Improving learning and confidence through small group, structured otoscopy teaching: A prospective interventional study

Background: Otologic diseases are common and associated with significant health care costs. While accurate diagnosis relies on physical exam, existing studies have highlighted a lack of comfort among trainees with regards to otoscopy. As such, dedicated otoscopy teaching time was incorporated into the undergraduate medical curriculum in the form of a small group teaching session. In this study, we aimed to examine the effect of a small-group, structured teaching session on medical students\u27 confidence with and learning of otoscopic examination. Methods: Using a prospective study design, an otolaryngologist delivered an one-hour, small group workshop to medical learners. The workshop included introduction and demonstration of otoscopy and pneumatic otoscopy followed by practice with peer feedback. A survey exploring students\u27 confidence with otoscopy and recall of anatomical landmarks was distributed before(T1), immediately after(T2), and 1 month following the session(T3). Results: One hundred and twenty five learners participated from February 2016 to February 2017. Forty nine participants with complete data over T1-T3 demonstrated significant improvement over time in confidence (Wilk\u27s lambda =.09, F(2,48) = 253.31 p \u3c.001, η 2 =.91) and learning (Wilk\u27s lambda = 0.34, F(2,47) = 24.87 p \u3c.001, η 2 =.66). Conclusions: A small-group, structured teaching session had positive effects on students\u27 confidence with otoscopy and identification of otologic landmarks. Dedicated otoscopy teaching sessions may be a beneficial addition to the undergraduate medical curriculum

The epidemiology, antibiotic resistance and post-discharge course of peritonsillar abscesses in London, Ontario

Background: Peritonsillar abscesses (PTA) are a common complication of tonsillitis. Recent global epidemiological data regarding PTAs have demonstrated increasing antimicrobial resistance patterns. No similar studies have been conducted in Canada and no Canadian study has examined the post-discharge course of treated patients. Methods: A prospective observational study of the epidemiology, antibiotic resistance and post-discharge course of patients presenting with a peritonsillar abscess to the Emergency Department in London, Ontario over one year. A follow-up telephone survey was conducted 2-3 weeks after abscess drainage. Results: 60 patients were diagnosed with an abscess, giving an incidence of 12/100,000. 46 patients were enrolled in the study; the average duration of symptoms prior to presentation was 6 days, with 51% treated with antibiotics prior to presentation. Streptococcus pyogenes and Streptococcus anginosus were present in 56% of isolates and of those, 7/23 (32%) of specimens demonstrated resistance to clindamycin. Eight patients were treated with clindamycin and had a culture that was resistant, yet only one had recurrence. Telephone follow-up was possible for 38 patients: 51% of patients reported a return to solid food within 2 days, and 75% reported no pain by 5 days. Resolution of trismus took a week or longer for 51%. Interpretation: Clindamycin resistance was identified in a third of Streptococcus isolates, which should be taken into account when prescribing antibiotics. Routine culture appears unnecessary as patients recover quickly from outpatient drainage and empiric therapy, with less pain than expected, but trismus takes time to resolve. © 2013 Sowerby et al.; licensee BioMed Central Ltd

Surgical interventions in velopharyngeal dysfunction: comparative perceptual speech and nasometric outcomes for three techniques

Background: The aim of this study was to evaluate speech outcomes following surgical intervention for velopharyngeal dysfunction (VPD). Perceptual speech outcome data were subsequently analyzed in conjunction with patient factors such as congenital abnormalities, presence of cleft lip and/or palate, and age of repair. We hope to aid in the eventual creation of treatment algorithms for VPD, allowing practitioners to tailor surgical technique selection to patient factors. Methods: A retrospective analysis was performed for all patients who underwent surgical correction of VPD at London Health Sciences Centre between the years 2005 and 2018. Two hundred and two consecutive VPD patients (median age 10.6 years) were followed for an average of 20.2 months after having undergone a superiorly based pharyngeal flap (121), Furlow palatoplasty (72), or sphincteroplasty (9). Speech outcomes were measured via the American Cleft Palate-Craniofacial Association (ACPA) perceptual speech assessment, and MacKay-Kummer Simplified Nasometric Assessment Procedures Revised (SNAP-R) was used to measure nasalence. Comparisons of mean preoperative and postoperative outcomes were made, as well as analyses regarding surgical procedure, syndrome, cleft status, and age. Results: Mean perceptual scores improved significantly postoperatively (p \u3c.0001), and successful perceptual resonance was identified in 86.1% patients (n = 174). Postoperative perceptual speech scores for three ACPA domains were superior with pharyngeal flap compared to both Furlow palatoplasty and sphincteroplasty ([hypernasality: p \u3c.001, p \u3c.02], [audible nasal emissions: p \u3c.002, p \u3c.05], [velopharyngeal function: p \u3c.001, p \u3c.05]). Success rate was higher in pharyngeal flap (94.2%) than in Furlow palatoplasty (75.0%, p \u3c.001) or sphincter pharyngoplasty (66.7%, p \u3c.001). No significant difference was identified in success rate based on syndrome or cleft status. Conclusion: Operative management of VPD is highly effective in improving perceptual speech outcomes. Given proper patient selection, all three procedures are viable treatment options for VPD. For those patients identified as appropriate to undergo a pharyngeal flap, robust improvements in speech outcomes were observed. Graphical abstract: [Figure not available: see fulltext.

