Prospective Outcomes of Microlaryngoscopy Versus Office Laser Photoangiolysis for Vocal Fold Polyps

OBJECTIVE(S)

The objective of this study is to compare treatment outcomes for vocal fold polyps (VFPs) between operating room microlaryngoscopy and office-based photoangiolysis with the potassium titanyl phosphate (KTP) laser.

METHODS

Prospective nonrandomized cohort study of patients with VFPs undergoing microlaryngoscopy ("OR group") or KTP laser photoangiolysis ("KTP group"). Voice outcomes (patient-reported outcome measures [Voice Handicap Index-10 (VHI-10) and Singing VHI-10 (SVHI-10)], auditory-perceptual measures [Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V)], videostroboscopic characteristics [Voice-Vibratory Assessment of Laryngeal Imaging (VALI)], and acoustic and aerodynamic measures) were performed at baseline and regular intervals after intervention.

RESULTS

Forty-four subjects (17 OR group, 27 KTP group) with VFPs were enrolled. Mean VHI-10 significantly improved from baseline to each follow-up interval in both groups, except for the 1-2-week interval in the OR group. Mean SVHI-10 improved for both groups at some intervals. Growth curve models and time-to-event analyses for patient-reported outcomes did not differ between groups. There were significant improvements in all categories of auditory-perceptual voice quality and some categories of videostroboscopic characteristics in both groups. No significant trends were identified in acoustic and aerodynamic measures. Improvements in most outcomes did not significantly differ between groups or based on polyp size. There were no major complications.

CONCLUSIONS

Significant improvements in patient-reported voice outcomes measures, auditory-perceptual voice evaluation, and videostroboscopic characteristics occur following surgical treatment of vocal fold polyps with either microlaryngoscopy or office-based KTP laser. Long-term voice outcomes do not significantly differ between treatment modalities.

LEVEL OF EVIDENCE

Level 3 Laryngoscope, 2024.

Mixed methods assessment of the influence of demographics on medical advice of ChatGPT

OBJECTIVES

To evaluate demographic biases in diagnostic accuracy and health advice between generative artificial intelligence (AI) (ChatGPT GPT-4) and traditional symptom checkers like WebMD.

MATERIALS AND METHODS

Combination symptom and demographic vignettes were developed for 27 most common symptom complaints. Standardized prompts, written from a patient perspective, with varying demographic permutations of age, sex, and race/ethnicity were entered into ChatGPT (GPT-4) between July and August 2023. In total, 3 runs of 540 ChatGPT prompts were compared to the corresponding WebMD Symptom Checker output using a mixed-methods approach. In addition to diagnostic correctness, the associated text generated by ChatGPT was analyzed for readability (using Flesch-Kincaid Grade Level) and qualitative aspects like disclaimers and demographic tailoring.

RESULTS

ChatGPT matched WebMD in 91% of diagnoses, with a 24% top diagnosis match rate. Diagnostic accuracy was not significantly different across demographic groups, including age, race/ethnicity, and sex. ChatGPT's urgent care recommendations and demographic tailoring were presented significantly more to 75-year-olds versus 25-year-olds (P < .01) but were not statistically different among race/ethnicity and sex groups. The GPT text was suitable for college students, with no significant demographic variability.

DISCUSSION

The use of non-health-tailored generative AI, like ChatGPT, for simple symptom-checking functions provides comparable diagnostic accuracy to commercially available symptom checkers and does not demonstrate significant demographic bias in this setting. The text accompanying differential diagnoses, however, suggests demographic tailoring that could potentially introduce bias.

CONCLUSION

These results highlight the need for continued rigorous evaluation of AI-driven medical platforms, focusing on demographic biases to ensure equitable care.

Correlates of U.S. Adults Aged 50-75 Years Having Had a Colorectal Cancer Screening Test

Introduction

Colorectal cancer is a leading cause of cancer death in the U.S. Until 2021, the U.S. Preventive Services Task Force recommended colorectal cancer screening for all adults aged 50-75 years. Using a nationally representative sample, we explored the associations between having colorectal cancer screening and key sociodemographic and health-related factors among U.S. adults aged 50-75 years.

Methods

We analyzed self-reported data from the National Cancer Institute's Health Information National Trends Survey 5 (Cycle 4) collected from February to June 2020. A multivariable weighted logistic regression model was conducted using all of the factors that were univariably significant with p<0.10. Using backward elimination, factors that were not significant with p>0.05 were removed one at a time until the remaining factors were all significant collectively with p<0.05.

Results

Complete data were available for 1,649 respondents: 1,384 (81.2% weighted) had a colorectal cancer screening test, and 265 (18.8% weighted) did not. Multivariably, the odds of having had a colorectal cancer screening test increased with age (OR=1.07) and were higher for participants who identified as Black/African American than for White participants (OR=2.4), participants who had a family member who ever had cancer (OR=1.7), participants who believed that being overweight and obese influences development of cancer a lot than those who believed not at all (OR=2.0), and participants who had friends or family to talk with about health (OR=2.3).

Conclusions

Age, race, family history, weight-related beliefs about the causes of cancer, and having someone to talk with about health were associated with having colorectal cancer screening test.

Virtual Reality for Pain Management During High-Resolution Manometry: A Randomized Clinical Trial

OBJECTIVE

High-resolution esophageal manometry (HRM) is the gold standard for the diagnosis of esophageal motility disorders. HRM is typically performed in the office with local anesthesia only, and many patients find it unpleasant and painful. The aim of this study was to examine the effects of the use of a virtual reality (VR) headset on pain and anxiety outcomes in patients with dysphagia undergoing HRM.

