- Department of Radiation Oncology University of Michigan, Ann Arbor, MI
| | - Michelle Mierzwa
- Department of Radiation Oncology University of Michigan, Ann Arbor, MI
| | | | - Joseph Evans
- Department of Radiation Oncology University of Michigan, Ann Arbor, MI
| | - Francis Worden
- Department of Internal Medicine University of Michigan, Ann Arbor, MI
| | - Richard Medlin
- Department of Emergency Medicine University of Michigan, Ann Arbor, MI
| | - Matthew Schipper
- Department of Biostatistics University of Michigan, Ann Arbor, MI
| | | | - Jennifer Shah
- Department of Radiation Oncology University of Michigan, Ann Arbor, MI
| | - Matthew Spector
- Department of Otolaryngology University of Michigan, Ann Arbor, MI
| | - Paul Swiecicki
- Department of Otolaryngology University of Michigan, Ann Arbor, MI
| | - Katherine Mayo
- Department of Computer Science and Engineering University of Michigan, Ann Arbor, MI
| | - Keith Casper
- Department of Otolaryngology University of Michigan, Ann Arbor, MI
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10
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Yalamanchi P, Casper KA, Malloy KM. Reducing Surgical Instruments In Otolaryngology Instrument Trays-Realized Cost Savings Remain Uncertain-Reply. JAMA Otolaryngol Head Neck Surg 2022; 148:893-894. [PMID: 35862059 DOI: 10.1001/jamaoto.2022.1719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Pratyusha Yalamanchi
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Keith A Casper
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Kelly M Malloy
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor
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11
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Yalamanchi P, Miller JE, Prout S, Matthews E, Spagnol C, Harrington S, Chang HF, Spector ME, Casper KA, Malloy KM. Association of Operating Room Costs With Head and Neck Surgical Instrumentation Optimization: A Surgeon-Led Quality Improvement Initiative. JAMA Otolaryngol Head Neck Surg 2022; 148:402-407. [PMID: 35266982 PMCID: PMC8914886 DOI: 10.1001/jamaoto.2022.0032] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance In an era of increasing health care expenditure, reduction of redundant head and neck surgical instrumentation may minimize waste. Objective To (1) optimize head and neck surgical instrument trays at a single large academic tertiary care center and (2) identify associated direct cost savings. Design, Setting, and Participants This prospective quality improvement initiative was conducted at an academic tertiary care medical center from July 2017 through July 2021. Participants were a multidisciplinary surgical quality team consisting of head and neck surgeons, operating room nurses, surgical technicians, and supply chain analysts. Main Outcomes and Measures The 4 primary surgical instrument trays (major otolaryngology [Oto], Oto plastics, direct laryngoscopy, and microdirect laryngoscopy) used in all head and neck procedures were reviewed by 10 head and neck surgical faculty with detailed case observation of instrument utilization performed by trained operating room nurses and surgical technologists. Instruments used in less than 40% of cases were excluded from surgical trays, and novel instrument trays were established based on faculty feedback and utilization. Data on instrument processing, utilization, and associated institutional direct costs were prospectively collected over a 3-year period. The primary outcome measure was change in operating room direct costs. Surgeon satisfaction with the quality improvement intervention was the secondary outcome. Direct cost savings were identified as a function of surgical volume, labor and supply costs, and instrument depreciation. Results More than 1500 eligible surgical cases were reviewed during the preintervention period. Of the 149 instruments in the major Oto tray, only 118 (79%) instruments were used in more than 40% of cases. There were 58 (49%) and 32 (21%) instruments in this tray that were used in more than 40% of neck dissections and sentinel lymph node biopsies, respectively. Resulting intervention included development of a streamlined major Oto tray with 118 instruments and novel neck dissection and sentinel lymph node biopsy trays. Similar processes were applied to the remaining head and neck trays, with a total of 257 instruments removed. Over a 3-year postintervention period, streamlined surgical trays were used 9284 times with direct cost savings of $228 338 (95% CI, $227 817-$228 854). Overall surgeon satisfaction with the optimized head and neck surgical trays was 100%. Conclusions and Relevance In this quality improvement study, surgeon-led elimination of redundant or rarely used instruments from surgical instrument trays was associated with reduced operating room direct costs while maintaining stakeholder satisfaction.