Surgical distance to the sphenoid ostium: A comparison of healthy patients and patients with cystic fibrosis

Objectives: To establish and compare the distance and angle from the limen nasi to the sphenoid ostium in pediatric patients with normal sinonasal anatomy vs pediatric patients with cystic fibrosis (CF). Design: Retrospective review of computed tomographic images. Setting: Tertiary university-based medical center. Participants: Patients (newborn to age 20 years) with normal sinonasal anatomy (n=117) or CF (n=15). Main Outcome Measures: We used a fourth-degree polynomial to curve-fit the distance to the sphenoid ostium vs age for patients with normal sinonasal anatomy, producing a coefficient of determination (R2) of 82%. With this regression curve, we produced a normative distance equation and a normative distance graph using age to predict the distance (95% confidence interval). We validated the normative distance curve fit among 30 new pediatric patients. Results: No significant difference in the distance to the sphenoid ostium was found between healthy patients and patients with CF. There was no correlation between age and angle in either patient group. The mean (SD) angle was statistically different between healthy patients (37.5° [7.5°]) and patients with CF (41.4° [7.4°]). Conclusions: Using a normative distance graph and the mean angle, surgeons performing pediatric endoscopic sinus surgery can predict the distance to the sphenoid ostium for healthy patients and for patients with CF. These findings may decrease complications of endoscopic sinus surgery among the pediatric population. ©2010 American Medical Association. All rights reserved

Characteristics of velopharyngeal dysfunction in 22q11.2 deletion syndrome: A retrospective case-control study

Objective: To identify and describe the dynamic features of velopharyngeal dysfunction (VPD) in patients with 22q11.2 deletion syndrome relative to patients with non-syndromic cleft palates. Study design: Retrospective case-control study. Setting: Pediatric tertiary care center. Subjects and methods: A total of 30 children (aged 9-16 years) with VPD were included in this study. Fifteen children with a definitive diagnosis of 22q11.2 deletion syndrome requiring surgical VPD repair were included in the 22q11.2 deletion syndrome group. Fifteen age-and sex-matched children with non-syndromic cleft palate requiring surgical VPD repair were included in the non-syndromic cleft palate group for comparison. Velar displacement, lateral pharyngeal wall displacement, and lateral pharyngeal wall motion pattern data were extracted from preoperative Multiview Videofluoroscopy imaging studies of all children and compared across groups. Results: Lateral pharyngeal wall displacement was found to be reduced in the 22q11.2 deletion syndrome group (U = 29.50, p =.001, r =.63). However, measures of velar displacement were not observed to differ between groups. Similarly, lateral pharyngeal wall motion pattern distributions were not found to differ across these two groups. Conclusions: Velopharyngeal dysfunction in patients with 22q11.2 deletion syndrome showed differences in dynamic velopharyngeal function when compared to non-syndromic cleft palate patients. The current findings provide initial insights into the unique aspects of velopharyngeal dysfunction for patients with 22q11.2 deletion syndrome. These findings may guide further efforts directed toward understanding the dynamic velopharyngeal characteristics of this population and potentially optimize surgical management and functional outcomes

How Consistent Is Competent? Examining Variance in Psychomotor Skills Assessment

Purpose Direct assessment of trainee performance across time is a core tenet of competency-based medical education. Unlike variability of psychomotor skills across levels of expertise, performance variability exhibited by a particular trainee across time remains unexplored. The goal of this study was to document the consistency of individual surgeons\u27 technical skill performance. Method A secondary analysis of assessment data (collected in 2010-2012, originally published in 2015) generated by a prospective cohort of participants at Montreal Children\u27s Hospital with differing levels of expertise was conducted in 2017. Trained raters scored blinded recordings of a myringotomy and tube insertion performed 4 times by junior and senior residents and attending surgeons over a 6-month period using a previously reported assessment tool. Descriptive exploratory analyses and univariate comparison of standard deviations (SDs) were conducted to document variability within individuals across time and across training levels. Results Thirty-six assessments from 9 participants were analyzed. The SD of scores for junior residents was highly variable (5.8 out of a scale of 30 compared with 1.8 for both senior residents and attendings [F(2,19) = 5.68, P \u3c 0.05]). For a given individual, the range of scores was twice as large for junior residents than for senior residents and attendings. Conclusions Surgical residents may display highly variable performances across time, and individual variability appears to decrease with increasing expertise. Operative skill variability could be underrepresented in direct observation assessment; emphasis on an adequate amount of repetitive evaluations for junior residents may be needed to support judgments of competence or entrustment

Face and content validity of a novel, web-based otoscopy simulator for medical education.