METHODS

Patients with dysphagia were prospectively recruited and randomized to undergo HRM with and without VR distraction. Data collected included the State-Trait Anxiety Inventory-6 (STAI-6), the Short-Form McGill Pain Questionnaire, heart rate, and galvanic skin response (GSR) tracings.

RESULTS

Forty subjects completed the study, including 20 subjects in the intervention arm and 20 in the control arm. There was evidence of a significant positive effect of VR on calmness (p = 0.0095) STAI-6 rating, as well as on physiologic measures of pain with significantly decreased GSR rise time (p = 0.0137) and average rate of change of conductance change (p = 0.0035).

CONCLUSION

The use of VR during HRM catheter insertion increased calmness compared to control. Change of skin conductance was also reduced in the VR group, suggesting decreased physiologic pain. This study supports the consideration of the use of VR as a distraction tool to improve patient comfort during HRM.

LEVEL OF EVIDENCE

2 Laryngoscope, 134:1118-1126, 2024.

Designing Electronic Data Capture Systems for Sustainability in Low-Resource Settings: Viewpoint With Lessons Learned From Ethiopia and Myanmar

Electronic data capture (EDC) is a crucial component in the design, evaluation, and sustainment of population health interventions. Low-resource settings, however, present unique challenges for developing a robust EDC system due to limited financial capital, differences in technological infrastructure, and insufficient involvement of those who understand the local context. Current literature focuses on the evaluation of health interventions using EDC but does not provide an in-depth description of the systems used or how they are developed. In this viewpoint, we present case descriptions from 2 low- and middle-income countries: Ethiopia and Myanmar. We address a gap in evidence by describing each EDC system in detail and discussing the pros and cons of different approaches. We then present common lessons learned from the 2 case descriptions as recommendations for considerations in developing and implementing EDC in low-resource settings, using a sociotechnical framework for studying health information technology in complex adaptive health care systems. Our recommendations highlight the importance of selecting hardware compatible with local infrastructure, using flexible software systems that facilitate communication across different languages and levels of literacy, and conducting iterative, participatory design with individuals with deep knowledge of local clinical and cultural norms.

The use of thyroid isthmusectomy for management of well differentiated thyroid carcinoma - A systematic review and meta-analysis

OBJECTIVE

With the growing global incidence of thyroid carcinomas, there is an increasing need for distinct guidelines for isthmus-confined carcinomas. Here, we performed the first systematic review on the topic to date, aiming to provide understanding to isthmusectomy as surgical management for well-differentiated thyroid carcinoma of the isthmus.

METHODS

We conducted a systematic review following the PRISMA guidelines, analyzing English-language studies from the past decade that report on thyroid isthmusectomy. Exclusion criteria included isthmusectomy performed alongside full thyroidectomy or partial thyroid lobectomy, lack of data on tumor characteristics or survival outcomes, and non-English publications where a translation was unavailable. Our review identified a total of 227 patients from seven studies.

RESULTS

The average 5-year overall survival and disease-free survival rates for patients with isthmus-confined PTC who underwent isthmusectomy were 100 % and 93.1 %, respectively. Similar to that of total thyroidectomy. 3.1 % of patients required completion thyroidectomy. Furthermore, isthmusectomy resulted in fewer surgical complications than total thyroidectomy.

CONCLUSIONS

The scarcity of studies providing detailed tumor characteristics and patient outcomes limits our ability to fully evaluate the safety and efficacy of isthmusectomy for isthmus-confined PTC. Additionally, the variable sample sizes and restricted geographic distribution of the included studies calls into questions the generalizability of their findings. Despite these limitations, the data suggest that isthmusectomy may be a viable surgical option for select patients with small, isthmus-confined PTC. In the absence of a randomized controlled trial on the noninferiority of isthmusectomy, significantly more publications are needed before strong conclusions can be drawn.

Role of digital health communication, sociodemographic factors, and medical conditions on perceived quality of patient-centered communication

OBJECTIVE

To simultaneously explore associations between digital health, sociodemographic factors, and medical conditions on patient-centered communication (PCC). These are under-explored, yet important knowledge gaps to fill because perceived quality PCC may influence health information seeking behaviors and health outcomes.

METHODS

Data from the 2019 Health Information National Trends Survey were analyzed. The primary outcome was PCC, which was the summed score of 7 PCC-related questions. Factors of interest included whether participants used electronic methods to communicate with health professionals, age, gender, race/ethnicity, education, feelings about household income, and history of medical conditions. Descriptive statistics and linear regressions were conducted.

RESULTS

In the multivariate linear regression model, people aged 65-74 years compared with 18-34 year-olds, those with some college compared with college graduates, and those who felt they were living comfortably on their household income compared with all others reported higher PCC scores. People with a history of hypertension compared with those without reported higher PCC scores.

CONCLUSION

Similar to past studies, sociodemographic factors were associated with PCC. A novel finding was that a history hypertension was associated with perceived quality of PCC.

PRACTICE IMPLICATIONS

This research may inform methods to enhance communication between patients and clinicians.

Examining and Addressing Telemedicine Disparities Through the Lens of the Social Determinants of Health: A Qualitative Study of Patient and Provider During the COVID-19 Pandemic

Accelerated use of telemedicine during the COVID-19 pandemic enabled uninterrupted healthcare delivery while unmasking care disparities for several vulnerable communities. The social determinants of health (SDOH) serve as a critical model for understanding how the circumstances in which people are born, work, and live impact health outcomes. We performed semi-structured interviews to understand patients and providers' experiences with telemedicine encounters during the COVID-19 pandemic. Through a deductive approach, we applied the SDOH to determine telemedicine's role and impact within this framework. Overall, patient and provider interviews supported the use of existing SDOH domains to describe disparities in Internet access and telemedicine use, rather than reframing technology as a sixth SDOH. In order to mitigate the digital divide, we identify and propose solutions that address SDOH-related barriers that shape the use of health information technologies.

Patient Experiences with and Preferences for Telemedicine Relative to In-Person Care During the COVID-19 Pandemic

Introduction: Although telemedicine emerged during the COVID-19 pandemic as a critical mode of health care delivery, there may be differences in the perceived ease of patient-clinician communication and quality of care for telemedicine versus in-person visits, as well as variation in perceptions across patient subgroups. We examined patients' experiences with and preferences for telemedicine relative to in-person care, based on their most recent visit. Methods: We conducted a survey of 2,668 adults in a large academic health care system in November 2021. The survey captured patients' reasons for their most recent visit, perceptions on patient-clinician communication and quality of care, and attitudes toward telemedicine versus in-person care. Results: Among respondents, 552 (21%) had a telemedicine visit. Patients with telemedicine and in-person visits had similar agreement on ease of patient-clinician communication and perceived quality of the visit on average. However, for individuals 65 years of age or older, men, and those not needing urgent care, telemedicine was associated with worse perceptions of patient-clinician communication (65 years of age or older: adjusted odds ratio [aOR], 0.51; 95% confidence interval [CI], 0.31-0.85; men: aOR, 0.50; 95% CI, 0.31-0.81; urgent care: aOR 0.67; 95% CI, 0.49-0.91) and lower perceived quality (65 years of age or older, aOR 0.51; 95% CI, 0.30-0.86; men: 0.51; 95% CI, 0.32-0.83; urgent care: aOR 0.68; 95% CI, 0.49-0.93). Conclusion: Patient-perceived quality of care and patient-clinician communication were similar for telemedicine and in-person visits overall. However, among men, older adults, and those not seeking urgent care, patients using telemedicine had lower perceptions of patient-clinician communication and quality.

Development of a novel instrument to characterize telemedicine programs in primary care

BACKGROUND

Given the rapid deployment of telemedicine at the onset of the COVID - 19 pandemic, updated assessment methods are needed to study and characterize telemedicine programs. We developed a novel semi - structured survey instrument to systematically describe the characteristics and implementation processes of telemedicine programs in primary care.

METHODS

In the context of a larger study aiming to describe telemedicine programs in primary care, a survey was developed in 3 iterative steps: 1) literature review to obtain a list of telemedicine features, facilitators, and barriers; 2) application of three evaluation frameworks; and 3) stakeholder engagement through a 2-stage feedback process. During survey refinement, items were tested against the evaluation frameworks while ensuring it could be completed within 20-25 min. Data reduction techniques were applied to explore opportunity for condensed variables/items.

RESULTS

Sixty initially identified telemedicine features were reduced to 32 items / questions after stakeholder feedback. Per the life cycle framework, respondents are asked to report a month in which their telemedicine program reached a steady state, i.e., "maturation". Subsequent questions on telemedicine features are then stratified by telemedicine services offered at the pandemic onset and the reported point of maturation. Several open - ended questions allow for additional telemedicine experiences to be captured. Data reduction techniques revealed no indication for data reduction.

CONCLUSION

This 32-item semi-structured survey standardizes the description of primary care telemedicine programs in terms of features as well as maturation process. This tool will facilitate evaluation of and comparisons between telemedicine programs across the United States, particularly those that were deployed at the pandemic onset.

Acoustic Screening of the "Wet voice": Proof of Concept in an ex vivo Canine Laryngeal Model

BACKGROUND

Current protocols for bedside swallow evaluation have high rates of false negative results. Though experts are not consistently able to screen for aspiration risk by assessing vocal quality, there is emerging evidence that vocal acoustic parameters are significantly different in patients at risk of aspiration. Herein, we aimed to determine whether the presence of material on the vocal folds in an excised canine laryngeal model may have an impact on acoustic and aerodynamic measures.

METHODS

Two ex vivo canine larynges were tested. Three liquids of different viscosities (1:100 diluted glycerin, pure glycerin, and honey-thick Varibar) were placed on the vocal folds at a constant volume. Acoustic and aerodynamic measures were obtained in both adducted and abducted vocal fold configurations. Intraglottal high-speed imaging was used to approximate the maximum divergence angle of the larynges in the studied conditions and examine its relationship to vocal efficiency (VE) and acoustic measures.

RESULTS

In glottic insufficiency conditions only, we found that several acoustic parameters could predict the presence of material on the vocal folds. Based on the combination of the aerodynamic and acoustic data, we found that decreased spectral energy in the higher harmonics was associated with decreased VE in the presence of material on the vocal folds and/or glottic insufficiency.

CONCLUSION

Decreased spectral energy in the higher harmonics of the voice was found to be a potential biomarker of swallowing dysfunction, as it correlates with decreased vocal efficiency due to material on the vocal folds and/or glottic insufficiency, both of which are known risk factors for aspiration.

LEVEL OF EVIDENCE

NA Laryngoscope, 133:2517-2524, 2023.

A Qualitative Study on Using Telemedicine for Precepting and Teaching in the Academic Setting

PURPOSE

To examine the impact of telemedicine use on precepting and teaching among preceptors and patients during the COVID-19 pandemic.

METHOD

The authors conducted a secondary analysis of a qualitative study focusing on providers' and patients' experiences with and attitudes toward telemedicine at 4 academic health centers. Teaching and precepting were emergent codes from the data and organized into themes. Themes were mapped to domains from the 2009 Consolidated Framework for Implementation Research (CFIR), a framework that assists with effective implementation and consists of 5 domains: intervention characteristics, outer settings, inner settings, characteristics of individuals, and process.

RESULTS

In total, 86 interviews were conducted with 65 patients and 21 providers. Nine providers and 3 patients recounted descriptions related to teaching and precepting with telemedicine. Eight themes were identified, mapping across all 5 CFIR domains, with the majority of themes (n = 6) within the domains of characteristics of individuals, processes, and intervention characteristics. Providers and patients described how a lack of prepandemic telemedicine experience and inadequate processes in place to precept and teach with telemedicine affected the learning environment and perceived quality of care. They also discussed how telemedicine exacerbated existing difficulties in maintaining resident continuity. Providers described ways communication changed with telemedicine use during the pandemic, including having to wear masks while in the same room as the trainee and sitting closely to remain within range of the camera, as well as the benefit of observing trainees with the attending's camera off. Providers expressed a lack of protected structure and time for teaching and supervising with telemedicine, and a general view that telemedicine is here to stay.

CONCLUSIONS

Efforts should focus on increasing knowledge of telemedicine skills and improving processes to implement telemedicine in the teaching setting in order to best integrate it into undergraduate and graduate medical education.

Outcomes of Gender-Affirming Voice and Communication Modification Training for Non-binary Individuals: A Case Series

OBJECTIVES

There is currently no research reporting solely on outcomes of voice and communication modification training (VCMT) in individuals who identify as non-binary and genderqueer (NBGQ) in the English literature. This study aimed to describe the objective and subjective impact of VCMT on the voice of NBGQ individuals undergoing a 12-week gender-affirming VCMT program.

METHODS

A retrospective consecutive case series of NBGQ individuals enrolled in a VCMT program was performed. Demographics, Transgender Self-Evaluation Questionnaire (TSEQ), fundamental frequency (F0), and frequency range were collected before and after the program.

RESULTS

Four NBGQ individuals enrolled between January 2019 and June 2021; the mean age was 27.0 years. While all four participants represented in this case series showed improvement in at least one of their initial goals, only one improved both their F0 and TSEQ scores; the other three participants had mixed results.

CONCLUSION

NBGQ individuals experienced improvements in self-reported outcomes and changes in acoustic measures after completing VCMT in our case series. Individuals experienced significant improvement in subjective outcomes despite small changes in acoustic measures, and vice versa. More research is needed to better understand the voice and communication needs of NBGQ individuals, along with their outcomes with VCMT.

LEVEL OF EVIDENCE

Level 4.

Perception of Proton Pump Inhibitor Side Effects Among Members of the American Broncho-Esophagological Association

OBJECTIVES

To investigate awareness of proton pump inhibitor (PPI) side effects and the resulting changes in reflux mana management among members of the American Broncho-Esophagological Association (ABEA) caring for adult patients in light of increasing concern for PPIs long-term adverse effects.

STUDY DESIGN

Cross-sectional survey study METHODS: Online surveys were electronically distributed to ABEA members assessing awareness of PPI side effects and current practice in reflux management.

RESULTS

374 ABEA members were contacted, of whom, 43 (11.5%) completed the survey. The majority of respondents (94.1%) selected laryngology as their principal focus. The entire cohort warned their patients about PPI side effects, with highest concern for osteoporotic risk. Most respondents (88.2%) had changed their PPI prescription frequency in light of recent studies on PPI side effects, with 55.9% avoiding PPI prescription and 94.1% limiting the duration of PPI courses. Instead of PPIs, 73.5% of responders prescribe H2-receptor blockers. The primary reasons for starting patients on PPIs were typical gastroesophageal reflux symptoms (47.1%), followed by laryngopharyngeal reflux symptoms (41.2%), and endoscopic findings suspicious for reflux (11.8%). Finally, the majority of respondents (82.4%) had referred at least one patient for surgical management of gastroesophageal reflux in the past year.

CONCLUSIONS

The majority of surveyed ABEA members were concerned about reports of PPI adverse effects and had modified their prescription patterns as a result. Avoidance of PPI recommendation was common, along with the preference for H2 blockers in the management of GERD and LPR. PPI side effects of greatest concern to broncho-esophagologists treating adult patients were osteoporosis, renal dysfunction and dementia.

LEVEL OF EVIDENCE: 5

The Telemedicine Experience in Primary Care Practices in the United States: Insights From Practice Leaders

PURPOSE

The need to rapidly implement telemedicine in primary care during the coronavirus disease 2019 (COVID-19) pandemic was addressed differently by various practices. Using qualitative data from semistructured interviews with primary care practice leaders, we aimed to report commonly shared experiences and unique perspectives regarding telemedicine implementation and evolution/maturation since March 2020.

METHODS

We administered a semistructured, 25-minute, virtual interview with 25 primary care practice leaders from 2 health systems in 2 states (New York and Florida) included in PCORnet, the Patient-Centered Outcomes Research Institute clinical research network. Questions were guided by 3 frameworks (health information technology evaluation, access to care, and health information technology life cycle) and involved practice leaders' perspectives on the process of telemedicine implementation in their practice, with a specific focus on the process of maturation and facilitators/barriers. Two researchers conducted inductive coding of qualitative data open-ended questions to identify common themes. Transcripts were electronically generated by virtual platform software.

RESULTS

Twenty-five interviews were administered for practice leaders representing 87 primary care practices in 2 states. We identified the following 4 major themes: (1) the ease of telemedicine adoption depended on both patients' and clinicians' prior experience using virtual health platforms, (2) regulation of telemedicine varied across states and differentially affected the rollout processes, (3) visit triage rules were unclear, and (4) there were positive and negative effects of telemedicine on clinicians and patients.

CONCLUSIONS

Practice leaders identified several challenges to telemedicine implementation and highlighted 2 areas, including telemedicine visit triage guidelines and telemedicine-specific staffing and scheduling protocols, for improvement.

Changes in Cough Airflow and Acoustics After Injection Laryngoplasty

OBJECTIVE/HYPOTHESIS

We explored the following hypotheses in a cohort of patients undergoing injection laryngoplasty: (1) glottic insufficiency affects voluntary cough airflow dynamics and restoring glottic competence may improve parameters of cough strength, (2) cough strength can be inferred from cough acoustic signal, and (3) glottic competence changes cough sounds and correlates with spectrogram morphology.

STUDY TYPE/DESIGN

Prospective interventional study.

METHODS

Subjects with glottic insufficiency secondary to unilateral vocal fold paresis, paralysis, or atrophy, and scheduled for injection laryngoplasty completed an instrumental assessment of voluntary cough airflow using a pneumotachometer and a protocolized voluntary cough sound recording. A Wilcoxon signed-rank test was used to compare the differences between pre- and post-injection laryngoplasty in airflow and acoustic measures. A Spearman rank-order correlation was used to evaluate the association between airflow and acoustic cough measures.

RESULTS

Twenty-five patients (13F:12M, mean age 68.8) completed voluntary cough airflow measurements and 22 completed cough sound recordings. Following injection laryngoplasty, patients had a statistically significant decreased peak expiratory flow rise time (PEFRT) (mean change: -0.03 s, SD: 0.06, p = 0.04) and increased cough volume acceleration (mean change: 13.1 L/s2 , SD: 33.9, p = 0.03), suggesting improved cough effectiveness. Correlation of cough acoustic measures with airflow measures showed a weak relationship between PEFRT and acoustic energy (coefficient: -0.31, p = 0.04) and peak power density (coefficient: -0.35, p = 0.02).

CONCLUSIONS

Our study thus indicates that injection laryngoplasty may help avert aspiration in patients with glottic insufficiency by improving cough effectiveness and that improved cough airflow measures may be tracked with cough sounds.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:S1-S14, 2023.

Telemedicine Impact on the Patient-Provider Relationship in Primary Care During the COVID-19 Pandemic

BACKGROUND

The COVID-19 pandemic has necessitated a rapid uptake of telemedicine in primary care requiring both patients and providers to learn how to navigate care remotely. This change can impact the patient-provider relationship that often defines care, especially in primary care.

OBJECTIVE

This study aims to provide insight into the experiences of patients and providers with telemedicine during the pandemic, and the impact it had on their relationship.

RESEARCH DESIGN

A qualitative study using thematic analysis of semistructured interviews.

SUBJECTS

Primary care providers (n=21) and adult patients (n=65) with chronic disease across primary care practices in 3 National Patient-centered Clinical Research Network sites in New York City, North Carolina, and Florida.

MEASURES

Experiences with telemedicine during the COVID-19 pandemic in primary care. Codes related to the patient-provider relationship were analyzed for this study.

RESULTS

A recurrent theme was the challenge telemedicine posed on rapport building and alliance. Patients felt that telemedicine affected provider's attentiveness in varying ways, whereas providers appreciated that telemedicine provided unique insight into patients' lives and living situations. Finally, both patients and providers described communication challenges.

CONCLUSIONS

Telemedicine has altered structure and process aspects of primary health care such as the physical spaces of encounters, creating a new setting to which both patients and providers must adjust. It is important to recognize the opportunities and limits that this new technology has to help providers maintain the type of one-on-one attention that patients expect and that contributes to relationship building.

Patient and Provider Recommendations for Improved Telemedicine User Experience in Primary Care: A Multi-Center Qualitative Study

OBJECTIVE

The purpose of this study was to explore telemedicine use and obtain actionable recommendations to improve telemedicine user experience from a diverse group of patients and providers.

METHODS

We interviewed adult patients and primary care providers (PCPs) across three National Patient-Centered Clinical Research Network (PCORnet) sites in New York City, North Carolina, and Florida. Both patients and providers could participate via phone or videoconferencing; patients could complete the interview in English or Spanish. Spanish interviews were conducted by a member of the research team who spoke Spanish fluently. Interviews were audio-recorded, transcribed verbatim, and when necessary, professionally translated.

RESULTS

We interviewed 21 PCPs and 65 patients between March and October 2021. We found that patients' and providers' perspectives on ways to improve the telemedicine experience focused on three recommendation themes: (1) expectations of care provided via telemedicine, (2) innovations to support usability, and (3) alleviation of physician burden. Key recommendations were related to expectations regarding (1) care provided, for example, adding educational content for the patients, and clarity about long-term payment models; (2) support innovation to improve telemedicine usability, for example, providing patients with remote monitoring devices, integrating in-home testing and nursing evaluation; (3) and reduce physician burden, for example, virtual rooming, reimbursement of time spent outside of the telemedicine encounter.

DISCUSSION

Primary care patients and providers see merit in telemedicine. However, both groups recommended novel ways to improve the quality of care and user experience. Findings from this article suggest that policymakers would be best served by addressing current gaps in patient digital literacy by creating technical support strategies, and gaps in telemedicine reimbursement to present an equitable form of payment.

Provider and Patient Experiences of Delays in Primary Care During the Early COVID-19 Pandemic

BACKGROUND

The necessary suspension of nonacute services by healthcare systems early in the COVID-19 pandemic was predicted to cause delays in routine care in the United States, with potentially serious consequences for chronic disease management. However, limited work has examined provider or patient perspectives about care delays and their implications for care quality in future healthcare emergencies.

OBJECTIVE

This study explores primary care provider (PCP) and patient experiences with healthcare delays during the COVID-19 pandemic.

METHODS

PCPs and patients were recruited from four large healthcare systems in three states. Participants underwent semistructured interviews asking about their experiences with primary care and telemedicine. Data were analyzed using interpretive description.

RESULTS

Twenty-one PCPs and 65 patients participated in interviews. Four main topics were identified: (1) types of care delayed, (2) causes for delays, (3) miscommunication contributing to delays, and (4) patient solutions to unmet care needs.

CONCLUSIONS

Both patients and providers reported delays in preventive and routine care early in the pandemic, driven by healthcare system changes and patient concerns about infection risk. Primary care practices should develop plans for care continuity and consider new strategies for assessing care quality for effective chronic disease management in future healthcare system disruptions.

Performers' Perceptions of Vocal Function During Oral Steroid Treatment of Vocal Fold Edema

OBJECTIVES

Acute vocal fold edema (VFE) is often a consequence of illness, allergy, or voice overuse, causing dysphonia. Although VFE typically resolves with voice rest and treatment of predisposing causes, oral glucocorticoids are often considered for performers with imminent performance demands. There are limited data about performers' perceptions of vocal change during treatment and how this relates to their ability to perform. This study aims to examine performers' self-perceptions of vocal function with steroid treatment.

METHODS

Fifty-five performers (34 F; 21 M) diagnosed with VFE who chose treatment with a 6-day methylprednisolone taper were prospectively assessed. They completed the Evaluation of the Ability to Sing Easily (EASE) and reported on their voice use, regimen, performance obligations, and ability to perform. Findings were compared between Day 1 and Day 6 using paired t-tests and nonparametric Wilcoxon signed-rank tests.

RESULTS

Nearly all subjects completed scheduled performances without interruption. Following treatment, all subscales of the EASE were decreased at Day 6 (Vocal Function 29.78-20.59; Pathologic Risk Indicator 26.60-17.33; Vocal Concerns 6.10-4.20). These differences were statistically significant (p < 0.0001) and greater in subjects with performances scheduled and subjects who consistently completed vocal warmups. These findings demonstrate significant improvement in several facets of performers' self-perception of function.

CONCLUSION

Subjects reported significant improvement in vocal function with oral steroid treatment and were able to meet performance obligations. It remains important that steroids are not prescribed without laryngeal examination. Examination should be repeated when dysphonia persists, recurs swiftly, or when patients seek repeated treatment, as there may be increased risk of adverse outcomes, and continued steroid use may mask underlying chronic pathology that is best treated by other means.

LEVEL OF EVIDENCE

4 Laryngoscope, 132:2434-2441, 2022.

Are Mobile Applications in Laryngology Designed for All Patients?

OBJECTIVES

Mobile applications (apps) are multiplying in laryngology, with little standardization of content, functionality, or accessibility. The purpose of this study is to evaluate the quality, functionality, health literacy, readability, accessibility, and inclusivity of laryngology mobile applications.

METHODS

Of the 3230 apps identified from the Apple and Google Play stores, 28 patient-facing apps met inclusion criteria. Apps were evaluated using validated scales assessing quality and functionality: the Mobile App Rating Scale (MARS) and the Institute for Healthcare Informatics App Functionality Scale. The Clear Communication Index (CDC) Institute of Medicine Strategies for Creating Health Literate Mobile Applications, and Patient Education Materials Assessment Tool (PEMAT) were used to evaluate apps health literacy level. Readability was assessed using established readability formulas. Apps were evaluated for language, accessibility features, and representation of a diverse population.

RESULTS

Twenty-six apps (92%) had adequate quality (MARS score > 3). The mean PEMAT score was 89% for actionability and 86% for understandability. On average, apps utilized 25/33 health literate strategies. Twenty-two apps (79%) did not pass the CDC index threshold of 90% for health literacy. Twenty-four app descriptions (86%) were above an 8^th grade reading level. Only 4 apps (14%) showed diverse representation, 3 (11%) had non-English language functions, and 2 (7%) offered subtitles. Inter-rater reliability for MARS was adequate (CA-ICC = 0.715).

CONCLUSION

While most apps scored well in quality and functionality, many laryngology apps did not meet standards for health literacy. Most apps were written at a reading level above the national average, lacked accessibility features, and did not represent diverse populations. Laryngoscope, 2022.

Evaluation of Laryngeal Motor Neuropathy Using Transcranial Magnetic Stimulation-Mediated Evoked Potentials

OBJECTIVES/HYPOTHESIS

Contemporary evaluation of vocal fold motion impairment largely relies on clinical laryngoscopy, with the diagnoses of vocal fold paresis (VFPa) and paralysis (VFP) being based on identification of partial and complete restriction of gross vocal fold motion, respectively. No consensus exists on the diagnostic criteria of VFPa. Laryngeal electromyography does not offer any insight into nerve conduction velocity without the adjunction of nerve conduction studies, which are impractical to perform on laryngeal nerves due to their anatomic location. The present study aims to assess the feasibility of laryngeal nerve conduction studies using transcranial magnetic stimulation (TMS)-mediated myogenic evoked potentials in the evaluation of laryngeal motor nerve function.

STUDY DESIGN

Prospective controlled cohort study.

METHODS

Enrollment of three groups of subjects defined as healthy volunteers, subjects with clinically diagnosed unilateral VFP, and subjects with clinically diagnosed unilateral VFPa of peripheral etiology. Electrodiagnostic studies consisting of bilateral stimulation of the laryngeal motor cortex, proximal cisternal, and peripheral portions of the vagus nerves were performed using figure-of-eight magnetic stimulation coils, and myogenic evoked potentials recorded from bilateral thyroarytenoid, cricothyroid, and posterior cricoarytenoid muscles using indwelling hook wire electrodes. Conduction latencies were plotted against demographic and anthropometric variables. Values obtained in healthy volunteers were used as normative references and compared to aggregated latencies of VFP and VFPa groups.

RESULTS

Enrolled subjects included 19 healthy volunteers, 5 subjects with VFP, and 4 subjects with VFPa. Normative laryngeal nerve conduction latency ranges measured in healthy subjects were comparable to prior published values, and recorded latencies increased in positive correlation with age. VFPa subjects exhibited increased latencies in affected nerve sites, while VFP subjects presented more variability in electrophysiologic manifestations, mostly dependent on their degree of compensatory reinnervation. Aberrant and synkinetic reinnervation patterns were more predominant in the VFP group than the VFPa group.

CONCLUSIONS

Laryngeal nerve conduction studies using TMS-mediated myogenic evoked potentials are safely feasible. They may serve as a useful complement to laryngeal electromyography in the evaluation of motor laryngeal neuropathy and represent a promising diagnostic modality in the evaluation of VFPa. Based on the present study's findings, the commonly accepted notion of VFPa as a manifestation of a less severe form of neuropathy than VFP may be unsubstantiated. Aging may contribute to progressive motor nerve dysfunction. Future investigations are needed to ascertain the role of nerve conduction studies in clinical laryngology practice.

LEVEL OF EVIDENCE

3 Laryngoscope, 2022.

Automatic classification of informative laryngoscopic images using deep learning

Objective

This study aims to develop and validate a convolutional neural network (CNN)‐based algorithm for automatic selection of informative frames in flexible laryngoscopic videos. The classifier has the potential to aid in the development of computer‐aided diagnosis systems and reduce data processing time for clinician‐computer scientist teams.

Methods

A dataset of 22,132 laryngoscopic frames was extracted from 137 flexible laryngostroboscopic videos from 115 patients. 55 videos were from healthy patients with no laryngeal pathology and 82 videos were from patients with vocal fold polyps. The extracted frames were manually labeled as informative or uninformative by two independent reviewers based on vocal fold visibility, lighting, focus, and camera distance, resulting in 18,114 informative frames and 4018 uninformative frames. The dataset was split into training and test sets. A pre‐trained ResNet‐18 model was trained using transfer learning to classify frames as informative or uninformative. Hyperparameters were set using cross‐validation. The primary outcome was precision for the informative class and secondary outcomes were precision, recall, and F1‐score for all classes. The processing rate for frames between the model and a human annotator were compared.

Results

The automated classifier achieved an informative frame precision, recall, and F1‐score of 94.4%, 90.2%, and 92.3%, respectively, when evaluated on a hold‐out test set of 4438 frames. The model processed frames 16 times faster than a human annotator.

Conclusion

The CNN‐based classifier demonstrates high precision for classifying informative frames in flexible laryngostroboscopic videos. This model has the potential to aid researchers with dataset creation for computer‐aided diagnosis systems by automatically extracting relevant frames from laryngoscopic videos.

Outcomes of Gender-Affirming Voice and Communication Modification for Transgender Individuals

OBJECTIVES

Transgender individuals' voices are closely related to gender identity. A primary goal of gender-affirming voice modification is to help individuals alter their voices to improve gender congruence; however, there is a paucity of research to support this approach. This study aimed to evaluate the outcomes of a 12-week gender-affirming voice and communication modification program.

STUDY DESIGN

Retrospective cohort study.

METHODS

A retrospective consecutive case series of transgender women enrolled in a voice and communication modification program was performed. Demographics, Trans Woman Voice Questionnaire (TWVQ), fundamental frequency (F₀ ), and frequency range were collected before and after the program. A Wilcoxon signed-rank test assessed changes in outcomes. Spearman's rank-order correlation coefficients quantified associations between self-reported outcomes and acoustic measures.

RESULTS

A total of 16 trans women individuals were enrolled. The mean age was 31.5 years. After program completion, TWVQ improved 20.4 points, F₀ increased 26.5 Hz (spontaneous speech) and 25.7 Hz (reading), and the range increased 24.7 Hz (spontaneous speech) and 0.1 Hz (reading). None of the changes in acoustic measures significantly correlated with improvement in TWVQ scores in the cohort.

CONCLUSION

Trans women experience improvements in self-reported outcomes and changes in acoustic measures after completing a gender-affirming voice and communication modification program. Individuals may experience significant improvement in subjective outcomes despite small changes in acoustic measures and vice versa.

LEVEL OF EVIDENCE

Level 4 (case series) Laryngoscope, 2021.

Applications of Artificial Intelligence to Office Laryngoscopy: A Scoping Review

OBJECTIVES/HYPOTHESIS

This scoping review aims to provide a broad overview of the applications of artificial intelligence (AI) to office laryngoscopy to identify gaps in knowledge and guide future research.

STUDY DESIGN

Scoping Review.

METHODS

Searches for studies on AI and office laryngoscopy were conducted in five databases. Title and abstract and then full-text screening were performed. Primary research studies published in English of any date were included. Studies were summarized by: AI applications, targeted conditions, imaging modalities, author affiliations, and dataset characteristics.

RESULTS

Studies focused on vocal fold vibration analysis (43%), lesion recognition (24%), and vocal fold movement determination (19%). The most frequently automated tasks were recognition of vocal fold nodules (19%), polyp (14%), paralysis (11%), paresis (8%), and cyst (7%). Imaging modalities included high-speed laryngeal videos (45%), stroboscopy (29%), and narrow band imaging endoscopy (7%). The body of literature was primarily authored by science, technology, engineering, and math (STEM) specialists (76%) with only 30 studies (31%) involving co-authorship by STEM specialists and otolaryngologists. Datasets were mostly from single institution (84%) and most commonly originated from Germany (23%), USA (16%), Spain (9%), Italy (8%), and China (8%). Demographic information was only reported in 39 studies (40%), with age and sex being the most commonly reported, whereas race/ethnicity and gender were not reported in any studies.

CONCLUSION

More interdisciplinary collaboration between STEM and otolaryngology research teams improved demographic reporting especially of race and ethnicity to ensure broad representation, and larger and more geographically diverse datasets will be crucial to future research on AI in office laryngoscopy.

LEVEL OF EVIDENCE

N/A Laryngoscope, 2021.

Prospective Evaluation of Safety of Singing on Steroids: Testing the Truth of Received Wisdom

OBJECTIVES/HYPOTHESIS

Performing while on steroids is widely considered to increase risk of vocal injury. This study aims to determine incidence and type of injury, and changes in performers' voices after treatment of vocal fold edema (VFE) with glucocorticoids.

STUDY DESIGN

Prospective Cohort.

METHODS

Fifty-five performers (34 female; 21 male) treated for acute VFE with short-course oral glucocorticoids were prospectively evaluated pre- and post-treatment. Subjects underwent videostroboscopy, acoustic/aerodynamic assessment, and functional assessment with the Singing Voice Handicap Index-10 (SVHI-10) and Evaluation of the Ability to Sing Easily (EASE). Blinded reviewers rated videostroboscopic examinations and performed audio-perceptual assessment. Chi-square tests and Wilcoxon signed rank tests were applied for analyses of treatment changes.

RESULTS

Following glucocorticoid treatment, two instances of vocal fold hemorrhage (3.6%) and three instances of glottic thrush (5.5%) were observed. These resolved without consequence. Mucosal wave dynamics and edema improved. Nearly all subjects completed scheduled performances, and significant improvement was noted on the EASE, reflecting improved function after treatment. These were further supported by statistically significant improvements in CAPE-V and some acoustic and aerodynamic outcomes (semitone pitch range for females, airflow measures for males).

CONCLUSIONS

Oral glucocorticoids appear to be generally safe for performers presenting with acute VFE. The incidence of adverse effects, specifically hemorrhage and thrush, was low and the effects transient. Vocal fold examination should be considered obligatory before prescribing glucorticoids to working performers. A treatment strategy for acute VF edema incorporating glucocorticoids when appropriate appears to result in significant improvements in measures of glottal function including videostroboscopic appearance, subject perception, and auditory perception.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Healthcare Disparities in Laryngology: A Scoping Review

OBJECTIVES/HYPOTHESIS

This scoping review aims to map out existing disparities research within the subspecialty of laryngology in order to highlight gaps in knowledge and guide future research.

STUDY DESIGN

Scoping Review.

METHODS

We completed a scoping review of PubMed, Ovid Embase, and the Cochrane Library for primary research focused on evaluating the existence and impact of disparities in race/ethnicity, sex/gender, insurance status, education level, income, geography, and LGBTQ identity in the context of various laryngological conditions. Publications of any design and date, performed in the United States, and focusing on the adult population exclusively were included.

RESULTS

Of the 4,999 unique abstracts identified, 51 articles were ultimately included. The most frequently examined condition in relation to disparities was laryngeal cancer (27 of 51), followed by voice disorders (15 of 51), deglutitive disorders (eight of 51), and airway disorders (one of 51). Sources of inequity evaluated from most common to least common were race/ethnicity (43 of 51), sex/gender (39 of 51), insurance status (23 of 51), geography (23 of 51), income (21 of 51), and education level (16 of 51). No study examined the association of LGBTQ identity with inequity.

CONCLUSIONS

This scoping review highlights the limited extent of disparities research in laryngology and establishes the need for further scholarship on the impact of disparities in laryngology care. The pathologies studied were, in decreasing order of frequency: laryngeal cancer, voice disorders, deglutitive disorders, and airway disorders. Race/ethnicity and sex/gender were the most common disparities examined, with no evaluation of LGBTQ-related care inequity.

LEVEL OF EVIDENCE

NA Laryngoscope, 2020.

An Open-Source Three-Dimensionally Printed Laryngeal Model for Injection Laryngoplasty Training

OBJECTIVES/HYPOTHESIS

A limited number of three-dimensionally (3D)-printed laryngeal simulators have been described in the literature, only one of which is specifically designed for percutaneous injection laryngoplasty (PIL) training and is currently of limited availability. This study describes the development and evaluation of a high-fidelity, open-source, low-cost 3D-printed simulator for PIL training, improving on existing models.

STUDY DESIGN

Simulator design and survey evaluation.

METHODS

Computed tomography scans of the upper airways were processed with 3D Slicer to generate a computer model of the endolarynx. Blender and Fusion 360 were used to refine the mucosal model and develop casts for silicone injection molding. The casted endolaryngeal structures were inserted into a modified version of a publicly available laryngeal cartilage model. The final models were evaluated by 10 expert laryngologists using a customized version of the Michigan Standard Simulation Experience Scale. Internal consistency and interrater reliability of the survey were evaluated using Cronbach's α and intraclass correlation, respectively.

RESULTS

Expert laryngologists highly rated the model for measures of fidelity, educational value, and overall quality (mean = 4.8, standard deviation = 0.5; 1 = strongly disagree, 5 = strongly agree). All reviewers rated the model as ready for use as is or with slight modifications. The filament needed for one cartilage model costs $0.96, whereas the silicone needed for one soft-tissue model costs $1.89.

CONCLUSIONS

Using 3D-printing technology, we successfully created the first open-source, low-cost, and anatomically accurate laryngeal model for injection laryngoplasty training. Our simulator is made freely available for download on Wikifactory with step-by-step tutorials for 3D printing, silicone molding, assembly, and use.

LEVEL OF EVIDENCE

NA Laryngoscope, 131:E890-E895, 2021.