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Affiliation(s)
- Pratyusha Yalamanchi
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Jessa E Miller
- Department of Head and Neck Surgery, University of California Los Angeles
| | - Stephanie Prout
- University Operating Rooms Administration, Michigan Medicine, Ann Arbor
| | - Eden Matthews
- University Operating Rooms Administration, Michigan Medicine, Ann Arbor
| | - Colleen Spagnol
- University Operating Rooms Administration, Michigan Medicine, Ann Arbor
| | | | - Helen F Chang
- University Operating Rooms Administration, Michigan Medicine, Ann Arbor
| | - Matthew E Spector
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Keith A Casper
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor
| | - Kelly M Malloy
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor
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12
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Patel AU, Yalamanchi P, Peddireddy NS, Hoff PT. Hypoglossal Nerve Stimulator Explantation: A Case Series. OTO Open 2022; 6:2473974X221106778. [PMID: 35733445 PMCID: PMC9208050 DOI: 10.1177/2473974x221106778] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 05/25/2022] [Indexed: 12/02/2022] Open
Abstract
Hypoglossal nerve stimulation (HGNS) has emerged as a successful surgical treatment strategy for moderate to severe obstructive sleep apnea in patients failing first-line positive airway pressure therapy. HGNS explantation due to adverse events such as pain and infection is rare and has yet to be well described. Here, our correspondence describes the first case series of patients who have undergone explantation of the Inspire HGNS system. Five patients were identified who underwent HGNS explantation. Three patients underwent explantation due to magnetic resonance imaging (MRI) incompatibility. One patient underwent explantation due to poor cosmesis. One patient underwent explantation due to surgical site infection. Average operative explant time was 163 minutes. MRI incompatibility, poor cosmesis, and device-related infection are reasons for HGNS explantation. Future need for MRI or chest wall surgery should be considered in patients being evaluated for HGNS implants.
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Affiliation(s)
- Anuj U Patel
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Pratyusha Yalamanchi
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Nithin S Peddireddy
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Paul T Hoff
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, USA
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13
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Haring CT, Dermody SM, Yalamanchi P, Kang SY, Old MO, Chad Brenner J, Spector ME, Rocco JW. The future of circulating tumor DNA as a biomarker in HPV related oropharyngeal squamous cell carcinoma. Oral Oncol 2022; 126:105776. [DOI: 10.1016/j.oraloncology.2022.105776] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/02/2022] [Accepted: 02/13/2022] [Indexed: 12/30/2022]
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14
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Yalamanchi P, Casper KA, Evans J, Mierzwa M, Morrison RJ, Prince ME, Mayo CS. Facilitating Automated Data Analytics Through Structured Head and Neck Oncology Tumor Board Documentation. JCO Clin Cancer Inform 2022; 6:e2100168. [PMID: 35258988 PMCID: PMC8920465 DOI: 10.1200/cci.21.00168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Expert-driven, electronic tumor board documentation automates oncologic data capture and reporting.![]()
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Affiliation(s)
- Pratyusha Yalamanchi
- Pratyusha Yalamanchi, MD, MBA, and Keith A. Casper, MD, Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor, MI; Joseph Evans, MD, and Michelle Mierzwa, MD, Department of Radiation Oncology, University of Michigan, Ann Arbor, MI; Robert J. Morrison, MD, and Mark E. Prince, MD, Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor, MI; and Charles S. Mayo, PhD, Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Keith A Casper
- Pratyusha Yalamanchi, MD, MBA, and Keith A. Casper, MD, Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor, MI; Joseph Evans, MD, and Michelle Mierzwa, MD, Department of Radiation Oncology, University of Michigan, Ann Arbor, MI; Robert J. Morrison, MD, and Mark E. Prince, MD, Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor, MI; and Charles S. Mayo, PhD, Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Joseph Evans
- Pratyusha Yalamanchi, MD, MBA, and Keith A. Casper, MD, Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor, MI; Joseph Evans, MD, and Michelle Mierzwa, MD, Department of Radiation Oncology, University of Michigan, Ann Arbor, MI; Robert J. Morrison, MD, and Mark E. Prince, MD, Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor, MI; and Charles S. Mayo, PhD, Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Michelle Mierzwa
- Pratyusha Yalamanchi, MD, MBA, and Keith A. Casper, MD, Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor, MI; Joseph Evans, MD, and Michelle Mierzwa, MD, Department of Radiation Oncology, University of Michigan, Ann Arbor, MI; Robert J. Morrison, MD, and Mark E. Prince, MD, Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor, MI; and Charles S. Mayo, PhD, Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Robert J Morrison
- Pratyusha Yalamanchi, MD, MBA, and Keith A. Casper, MD, Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor, MI; Joseph Evans, MD, and Michelle Mierzwa, MD, Department of Radiation Oncology, University of Michigan, Ann Arbor, MI; Robert J. Morrison, MD, and Mark E. Prince, MD, Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor, MI; and Charles S. Mayo, PhD, Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Mark E Prince
- Pratyusha Yalamanchi, MD, MBA, and Keith A. Casper, MD, Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor, MI; Joseph Evans, MD, and Michelle Mierzwa, MD, Department of Radiation Oncology, University of Michigan, Ann Arbor, MI; Robert J. Morrison, MD, and Mark E. Prince, MD, Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor, MI; and Charles S. Mayo, PhD, Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Charles S Mayo
- Pratyusha Yalamanchi, MD, MBA, and Keith A. Casper, MD, Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor, MI; Joseph Evans, MD, and Michelle Mierzwa, MD, Department of Radiation Oncology, University of Michigan, Ann Arbor, MI; Robert J. Morrison, MD, and Mark E. Prince, MD, Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor, MI; and Charles S. Mayo, PhD, Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
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15
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Yalamanchi P, Parent AL, Baetzel AE, Crowe SM, Gutting AA, Gisondo G, Portice LC, Thorne MC, Wagner DS, Bates KE, Tribble AC. Optimization of Antibiotic Prophylaxis Delivery for Pediatric Surgical Procedures. Pediatrics 2021; 148:peds.2020-001669. [PMID: 34272341 DOI: 10.1542/peds.2020-001669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/09/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To optimize prophylactic antibiotic timing and delivery across all surgeries performed at a single large pediatric tertiary care center. METHODS A multidisciplinary surgical quality team conducted a quality improvement initiative from July 2015 to December 2019 by using the A3 problem-solving method to identify and evaluate interventions for appropriate antibiotic administration. The primary outcome measure was the percentage of surgical encounters for pediatric patients with appropriate timing of antibiotic administration before surgical incision. Surgical site infection rates was the secondary outcome. Intervention effectiveness was assessed by using statistical process control. RESULTS A total of 32 192 eligible surgical cases for pediatric patients were completed during the study period. Identified barriers to timely perioperative antibiotic administration included failure to order antibiotics before the surgical date and lack of antibiotic availability in the operating room at the time of administration. Resulting sequential interventions included updating institutional guidelines to reflect procedure-specific antibiotic choices and clarifying timing of administration to optimize pharmacokinetics, creating a hard-stop antibiotic order within electronic health record case requests, optimizing pharmacy and nursing workflow, and implementing an automatic antibiotic prophylaxis timer in the operating room. Administration of prophylactic antibiotics during the recommended preincision time window significantly improved; the correct timing was recorded in 38.6% of preintervention cases versus 94.0% at the conclusion of rollout of the sequential interventions (P < .001). Surgical site infection rates remained stable. CONCLUSIONS Here we demonstrate utility of the A3 problem-solving schematic to successfully optimize prophylactic antibiotic timing and delivery in the surgical setting for pediatric patients by implementing systems-based interventions.
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Affiliation(s)
| | - Ashley L Parent
- C.S. Mott Children's Hospital and University of Michigan, Ann Arbor, Michigan
| | - Anne E Baetzel
- C.S. Mott Children's Hospital and University of Michigan, Ann Arbor, Michigan
| | - Susan M Crowe
- C.S. Mott Children's Hospital and University of Michigan, Ann Arbor, Michigan
| | - Andrew A Gutting
- C.S. Mott Children's Hospital and University of Michigan, Ann Arbor, Michigan
| | - Gino Gisondo
- C.S. Mott Children's Hospital and University of Michigan, Ann Arbor, Michigan
| | - Lynda C Portice
- C.S. Mott Children's Hospital and University of Michigan, Ann Arbor, Michigan
| | - Marc C Thorne
- C.S. Mott Children's Hospital and University of Michigan, Ann Arbor, Michigan
| | - Deborah S Wagner
- C.S. Mott Children's Hospital and University of Michigan, Ann Arbor, Michigan
| | - Katherine E Bates
- C.S. Mott Children's Hospital and University of Michigan, Ann Arbor, Michigan
| | - Alison C Tribble
- C.S. Mott Children's Hospital and University of Michigan, Ann Arbor, Michigan
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16
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Yalamanchi P, Mott N, Ali SA, Peddireddy NS, Kovatch KJ, Stanley JJ, Hoff PT. Evaluation of In-Office Volitional Snore as a Screening Tool for Candidacy for Hypoglossal Nerve Stimulation. Otolaryngol Head Neck Surg 2021; 166:595-597. [PMID: 34182856 DOI: 10.1177/01945998211023733] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Candidacy evaluation for hypoglossal nerve stimulation (HGNS) is resource intensive. This proof-of-concept study investigates use of in-office volitional snore during flexible laryngoscopy as an efficient, cost-effective screening tool for HGNS evaluation. Adults with moderate to severe obstructive sleep apnea that failed continuous positive airway pressure treatment (n = 41) underwent evaluation for HGNS from 2018 to 2019. Volitional snore and drug-induced sleep endoscopy (DISE) data were collected and scored by VOTE classification (velum/palate, oropharynx, tongue base, epiglottis). A chi-square test of independence was performed that demonstrated a significant relationship between volitional snore and DISE (χ2 = 4.39, P = .036) for velum collapse pattern. Sensitivity and specificity of volitional snore for detecting velum collapse pattern were 93.6% (95% CI, 75.6%-99.2%) and 40% (95% CI, 12.2%-73.8%), respectively, illustrating its utility in screening for HGNS. Patients who demonstrate anterior-posterior velum collapse on volitional snore may be excellent candidates for confirmatory DISE at the time of HGNS implantation.
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Affiliation(s)
- Pratyusha Yalamanchi
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Nicole Mott
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Syed Ahmed Ali
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Nithin S Peddireddy
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Kevin J Kovatch
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jeffrey J Stanley
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Paul T Hoff
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
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17
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Yalamanchi P, Blythe M, Gidley KS, Blythe WR, Waguespack RW, Brenner MJ. The Evolving Role of Advanced Practice Providers in Otolaryngology: Improving Patient Access and Patient Satisfaction. Otolaryngol Head Neck Surg 2021; 166:6-9. [PMID: 34154448 DOI: 10.1177/01945998211020314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The aging US population requires an increasing volume of otolaryngology-head and neck surgery services, yet the otolaryngologist physician workforce remains static. Advanced practice providers (APPs), including physician assistants and nurse practitioners, improve access across the continuum of primary and subspecialty health care. The rapid growth of APP service is evidenced by a 51% increase in APP Medicare billing for otolaryngology procedures over 5 years. APPs increasingly participate in delivering otolaryngology care; however, reaping the benefits of enhanced patient access and modernizing care delivery is predicated on successful integration of APPs into practices. Few data are available on how best to incorporate APPs into team-based models or how to restructure practices to allow graduated responsibility that supports autonomy and effective teamwork. We compare national APP and physician workforce trends in otolaryngology, consider approaches to optimizing efficiency by integrating APPs, and identify opportunities for improving data collection and practice.
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Affiliation(s)
- Pratyusha Yalamanchi
- Department of Otolaryngology-Head & Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | | | - Kristi S Gidley
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - Richard W Waguespack
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Michael J Brenner
- Department of Otolaryngology-Head & Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Yalamanchi P, Thomas WW, Workman AD, Rajasekaran K, Chalian AA, Shanti RM, Newman JG, Cannady SB. Value of Intensive Care Unit-Based Postoperative Management for Microvascular Free Flap Reconstruction in Head and Neck Surgery. Facial Plast Surg Aesthet Med 2021; 23:49-53. [PMID: 32552082 DOI: 10.1089/fpsam.2020.0055] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Importance: Although routine postoperative care for microvascular free flap reconstruction typically involves admission to the intensive care unit (ICU), few studies have investigated the effect of postoperative care setting on clinical outcomes and institution cost. Objectives: To determine the value of non-ICU-based postoperative management for free tissue transfer for head and neck surgery, in terms of clinical outcomes and cost-effectiveness. Design, Setting, and Participants: This is a retrospective cohort study of two groups of adults who underwent vascularized free tissue transfer from October 2013 to October 2017 at an academic tertiary care center and community-based hospital, respectively. Postoperative management differed such that the first group recovered in a protocol-driven non-ICU setting and the second group was cared for in a planned admission to the ICU. A single surgeon performed all tissue harvest and reconstruction at both centers. Main Outcomes and Measures: Descriptive statistics and cost analyses were performed to compare clinical outcomes and total surgical and downstream direct cost to the institution between the two patient groups. Categorical variables were compared using χ2 test where appropriate. Results: Among a total of 338 patients who underwent microvascular free flap reconstruction for head and neck surgical defects, there was no significant difference in patient characteristics such as demographics, comorbidities, history of surgical resection, prior free flap, and locoradiation between the postoperative ICU cohort (n = 146) and protocol-driven non-ICU cohort (n = 192). There were 16 patients in the non-ICU group who spent >3 days in the ICU postoperatively secondary to patient comorbidities and patient care priorities. Still, the average ICU length of stay was 7 days (interquartile range [IQR] 6-9 days) for the planned ICU cohort versus 1 day (IQR 0-1) for the non-ICU group (p < 0.00001). There was no difference in operative variables such as donor site, case length, or total length of stay, and postoperative management in the ICU versus non-ICU setting resulted in no significant difference in terms of flap survival, reoperation, readmission, and postoperative complications. However, average cost of care was significantly higher for patients who received ICU-based care versus non-ICU postoperative care. Specifically, room and board were 239% more costly for the planned ICU care group than the non-ICU setting (p < 0.00001). Conclusions and Relevance: This study demonstrates that postoperative management after vascularized free tissue transfer in a non-ICU setting is equivalent to standard ICU-based management, in terms of clinical outcomes, while being less costly.
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Affiliation(s)
- Pratyusha Yalamanchi
- Department of Otolaryngology-Head & Neck Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - William W Thomas
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alan D Workman
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ara A Chalian
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rabie M Shanti
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Oral and Maxillofacial Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason G Newman
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Steven B Cannady
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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VanKoevering KK, Yalamanchi P, Haring CT, Phillips AG, Harvey SL, Rojas-Pena A, Zopf DA, Green GE. Delivery system can vary ventilatory parameters across multiple patients from a single source of mechanical ventilation. PLoS One 2020; 15:e0243601. [PMID: 33301512 PMCID: PMC7728450 DOI: 10.1371/journal.pone.0243601] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 11/24/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Current limitations in the supply of ventilators during the Covid19 pandemic have limited respiratory support for patients with respiratory failure. Split ventilation allows a single ventilator to be used for more than one patient but is not practicable due to requirements for matched patient settings, risks of cross-contamination, harmful interference between patients and the inability to individualize ventilator support parameters. We hypothesized that a system could be developed to circumvent these limitations. METHODS AND FINDINGS A novel delivery system was developed to allow individualized peak inspiratory pressure settings and PEEP using a pressure regulatory valve, developed de novo, and an inline PEEP 'booster'. One-way valves, filters, monitoring ports and wye splitters were assembled in-line to complete the system and achieve the design targets. This system was then tested to see if previously described limitations could be addressed. The system was investigated in mechanical and animal trials (ultimately with a pig and sheep concurrently ventilated from the same ventilator). The system demonstrated the ability to provide ventilation across clinically relevant scenarios including circuit occlusion, unmatched physiology, and a surgical procedure, while allowing significantly different pressures to be safely delivered to each animal for individualized support. CONCLUSIONS In settings of limited ventilator availability, systems can be developed to allow increased delivery of ventilator support to patients. This enables more rapid deployment of ventilator capacity under constraints of time, space and financial cost. These systems can be smaller, lighter, more readily stored and more rapidly deployable than ventilators. However, optimizing ventilator support for patients with individualized ventilation parameters will still be dependent upon ease of use and the availability of medical personnel.
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Affiliation(s)
- Kyle K. VanKoevering
- Department of Otolaryngology, Head & Neck Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States of America
- Department of Otolaryngology, Head and Neck Surgery, Wexner Medical Center, Ohio State University, Columbus, OH, United States of America
- * E-mail:
| | - Pratyusha Yalamanchi
- Department of Otolaryngology, Head & Neck Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States of America
| | - Catherine T. Haring
- Department of Otolaryngology, Head & Neck Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States of America
| | - Anne G. Phillips
- Department of Surgery, Section of Transplantation, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States of America
| | - Stephen Lewis Harvey
- Department of Surgery, Section of Transplantation, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States of America
| | - Alvaro Rojas-Pena
- Department of Surgery, Section of Transplantation, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States of America
| | - David A. Zopf
- Department of Otolaryngology, Head & Neck Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States of America
| | - Glenn E. Green
- Department of Otolaryngology, Head & Neck Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States of America
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Hanks JE, Yalamanchi P, Kovatch KJ, Ali SA, Smith JD, Durham AB, Bradford CR, Malloy KM, McLean SA. Cranial nerve outcomes in regionally recurrent head & neck melanoma after sentinel lymph node biopsy. Laryngoscope 2020; 130:1707-1714. [PMID: 31441955 DOI: 10.1002/lary.28243] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 06/28/2019] [Accepted: 07/31/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Characterize long-term cranial nerve (CN) outcomes following sentinel lymph node biopsy (SLNB) based management for head and neck cutaneous melanoma (HNCM). METHODS Longitudinal review of HNCM patients undergoing SLNB from 1997-2007. RESULTS Three hundred fifty-six patients were identified, with mean age 53.5 ± 19.0 years, mean Breslow depth 2.52 ± 1.87 mm, and 4.9 years median follow-up. One hundred five (29.4%) patients had SLNB mapping to the parotid basin. Eighteen patients had positive parotid SLNs and underwent immediate parotidectomy / immediate completion lymph node dissection (iCLND), with six possessing positive parotid non-sentinel lymph nodes (NSLNs). Fifty-two of 356 (14.6%) patients developed delayed regional recurrences, including 20 total intraparotid recurrences: five following false negative (FN) parotid SLNB, three following prior immediate superficial parotidectomy, two following iCLND without parotidectomy, and the remaining 12 parotid recurrences had negative extraparotid SLNBs. Parotid recurrences were multiple (4.9 mean recurrent nodes) and advanced (n = 4 extracapsular extension), and all required salvage dissection including parotidectomy. Immediate parotidectomy/iCLND led to no permanent CN injuries. Delayed regional HNCM macrometastasis precipitated 16 total permanent CN injuries in 13 patients: 10 CN VII, five CN XI, and one CN XII deficits. Fifty percent (n = 10) of parotid recurrences caused ≥1 permanent CN deficits. CONCLUSIONS Regional HNCM macrometastases and salvage dissection confer marked CN injury risk, whereas early surgical intervention via SLNB ± iCLND ± immediate parotidectomy yielded no CN injuries. Further, superficial parotidectomy performed in parotid-mapping HNCM does not obviate delayed intraparotid recurrences, which increase risk of CN VII injury. Despite lack of a published disease-specific survival advantage in melanoma, early disease control in cervical and parotid basins is paramount to minimize CN complications. LEVEL OF EVIDENCE 4 (retrospective case series) Laryngoscope, 130:1707-1714, 2020.
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Affiliation(s)
- John E Hanks
- Department of Otolaryngology-Head & Neck Surgery, University of California-Davis Medical center, Ann Arbor, Michigan, U.S.A
| | - Pratyusha Yalamanchi
- Department of Dermatology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, U.S.A
| | - Kevin J Kovatch
- Department of Dermatology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, U.S.A
| | - S Ahmed Ali
- Department of Dermatology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, U.S.A
| | - Joshua D Smith
- Department of Dermatology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, U.S.A
| | - Alison B Durham
- Department of Dermatology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, U.S.A
| | - Carol R Bradford
- Department of Dermatology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, U.S.A
- University of Michigan Medical School, Ann Arbor, Michigan, U.S.A
| | - Kelly M Malloy
- Department of Dermatology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, U.S.A
| | - Scott A McLean
- Department of Dermatology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, U.S.A
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Abstract
OBJECTIVES There is limited evidence regarding use of routine perioperative antibiotics for pediatric otolaryngologic procedures. The objectives of this quality improvement study were (1) to characterize the otolaryngology case mix for which antibiotics were delivered and (2) determine the percentage of surgical encounters with appropriate timing of antibiotic administration. METHODS Pediatric otolaryngology procedures meeting criteria from 2015 to 2019 were evaluated as a component of an institution-wide pediatric surgical antibiotic prophylaxis study using A3 problem solving to identify and roll out interventions for appropriate antibiotic administration. Descriptive statistical analysis of the interrupted time-series data was used to describe the otolaryngology case mix for which antibiotics were delivered. The primary outcome measure was percentage of surgical encounters with appropriate timing of antibiotic administration in minutes relative to incision. RESULTS In total, 1520 pediatric otolaryngology procedures with perioperative antibiotic delivery were performed from July 2015 to September 2019. While surgical site infection number (n = 2/year) was stable, administration of timely prophylactic antibiotics significantly improved: 27.5% of cases per month at baseline and 86.9% at the conclusion of the rollout of the sequential interventions (P < .001). DISCUSSION Given the exceedingly low infection rate of clean otolaryngology surgery, there is limited evidence in favor of perioperative antibiotics for the majority of procedures. Prophylactic antibiotics were most commonly used in otologic surgery involving cochlear implantation or in the setting of draining ears or cholesteatoma and in clean-contaminated head and neck surgery cases. IMPLICATIONS FOR PRACTICE Iterative continuous performance improvement can optimize evidence-based delivery of preoperative prophylactic antibiotics. Additional interventions to ensure antimicrobial stewardship in pediatric otolaryngology are indicated.
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Affiliation(s)
- Pratyusha Yalamanchi
- Department of Otolaryngology, Head & Neck Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Ashley Parent
- CS Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
| | - Marc Thorne
- Department of Otolaryngology, Head & Neck Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Yalamanchi P, Coblens O, Ahn M, Cannady SB, Newman JG. A rare case of odontoameloblastoma in a geriatric patient. Ear Nose Throat J 2018; 97:E43-E45. [PMID: 30138526 DOI: 10.1177/014556131809700809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Odontoameloblastoma is an extremely rare tumor derived from odontogenic epithelium and mesenchyme. In the fewer than 20 reported cases, odontoameloblastoma is described as occurring in the maxilla or mandible of young men with a history of unerupted teeth. Here we report a case of a 73-year-old woman who presented to the dentist for routine cleaning and x-rays, which displayed a mandibular lesion. After referral to multiple providers, a biopsy of two involved teeth was obtained and computed tomography of the neck was performed, revealing a large, destructive lesion of the mandible. Histology was consistent with odontoameloblastoma. The patient underwent wide segmental mandibular resection and scapula tip free flap reconstruction. She recovered uneventfully and continues to have close follow-up, given the risk of recurrence. To the best of our knowledge, this is the first reported case of odontoameloblastoma in a patient over age 50. The goal of the authors is to raise awareness of this rare pathology and its diagnostic and management modalities.
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Affiliation(s)
- Pratyusha Yalamanchi
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA.
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Rajasekaran K, Stubbs V, Chen J, Yalamanchi P, Cannady S, Brant J, Newman J. Mucoepidermoid carcinoma of the parotid gland: A National Cancer Database study. Am J Otolaryngol 2018; 39:321-326. [PMID: 29559174 DOI: 10.1016/j.amjoto.2018.03.022] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 03/11/2018] [Accepted: 03/13/2018] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To describe the demographics, tumor characteristics, and prognostic features of mucoepidermoid carcinoma of the parotid gland. MATERIALS AND METHODS A retrospective study of the National Cancer Database was reviewed for all mucoepidermoid carcinomas of the parotid gland between 2004 and 2012). Patient demographics and tumor characteristics were abstracted and analyzed. Univariate and multivariate Cox multivariate regression models were used to identify predictors of survival. RESULTS A total of 4431 patients met inclusion criteria. Average age at diagnosis was 57 years (median 62, SD 19), with no overall sex preference (52% female), and majority white (78%). The 1-year overall survival was 92.9% (95% CI [92.1-93.6]) and 5-year overall survival was 75.2% (95% CI [73.8-76.7%]). Median overall survival was not reached at 5 years. Factors associated with decreased survival were increasing age, comorbidities, high tumor grade, advanced pathologic group stage, and positive surgical margins. Female sex was the only factor associated with improved survival. Controlling for either histopathologic grade or pathologic stage to determine how patient demographics and tumor characteristics affected overall survival yielded similar results. Of note, intermediate grade tumors, although not independently associated with worse survival, when seen in conjunction with tumors ≥T2 and/or ≥N2, a negative impact on overall survival was seen. CONCLUSION Although mucoepidermoid carcinoma of the parotid gland is the most common parotid gland malignancy, it is still a rare tumor with a lack of large population-based studies. Advanced stage and high-grade tumors are significant predictors of decreased survival. Females have improved survival compared to males.
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Affiliation(s)
- Karthik Rajasekaran
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA 19104, United States.
| | - Vanessa Stubbs
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Jinbo Chen
- Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, United States
| | - Pratyusha Yalamanchi
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Steven Cannady
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Jason Brant
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Jason Newman
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA 19104, United States
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Yalamanchi P, Brant JA, Chen J, Newman JG. Clinicopathologic Factors Predictive of Occult Lymph Node Involvement in Cutaneous Head and Neck Melanoma. Otolaryngol Head Neck Surg 2017; 158:489-496. [DOI: 10.1177/0194599817741641] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives Evaluate clinicopathologic factors contributing to regional lymph node (LN) metastases in cutaneous head and neck melanoma (HNM). Study Design Retrospective review of a national cancer database. Setting National Cancer Database (2004-2012). Methods National Cancer Database (NCDB) cases diagnosed between 2004 and 2012 were reviewed. Inclusion criteria were head and neck cutaneous site codes, melanoma histology codes, and clinically node-negative status. Independent, clinicopathologic factors associated with pathologic positive LN status were identified by multivariable logistic regression. Subset analysis was performed on thin melanoma cases of 0.75 to 1 mm tumor depth to determine factors predictive of LN involvement and survival. Results Of 66,495 cases meeting inclusion criteria, 18,882 had nodes examined pathologically with 9.7% presenting with occult positive LN involvement. Mean (SD) age was 62.9 (16.13) years, and primary sites were scalp and neck (42.2%), face (40.2%), and external ear, lip, or eyelid (7.6%). Multivariable analysis found younger age; primary site of cutaneous scalp, neck, or face; increasing thickness; mitoses; ulceration; and vertical growth phase presence were independently associated with LN positivity ( P < .001). Only 2% of 0.75- to 1.0-mm Breslow thickness cases had regional LN involvement, and age >70 was negatively associated with LN involvement ( P = .002) in this subset. Conclusion This is the largest study examining factors predictive of occult LN involvement in patients with clinical node-negative cutaneous HNM who may benefit from sentinel LN biopsy. Primary sites of external ear, lip, or eyelid are less likely to present with occult nodal involvement, and older patients with T1a melanoma ≥0.76 mm are unlikely to present with regional node metastasis and may not require sentinel node guided management.
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Affiliation(s)
- Pratyusha Yalamanchi
- Department of Otorhinolaryngology–Head and Neck Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason A. Brant
- Department of Otorhinolaryngology–Head and Neck Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jinbo Chen
- Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jason G. Newman
- Department of Otorhinolaryngology–Head and Neck Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Yalamanchi P, Yu J, Chandler L, Mirza N. High-Level Disinfection of Otorhinolaryngology Clinical Instruments: An Evaluation of the Efficacy and Cost-effectiveness of Instrument Storage. Otolaryngol Head Neck Surg 2017; 158:163-166. [DOI: 10.1177/0194599817738977] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives Despite increasing interest in individual instrument storage, risk of bacterial cross-contamination of otorhinolaryngology clinic instruments has not been assessed. This study is the first to determine the clinical efficacy and cost-effectiveness of standard high-level disinfection and clinic instrument storage. Methods To assess for cross-contamination, surveillance cultures of otorhinolaryngology clinic instruments subject to standard high-level disinfection and storage were obtained at the start and end of the outpatient clinical workday. Rate of microorganism recovery was compared with cultures of instruments stored in individual peel packs and control cultures of contaminated instruments. Based on historical clinic data, the direct allocation method of cost accounting was used to determine aggregate raw material cost and additional labor hours required to process and restock peel-packed instruments. Results Among 150 cultures of standard high-level disinfected and co-located clinic instruments, 3 positive bacterial cultures occurred; 100% of control cultures were positive for bacterial species ( P < .001). There was no statistical difference between surveillance cultures obtained before and after the clinic day. While there was also no significant difference in rate of contamination between peel-packed and co-located instruments, peel packing all instruments requires 6250 additional labor hours, and conservative analyses place the cost of individual semicritical instrument storage at $97,852.50 per year. Discussion With in vitro inoculation of >200 otorhinolaryngology clinic instruments, this study demonstrates that standard high-level disinfection and storage are equally efficacious to more time-consuming and expensive individual instrument storage protocols, such as peel packing, with regard to bacterial contamination. Implications for Practice Standard high-level disinfection and storage are equally effective to labor-intensive and costly individual instrument storage protocols.
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Affiliation(s)
- Pratyusha Yalamanchi
- Department of Otorhinolaryngology–Head and Neck Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason Yu
- Department of Otorhinolaryngology–Head and Neck Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Laura Chandler
- Department of Clinical Microbiology, Philadelphia VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Natasha Mirza
- Department of Otorhinolaryngology–Head and Neck Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Sinnamon AJ, Neuwirth MG, Yalamanchi P, Gimotty P, Elder DE, Xu X, Kelz RR, Roses RE, Chu EY, Ming ME, Fraker DL, Karakousis GC. Association Between Patient Age and Lymph Node Positivity in Thin Melanoma. JAMA Dermatol 2017; 153:866-873. [PMID: 28724122 DOI: 10.1001/jamadermatol.2017.2497] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Importance More than half of all new melanoma diagnoses present as clinically localized T1 melanoma, yet sentinel lymph node biopsy (SLNB) is controversial in this population given the overall low yield. Guidelines for SLNB have focused on pathologic factors, but patient factors, such as age, are not routinely considered. Objectives To identify indicators of lymph node (LN) metastasis in thin melanoma in a large, generalizable data set and to evaluate the association between patient age and LN positivity. Design, Setting, and Participants A retrospective cohort study using the National Cancer Database, an oncology database representing patients from more than 1500 hospitals throughout the United States, was performed (2010-2013). Data analysis was conducted from October 1, 2016, to January 15, 2017. A total of 8772 patients with clinical stage I 0.50 to 1.0 mm thin melanoma undergoing wide excision and surgical evaluation of regional LNs were included for study. Main Outcome and Measures The primary outcome of interest was presence of melanoma in a biopsied regional LN. Clinicopathologic factors associated with LN positivity were characterized, using logistic regression. Age was categorized as younger than 40 years, 40 to 64 years, and 65 years or older for multivariable analysis. Classification tree analysis was performed to identify high-risk groups for LN positivity. Results Among the study cohort (n = 8772), 333 patients had nodal metastases, for an overall positivity rate of 3.8% (95% CI, 3.4%-4.2%). A total of 4087 (54.0%) patients were women. Median age was 56 years (interquartile range [IQR], 46-67) in patients with negative LNs and 52 years (IQR, 41-61) in those with positive LNs (P < .001). In multivariable analysis, younger age, female sex, thickness of 0.76 mm or larger, increasing Clark level, mitoses, ulceration, and lymphovascular invasion were independently associated with LN positivity. In decision tree analysis, patient age was identified as an important risk stratifier for LN metastases, after mitoses and thickness. Patients younger than 40 years with category T1b tumors 0.50 to 0.75 mm, who would generally not be recommended for SLNB, had an LN positivity rate of 5.6% (95% CI, 3.3%-8.6%); conversely, patients 65 years or older with T1b tumors 0.76 mm or larger, who would generally be recommended for SLNB, had an LN positivity rate of only 3.9% (95% CI, 2.7%-5.3%). Conclusions and Relevance Patient age is an important factor in estimating lymph node positivity in thin melanoma independent of traditional pathologic factors. Age therefore should be taken into consideration when selecting patients for nodal biopsy.
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Affiliation(s)
- Andrew J Sinnamon
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia
| | - Madalyn G Neuwirth
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia
| | | | - Phyllis Gimotty
- Department of Biostatics and Epidemiology, University of Pennsylvania, Philadelphia
| | - David E Elder
- Department of Pathology, Hospital of the University of Pennsylvania, Philadelphia
| | - Xiaowei Xu
- Department of Pathology, Hospital of the University of Pennsylvania, Philadelphia
| | - Rachel R Kelz
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia
| | - Robert E Roses
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia
| | - Emily Y Chu
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia
| | - Michael E Ming
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia
| | - Douglas L Fraker
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia
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Loffredo FS, Steinhauser ML, Jay SM, Gannon J, Pancoast JR, Yalamanchi P, Sinha M, Dall'Osso C, Khong D, Shadrach JL, Miller CM, Singer BS, Stewart A, Psychogios N, Gerszten RE, Hartigan AJ, Kim MJ, Serwold T, Wagers AJ, Lee RT. Growth differentiation factor 11 is a circulating factor that reverses age-related cardiac hypertrophy. Cell 2013; 153:828-39. [PMID: 23663781 DOI: 10.1016/j.cell.2013.04.015] [Citation(s) in RCA: 693] [Impact Index Per Article: 63.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Revised: 02/21/2013] [Accepted: 04/03/2013] [Indexed: 02/06/2023]
Abstract
The most common form of heart failure occurs with normal systolic function and often involves cardiac hypertrophy in the elderly. To clarify the biological mechanisms that drive cardiac hypertrophy in aging, we tested the influence of circulating factors using heterochronic parabiosis, a surgical technique in which joining of animals of different ages leads to a shared circulation. After 4 weeks of exposure to the circulation of young mice, cardiac hypertrophy in old mice dramatically regressed, accompanied by reduced cardiomyocyte size and molecular remodeling. Reversal of age-related hypertrophy was not attributable to hemodynamic or behavioral effects of parabiosis, implicating a blood-borne factor. Using modified aptamer-based proteomics, we identified the TGF-β superfamily member GDF11 as a circulating factor in young mice that declines with age. Treatment of old mice to restore GDF11 to youthful levels recapitulated the effects of parabiosis and reversed age-related hypertrophy, revealing a therapeutic opportunity for cardiac aging.
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Affiliation(s)
- Francesco S Loffredo
- Harvard Stem Cell Institute, Brigham and Women's Hospital, Boston, MA 02115, USA
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