BACKGROUND: Despite the fact that otoscopy is a widely used and taught diagnostic tool during medical training, errors in diagnosis are common. Physical otoscopy simulators have high fidelity, but they can be expensive and only a limited number of students can use them at a given time. OBJECTIVES: 1) To develop a purely web-based otoscopy simulator that can easily be distributed to students over the internet. 2) To assess face and content validity of the simulator by surveying experts in otoscopy. METHODS: An otoscopy simulator, OtoTrain™, was developed at Western University using web-based programming and Unity 3D. Eleven experts from academic institutions in North America were recruited to test the simulator and respond to an online questionnaire. A 7-point Likert scale was used to answer questions related to face validity (realism of the simulator), content validity (expert evaluation of subject matter and test items), and applicability to medical training. RESULTS: The mean responses for the face validity, content validity, and applicability to medical training portions of the questionnaire were all ≤3, falling between the Agree , Mostly Agree , and Strongly Agree categories. The responses suggest good face and content validity of the simulator. Open-ended questions revealed that the primary drawbacks of the simulator were the lack of a haptic arm for force feedback, a need for increased focus on pneumatic otoscopy, and few rare disorders shown on otoscopy. CONCLUSION: OtoTrain™ is a novel, web-based otoscopy simulator that can be easily distributed and used by students on a variety of platforms. Initial face and content validity was encouraging, and a skills transference study is planned following further modifications and improvements to the simulator

Changes to the practice of pediatric otolaryngology as a consequence of the COVID-19 pandemic

Background: The COVID-19 pandemic has shifted medical practice globally. The objective of this study was to examine the changes to the practice of pediatric otolaryngology internationally due to the COVID-19 pandemic and examine potential contributors. Method: An online survey was designed to assess practice demographics, patterns of COVID-19 related restrictions in communities, and changes to practice and referrals. This was disseminated via an international Covid-19 WhatsApp™ group of pediatric otolaryngologists. Results: There were 45 respondents of 177 group members (25.4%) from 15 countries. The mean estimated time spent under strictest lockdown measures was 16.2 (±10.7) weeks (range: 1–45 weeks). Operating room time was reduced for 82.9%, with an average reported reduction of 41.5%. Almost all (\u3e75%) of respondents reported reduced referrals for five common conditions: otitis media with effusion (average reported decrease – 56.1%); acute otitis media (average decrease 62.8%); acute mastoiditis (average decrease 66.6%); recurrent pharyngotonsillitis (average decrease 51.0%); and peritonsillar abscess (average decrease 52.1%). COVID-19 cases per million population significantly influenced the acuity of referrals received (p \u3c.05). No conditions were reported as increased in frequency and the acuity of most conditions was reported as unchanged by the majority of respondents. Conclusion: The measures taken to reduce the spread of COVID-19 have resulted in many changes to pediatric otolaryngology practice and the referral patterns of common conditions. Some of these changes may have enduring sequelae

Discovery of an exosite on the SOCS2-SH2 domain that enhances SH2 binding to phosphorylated ligands

Suppressor of cytokine signaling (SOCS)2 protein is a key negative regulator of the growth hormone (GH) and Janus kinase (JAK)-Signal Transducers and Activators of Transcription (STAT) signaling cascade. The central SOCS2-Src homology 2 (SH2) domain is characteristic of the SOCS family proteins and is an important module that facilitates recognition of targets bearing phosphorylated tyrosine (pTyr) residues. Here we identify an exosite on the SOCS2-SH2 domain which, when bound to a non-phosphorylated peptide (F3), enhances SH2 affinity for canonical phosphorylated ligands. Solution of the SOCS2/F3 crystal structure reveals F3 as an α-helix which binds on the opposite side of the SH2 domain to the phosphopeptide binding site. F3:exosite binding appears to stabilise the SOCS2-SH2 domain, resulting in slower dissociation of phosphorylated ligands and consequently, enhances binding affinity. This biophysical enhancement of SH2:pTyr binding affinity translates to increase SOCS2 inhibition of GH signaling

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries